Transection of Duplex Ureter During Vaginal Hysterectomy

Amenda Ann Davis

doi:10.7759/cureus.6597

Abstract

Duplex ureter, an embryological developmental anomaly, can lead to intra-operative injuries, even by surgeons with a stronghold on normal ureteric anatomy. We describe the first case of an ectopic ureter transected during vaginal hysterectomy performed for pelvic organ proplase, due to its abnormally low implantation into the bladder, worsened by cystocoele. The injury was recognised, and the duplex ureter was diagnosed with cystoscopy and retrograde pyelography. A post-operative computed tomography urogram allowed us to map the exact course. In this case, there was injury to the ectopic, non-functional ureter, thus averting any further intervention. However, lower urinary tract injuries are serious complications with high morbidity, especially during delayed diagnosis. Knowledge of the ureter variants, meticulous tracing of the course, and use of post-operative cystoscopy could reduce these complications, particularly in face of increasing minimally invasive approaches.

Highlights

Iatrogenic ureteric injury is a significant intra-operative concern for gynaecologists, owing to its proximity to the uterine arteries and cervix, retroperitoneal pelvic course, and at the infundibulopelvic ligament [1]
The overall incidence of iatrogenic ureteric injuries during gynaecological surgeries is less than 1%-2%, and even less during vaginal hysterectomy [2]
Normal ureteric anatomy is ingrained with due diligence, but unanticipated ureteric abnormalities may lead to intra-operative injury

Summary

Introduction

Iatrogenic ureteric injury is a significant intra-operative concern for gynaecologists, owing to its proximity to the uterine arteries and cervix, retroperitoneal pelvic course, and at the infundibulopelvic ligament [1]. The mass required manual reduction and splinting during micturition She had no history of vaginal discharge or post-menopausal bleeding. Stress test for SUI and Bonney’s test were positive She had been advised pelvic floor training exercises many years ago, which led to a minimal improvement of symptoms, but due to worsening of the prolapse and urinary symptoms, a surgical plan for vaginal hysterectomy and pelvic floor repair was made, with pre-operative vaginal packing with acriflavineglycerol for two weeks. The patient was discharged with urethral catheter on post-operative day 4 to promote epithelialisation of the ectopic ureter which was inserting into the bladder. She was doing well on follow-up at two weeks, and the catheter was removed.

Discussion

Conclusions

Disclosures

Meyer R