Duplicated ureter diagnosed during total laparoscopic hysterectomy

Abstract

2 ) with no history of health problems presented with hypermenorrhea. Transvaginal ultrasonography revealed a submucous leiomyoma measuring 4 cm in size. We suggested two surgical options (hysteroscopic myomectomy or TLH) to the patient. After a lengthy discussion with the patient about the various implications, at the patient’s request we decided to perform TLH. The patient was hospitalized and underwent TLH. The operative time was 161 minutes and the intraoperative blood loss was 100 mL. The weight of the resected specimen was 220 g. During TLH, we routinely expose the avascular retroperitoneal space by the lateral approach at the beginning of the operation. By displacing the uterus to the contralateral side, a pelvic sidewall triangle formed by the round ligament, the external iliac artery, and the infundibulopelvic ligament is identified. The peritoneum in the middle of the triangle is then incised, and the broad ligament is opened by bluntly separating the areolar tissues. We next proceed to locate the umbilical ligament in the retroperitoneal space. After identifying the umbilical ligament, we search caudally for the uterine artery along its structure. The uterine artery is then ligated at its origin with 2e0 Vicryl to reduce the blood flow. The ureter, which adheres to the posterior leaf of the broad ligament, can thus be identified at the same time. In order to prevent ureteral injury, the course of the ureter is caudallyexposed until the entrance of the ureteral tunnel. Usually, the entire pelvic course of the ureter becomes visible during these procedures. However, in this case, the course of the ureter was not clearly visible. Therefore, we searched for the ureter distal (cranial) to the pelvic brim and then peeled the ureter from the posterior leaf of the broad ligament for its entire pelvic course in order to expose it. Surprisingly, incomplete duplication of the right ureter was observed during the procedure (Fig.1). Distally, both ureters were joined together and running as a single segment for approximately 5 cm in length prior to entering the bladder. The left ureter and the bladder were normal in appearance. The patient was uneventfully discharged on postoperative Day 4. Renal ultrasonography later confirmed no evidence of hydronephrosis. Intravenous pyelography was not performed during the postoperative period at the patient’s request. The patient was doing well during the postoperative follow-up.