This case involves a 40-year-old woman who presented for an elective laparotomy with lysis of adhesions, enterolysis, and abdominal hysterectomy with bilateral salpingo oophorectomy. During surgery, the Foley catheter was removed because the patient did not pass urine for some time and a cytoscopy was performed. The bladder edges had prominent blood vessels and it was slightly hydrodistended. There was rapid flow from the patient’s left orifice. The right orifice had delayed function and at this point the attention was turned back to the abdominal cavity. The ureter was felt to be kinked under a suture. The suture was released, and there was good flow through the ureter. The surgery was completed without further complication and the patient was discharged. On post-op day 9, patient presented to the ER with complaints of an increase in abdominal pain, fever, and urinary frequency. The patient was diagnosed with right hydroureteronephrosis and acute kidney failure.
Questions to the Maternal Fetal Medicine expert and their responses
Was the care rendered to the kinked ureter within the standard of care?
During a hysterectomy procedure, a ureteral dissection is not routinely performed unless concern arises about a potential or actual injury to a ureter. Dissection presents significant risk, since the ureters course under the peritoneum and through a highly vascularized region that can easily be injured, resulting in major bleeding. In this case it seems as if the sutures were placed to stop some bleeding and the surgeon did not realize that the ureters were obstructed until some time later.
Was any additional testing/follow-up required to determine the delayed function of the right orifice?
The patients BUN/Cr should be followed closely after surgery and if it wasn't recognized then after abnormal lab values, that now becomes a failure to diagnose the more complicated issue of acute renal failure.
Questions to the OBGYN expert and their responses
How often do you perform laparoscopic hysterectomies and manage postoperative care?
I perform laparoscopic hysterectomies multiple times per week and manage all of their postop care.
What are the most pertinent measures a provider can perform to minimize the risk of ureteral injury during a total laparoscopic hysterectomy?
The mainstay of avoiding a ureteral injury is by identifying the ureter visually. There are other measures that can help to identify them, of which none of them are considered standard, but are adjuncts such as ureteral stent placement, injection of dyes to visualize the ureters, etc). Also, consideration of relevant anatomy based on the diagnosis being treated a preoperative imaging - endometriosis can lead the ureter being in a different location or adhered to areas of endometriosis. There are 3 main areas where a ureter can be injured in gynecologic surgery- by the ovarian vessels, by the uterine arteries, and suturing during vaginal closure after removal of the uterus.
About the expert
This board-certified gynecologic oncologist is an assistant professor at a Texas medical college with specialized training in obstetrics and gynecology and gynecologic oncology, including a fellowship at the Cleveland Clinic. The expert's clinical practice focuses on complex gynecologic surgery and the diagnosis and treatment of ovarian, endometrial, cervical, and vulvar cancers, as well as endometriosis, fibroids, gestational trophoblastic disease, and placenta accreta.
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Questions to the OBGYN expert and their responses
What steps should be taken when a ureteral or bladder injury is suspected intraoperatively or postoperatively to minimize complications?
If an injury to the ureter or bladder is suspected intraoperatively, cystoscopy with contrast can help diagnose it contemporaneously, which can then be managed by the gynecologist (if capable) or by consulting urology during the case, for performance of cystoscopy with retrograde pyelography under fluoroscopy to identify the site of ureteral injury and repair it right then and there. This can avoid future issues with bladder dysfunction. A bladder perforation is usually identified during cystoscopy, and can usually be repaired without future issues by suture closure of the perforation injury. A bladder perforation, if suspected during the case, can also be identified by retrograde filling of the bladder and observing a leak of fluid from the hole, allowing for immediate repair.
About the expert
This expert has nearly 30 years of experience in the field of obstetrics and gynecology. He earned his BA in biochemistry from Dartmouth College and his MD from the University of Miami School of Medicine. He then went on to complete a residency in obstetrics and gynecology at Emory University. Today, this expert is board certified in obstetrics and gynecology. He is an active member of several professional organizations, including the American Institute of Minimally Invasive Surgery, the American College of Obstetricians and Gynecologists, and the American Association of Gynecologic Laparoscopists. He is also active in academia, having published on topics related to obstetrics, gynecology, and minimally invasive gynecologic surgery. This expert previously served as the president of medical staff and as the chairman of obstetrics and gynecology at Cartersville Medical Center. Currently, he is an attending obstetrician and gynecologist at a medical center, the medical director of an advanced gynecologic surgery center, and an obstetrician and gynecologist at an obstetrics and gynecology private practice in Georgia.
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