Congenital Renal and Ureteral Anomaly in Ovarian Cancer Surgery

Abstract

Identifying the ureters during an operation is important in gynecologic surgery, especially in surgery involving retroperitoneal lymph node dissection. Accurate surgical technique and knowledge of the urogenital anatomy are important in avoiding intraoperative ureter injury in cases of unexpected intraoperative findings. Here, we present a case of congenital renal and ureteric anomalies complicating debulking surgery for ovarian cancer. A 43-year-old woman, gravida 2, para 2, suffered from persistent abdominal distension for one month. She had a history of bilateral endometrioma, with laparoscopic enucleation 6 years previously. Gynecologic ultrasonography revealed a heterogeneous complex 6.2 × 5.5 cm mass with an irregular surface in the cul-de-sac. Acute abdomen with fever developed, and laboratory data revealed leukocytosis (16,100/µL) and anemia (hemoglobin, 7.2 mg/dL). CA-125 was 29.07 U/mL. Tubo-ovarian abscess with peritonitis was suspected. Diagnostic laparoscopy was performed, and intraoperative frozen section revealed a right poorly differentiated ovarian carcinoma. The operation was then converted to a laparotomy. Maximal debulking with retroperitoneal pelvic lymphadenectomy was undertaken upon diagnosis of ovarian cancer. During the pelvic lymphadenectomy, we incidentally discovered the absence of a right ureter and kidney and duplication of the left ureter. We performed a comprehensive staging surgery for the ovarian cancer, without ureter injury. Postoperative intravenous pyelogram confirmed a left incompletely duplicated ureter with complete absence of a right kidney and ureter (Figure). Emergency surgery is indicated for acute abdomen. Ureteral injury is a rare but important complication of gynecologic surgery, with serious long-term sequelae. Gynecologic surgery accounts for 75% of surgical ureteral injury. Identifying the ureters during an operation is an especially important procedure in gynecologic surgery involving retroperitoneal lymph node dissection. Accurate surgical technique and knowledge of urogenital anatomy are important to avoid intraoperative ureter injury in cases of unexpected intraoperative findings. Duplication of the ureter is the most common anomaly of the urinary tract, with an incidence of approximately 1% [1]. During the fifth week of embryogenesis, the ureteric bud arises from the mesonephric duct. If a single ureteral bud bifurcates before penetrating the metanephric tissue, an incompletely duplicated or bifid ureter results. If two ureteral buds arise from the mesonephric duct, it will result in a complete ureteral