Case Report: The Importance of Cystoscopic Evaluation and Management of Iatrogenic Lower Ureteric Injuries

Gkentzis A,Struan Gray

doi:10.31487/j.jscr.2020.01.06

Abstract

Four days after emergency caesarean section, a 26-year-old lady presents with severe right flank pain and is found to have right hydronephrosis. A right nephrostomy was inserted, but antegrade stent insertion failed. Cystoscopy revealed two sutures obstructing the right intramural ureter. These sutures were removed via the cystoscope using Holmium LASER. Immediate and follow up investigations showed resolution of the injury and normal urinary drainage. This case highlights the importance of cystoscopic assessment of iatrogenic lower ureteric injuries, and its role in their management.

Highlights

A 26-year-old previously nulliparous woman underwent caesarean section (CS)
After multi-disciplinary discussion, with consideration of the difficulties of nephrostomy management in a new mother, we proceeded to rigid cystoscopy under general anesthetic (GA) to attempt retrograde ureteric stent insertion, or potentially a “rendezvouz” mixed antegrade and retrograde approach
Our novel technique allowed for the early, minimally invasive correction of the ureteric injury using a LASER without the need for major reconstructive surgery

Summary

Introduction

A 26-year-old previously nulliparous woman underwent caesarean section (CS). There were no perceived intra-operative complications. Day four post-operatively she returned complaining of severe right flank pain. She had no signs of sepsis and the laboratory tests revealed elevation of creatinine (140μmol/L). On the ninth postoperative day, she underwent attempted insertion of an antegrade right ureteric stent. After multi-disciplinary discussion, with consideration of the difficulties of nephrostomy management in a new mother, we proceeded to rigid cystoscopy under general anesthetic (GA) to attempt retrograde ureteric stent insertion, or potentially a “rendezvouz” mixed antegrade and retrograde approach. Cystoscopy revealed two sutures proximal to the right ureteric orifice causing an anterior ridge of the bladder wall in the region of the intra-mural right ureter (Figure 3). This resulted in resolution of the previously seen ridge, and efflux of urine from the right ureteric orifice. Return for MAG-3 Renogram to ensure there is no delayed stricture in 6 months’ time, with a view to possible discharge

Follow Up

Discussion