Mistaken Diagnosis of Iatrogenic Ureteric Injury- A Case Report with Review of Literature

Iatrogenic ureteral injury is most common in total abdominal hysterectomy among all pelvic surgeries. About two-third of these cases are diagnosed postoperatively. Clinical symptoms and signs lead to suspicion and the first evaluation is done by Trans abdominal Ultrasonography including grey scale and color Doppler mapping which is readily available, noninvasive, inexpensive, high diagnostic potential and has no ionized radiation exposure.  The triad of absence of ureteric jet, ascites or retroperitoneal collection and presence or absence of hydronephrosis can diagnose and differentiate complete, partial and nonobstructive ureteral injury. The ureteric jet angle diagnoses vesico ureteric reflux leading to dilated pelvi calyceal system and cystitis as the cause can also be diagnosed excluding ureteric ligation causing hydronephrosis. We present a case of posthysterectomy hydronephrosis in an asymptomatic patient which on   thorough evaluation was found to have cystitis having vesico ureteric reflux and responded well to sensitive antibiotics.

Iatrogenic ureteric injury as the gynecologist’s nightmare is most common in gynecologic surgery.  Total abdominal hysterectomy among all is the commonest cause [1]. It is more common in benign than malignant indications [2]. The incidence is 0.5 -1.5% in major benign gynecological surgery and has increased with the introduction of total laparoscopic and lap assisted vaginal hysterectomy. With close proximity to the genital organs in pelvis it is inadvertently get injured during hysterectomy even in benign conditions and without distortion of anatomy. Such injury can be trans-section, thermal, vascular, crushed or ligation of the ureter [3, 4]. Out of this 55-70% (one-third) cases are diagnosed postoperatively [5, 6]. Undiagnosed cases of trans-section in early post operative period develop symptoms of flank pain, costovertebral pain and total anuria if both the ureters are affected. Ultra-Sonography (USG) detects retroperitoneal or peritoneal collection and absent ureteric jet. Cases with ligated ureter may get fever, hydronephrosis, absent ureteric jet in USG, leucocytosis and also anuria if both sides are ligated. First line of investigation is USG which is easily available, noninvasive, inexpensive, reliable and no radiation exposure is there. Other investigations are cystoscopy and anti or retrograde urography, computerized tomography (CT) and magnetic resonance imaging for diagnosis [7,8]. Ureteric injury must be diagnosed and managed at the earliest for better outcome like prevention of morbidity and protecting the kidney. But hydronephrosis alone in USG is not conclusive of diagnosis of ureteric ligation.  Here we present a case of hydronephrosis on first postoperative day of total abdominal hysterectomy for benign indication and latter on further evaluation ureteric ligation was excluded.

Aim of presentation is to emphasize that all postoperative hydronephrosis cases are not due to iatrogenic ureteric injury but must be evaluated thoroughly. Preoperative Trans- abdominal Sonography (TAS) evaluation of KUB is also mandatory in all gynecological surgery near ureter to be protected from law suit.

A 45-year-old lady was admitted to the gynecology ward of the institution with the complaints of generalized weakness, excessive menstrual bleeding and pain during menses for four months which was not relieved with medication. She did not have any known medical disorder. There was history of two caesarean section (CS) and sterilization during last CS, 17 years back.  On examination she was of average built, severe pallor, no edema or lymphadenopathy and no thyromegaly. No clinically detectable abnormality in cardiovascular and respiratory system. Abdominal examination revealed healthy suprapubic transverse scar, no tenderness, organomegally or evidence of free fluid. Per speculum examination detected minimal bleeding, healthy vagina and cervix. Internal digital examination found a bulky irregular, firm uterus with a mildly tender mass of 5 x 5 cm in right fornix. USG reported normal kidney ureter bladder (KUB), bulky uterus with fibroid, endometrial thickness 12mm, simple right (RT) ovarian cyst of 5.5 x 5.4 cm.  Her hemoglobin was 7.ogm%, blood group O positive, and all pre operative investigations were within normal limit. With diagnosis of fibroid uterus, simple RT ovarian cyst and severe anemia, two units of packed cell and one unit of whole blood was transfused at intervals. Total Abdominal Hysterectomy with right salpingo-oophorectomy and left salpingectomy was done under spinal anesthesia. Bladder was densely adherent to uterus and separated with sharp dissection. Surgery was uneventful. One unit of whole blood transfusion was transfused postoperatively. On first postoperative day patient was comfortable, ambulatory, accepting soft diet, urine output was adequate and vitals were stable. Urine was sent for culture and sensitivity test and catheter was remover. The patient being treated under government health scheme post operative TAS with full bladder was done as routine which revealed RT hydronephrosis with pelvi calyceal system (PCS) dilation of 20 mm as shown in figure 1, no retroperitoneal or peritoneal collection, left kidney was normal.

Figure 1: Hydronephrosis. RT Kidney.

Figure 2: Ureteric Jet on color Doppler.

On second postoperative day patient was asymptomatic, taking usual diet and urine output was normal. Review USG reported RT PCS dilatation of 10mm, no retroperitoneal or peritoneal collection with partially filled bladder, which   with full bladder showed RT PCS diameter of 20mm, no pelvic collection, no adnexal lesion, urinary bladder wall thickness of 10 mm and free-floating internal echoes, ureteric jet was positive and normal in frequency per min on either side both on grey scale and Doppler USG as shown in figure 2. With the diagnosis of cystitis, the patient was treated conservatively by sensitive antibiotic. Abdominal wound stitches were removed on seventh postoperative day and review TAS on eighth postoperative day showed normal KUB. Patient was discharged and was asymptomatic on postoperative visit after a month.

Gynecological iatrogenic injury of ureter is rare but has serious complications of high morbidity and legal implications.  Early and correct diagnosis is important in proper management of postoperative cases with suspicion of damage to ureter. Symptoms and signs in the patient in post operative period is very important to suspect the injury like transection even in simple cases without altered pelvic anatomy. TAS with full bladder is the first line investigation in evaluation. TAS including color Doppler mapping has high diagnostic potential in diagnosing postoperative ureteric injury. The triad of absence of ureteric jet, ascites or retroperitoneal collection and presence or absence of hydronephrosis can diagnose and differentiate complete or partial obstruction and nonobstructive ureteral injury [9]. Retroperitoneal or peritoneal collection and absent ipsilateral ureteric jet with pain in flank, fever and leucocytosis indicates transection. Hydronephrosis and hydroureter with absence of ureteric jet indicates ligation on affected side. Normal ureteric jet is ≥ 2 / min on either side and less frequent cases diagnose partial obstruction and absent for 10 min indicate complete ureteral obstruction in functioning kidneys and normal hemodynamic stability [10]. But only hydronephrosis is not diagnostic of ureteric ligation as vesico ureteric reflux might be there. The most common cause of this is cystitis like it was there in our case. Vesico-ureteric reflux in cystitis pushes urine backward and the result is hydronephrosis. Ureteric jet angle is the angle between ureteric jet and interureteral ridge and angle of ≥ 55 degree has a sensitivity and specificity of 85.5% to 94.7% respectively in diagnosing vesico ureteral reflux by TAS [9]. It can be unilateral or bilateral depending on anatomy of intravesical part of the ureters. In our patient, PCS diameter was 10 mm with partially filled bladder and 20mm with full bladder and there was RT sided hydronephrosis only. Bilateral ureteric jet was present and normal in frequency in grey scale as well as in color Doppler study. Bladder wall thickness of 10 mm and suspended echoes in the cavity in TAS diagnosed cystitis though the patient was asymptomatic and preoperative complete urine examination was normal. She was treated with sensitive antibiotics and on sixth day of treatment, TAS reported normal KUB.

Hysterectomy being the commonest cause of ureteric injury in gynecology preoperative assessment of KUB should be mandatory in all cases even if a simple hysterectomy is planned for a benign indication. All postoperative hydronephrosis cases are not due to ureteric ligation. TAS as the simplest, easily available, affordable, sensitive, non-invasive and radiation free investigation in experienced hand is very helpful for diagnosis and management.

Acknowledgements

We are thankful to MR. Narasimhulu, MRO, Department of Medical Records of the institution for providing us the case records.

Conflict of interest: None

Funding: none