Oliguria after prophylactic ureteric stenting in gynaecological surgery—a report of three cases and review of the literature

Ureteric injury is one of the most serious complications of gynaecological surgery. Use of prophylactic preoperative bilateral ureteric stents to reduce ureteric injury is established in colorectal surgery and becoming commonplace in complex gynaecological surgery. The safety of the procedure has been questioned due to reports of stent-induced complications including a rare but serious phenomenon of stent-induced transient obstructive oligo-anuria termed reflex anuria, a response to manipulation and irritation of the ureters. A retrospective case-note review of patients who had bilateral ureteric stents placed prior to gynaecological surgery at Salford Royal Hospital, UK, from 2007 to 2011 was performed to identify cases of oligo-anuria post-stenting, which were not related to hypovolaemia, nephrotoxic drugs or a radiologically evident obstruction. All patients had their stents removed immediately at the end of surgery before leaving the operating theatre. Three out of 439 patients (0.7 %), who had preoperative bilateral ureteric stents, developed post-operative oligo-anuria despite relatively normal radiological assessment. In these three cases outlined below, one self-resolved, and two required urgent re-stenting to relieve obstruction. Use of ureteric stents for major gynaecological surgery can expedite intraoperative identification of the ureters to help reduce accidental ureteric injury but can directly cause complications. These three cases have contributed to knowledge of the complications of ureteric stents during major gynaecological surgery. Awareness of reflux anuria as a possible root cause of post-operative acute renal failure is important for guiding appropriate and timely management to preserve renal function.     

Proposal of the 3O (Obstruction,Ureteric Orifice,and Outcome) Subclassification System Associated with Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA)

Study ObjectiveTo propose a “3O” (obstruction, ureteric orifice, and outcome) subclassification system associated with obstructed hemivagina and ipsilateral renal anomaly (OHVIRA).DesignRetrospective case series.SettingXiangya Hospital, Central South University, Changsha, Hunan, China.ParticipantsA total of 26 women with obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) over a 9-year period.InterventionsNot applicable.Main Outcome MeasuresIn all cases, the obstruction, ureteric orifice, outcome and surgical strategy were reviewed.ResultsIn our study, the “obstruction” category included 14 cases of blind hemivagina, 8 cases of buttonhole septum, 3 cases of cervical fistula, and 1 case of cervical atresia. A total of 25 patients with vaginal obstruction underwent resection of the vaginal septum. The patient with cervical atresia underwent a failed cervicoplasty, followed by hemi-hysterectomy. The “ureteric orifice” category included 24 cases of absent ureter with no orifice, as well as 2 cases of ureteric orifice emptying into the obstructed hemivagina. The 2 patients were treated with laparoscopic extirpation of the ectopic ureter and renal moiety. Regarding the “outcome” category, 5 patients with severe recurrent hematometra, hematosalpinx, and ovarian endometrioma underwent hemi-hysterectomy, salpingectomy, and cystectomy of the ovarian endometrioma. Both patients (1 with a septate uterus and 1 with a bicornuate uterus) who experienced recurrent abortion accepted uterine correction.ConclusionWe provide new insights into the anatomical variants of this rare syndrome with the relevant surgical implications. Magnetic resonance imaging is the most useful tool in 3O diagnosis.     

Danazol in the management of ureteral obstruction secondary to endometriosis

Ureteral obstruction caused by endometriosis is uncommon. It is, however, an important complication that imposes a 25% chance for permanent loss of renal function on the affected side. The standard management is surgical; however, three cases have been reported in which regression of obstruction followed medical therapy. This case report concerns a patient with long-standing partial ureteric obstruction due to endometriosis who was treated for 2 months with danazol. Clinical response of the endometriosis was excellent, but the obstruction persisted, a retroperitoneal ureteroneocystotomy was therefore performed. The ureter was found to be obstructed by dense fibrous tissue that contained endometrial glands. It seems therefore that a trial of danazol may be attempted in selected cases, but that the drug is unlikely to relieve endometriotic ureteric obstruction once dense fibrosis has occurred.     

Obstruction of the upper urinary tract after treatment of carcinoma of the uterine cervix.

The frequency of obstruction of the upper urinary tract after treatment of carcinoma of the uterine cervix was assessed in an investigation of 100 consecutive patients. 64 of the women were treated surgically (Wertheim hysterectomy); the remaining 36, with Wertheim hysterectomy combined with radiotherapy (combined treatment). The patients were examined with isotope renography and with i.v. urography before, as well as 14 dyas, 2 months, 4-6 months, and 1, 2, 3, 4 and 5 years after, the operation. When necessary, these examinations were supplemented by retrograde pyelography, intravenous pyelography and selective renal function tests. Postoperatively 40.3% of the patients treated with surgery alone showed signs of ureteric obstruction whereas the figure for those treated with the combined treatment was 55%. Of the patients 25 developed in the early postoperative course mild ureteric obstruction which disappeared within half a year. Such mild obstruction was not regarded as a true complication of the treatment given. On the other hand, 21 patients developed obstinate ureteric obstruction. In 14 of these patients surgical intervention was necessary to save renal function. Most of the patients with serious ureteric obstruction had fairly advanced carcinoma (15 of stage 2 and 6 of stage1). Radiotherapy had been given more often in this group (15 out of 21) than in the rest. In 4 of the patients the ureteric obstruction was due to a recurrence of a tumour. This means that the true frequency of postoperative ureteric obstruction was 17%. In the group given combined treatement urinary stasis persisted longer than in the group treated with surgery alone. Renography and urography were done on 682 occasions and the results did not agree in 14%.     

Laparoscopic management of ureteral endometriosis: our experience

STUDY OBJECTIVE: Ureteral endometriosis is rare, accounting for less than 0.3% of all endometriotic lesions. The aim of our study is to evaluate the prevalence of extrinsic ureteral endometriosis in women undergoing laparoscopic surgery for severe endometriosis and to suggest that laparoscopic ureterolysis represents a mandatory measure in all cases to avoid ureteral injury. METHODS: A retrospective analysis was performed of all cases of patients who underwent laparoscopic surgery for severe endometriosis at the departments of obstetrics and gynecology at CMCO-SIHCUS and Hautepierre Hospital, Strasbourg, from November 2004 through January 2006. MEASUREMENTS AND MAIN RESULTS: We recorded 54 patients with a mean age of 31 years and a mean body mass index of 21.9. Reported symptoms were dysmenorrhea (88%), severe dyspareunia (88%), severe pelvic pain (38.8%), and infertility (74%). Five women presented with dysuria, frequency, recurrent urinary tract infections, and pain in the renal angle, and 2 patients had hydronephrosis. We observed 3 patients (5.6%) with ureteral stenosis, 35 (64.8%) with adenomyotic tissue surrounding the ureter without stenosis, and 16 (29.6%) with adenomyotic tissue adjacent to the ureter. It was on the left side in 47.4% of cases, on the right side in 31.6% cases, and bilaterally in 21% of cases. In 9 patients, ureteral involvement was associated with bladder endometriosis (16.7%). In all patients, ureterolysis was performed. There was 1 case of ureteral injury during the procedure, 2 of transitory urinary retention, and 1 of uretero-vaginal fistula after surgery. During the first year of follow-up, the disease recurred in 4 patients, with no evidence of the disease in the urinary tract. CONCLUSION: Conservative laparoscopic surgery to relieve ureteral obstruction and remove pathologic tissue is the management of choice. Resection of part of the ureter should be performed only in exceptional cases. Ureterolysis should be performed in all patients before endometriotic nodule resection to recognize and prevent any ureteral damage.     

Ureteral injury in obstetric and gynecologic operations in Nigeria.

Forty-eight cases of ureteral injuries resulting from obstetric gynecologic surgery were treated at the University of Nigeria Teaching Hospital between January 1978 and December 1987. Cesarean sections and cesarean hysterectomies were the leading causes of injury, being responsible for 18 (38%) and 12 (25%) of the cases, respectively. Ureteral transection was the commonest lesion observed, being noted in 29 (60%) of the patients. Attempt was made to reimplant the ureter into the bladder whenever possible, thus ureteroneocystostomy was performed in 27 (56%) cases while only 3 cases of end to end anastomosis were done. There was a case of mortality recorded from one of the referred patients. Forty patients recovered normal renal function after repair. Repair of ureteric injury as soon as the patient is fit for surgery is recommended.     

The use of percutaneous nephrostomy in patients with ureteric obstruction undergoing renal transplantation

The use of percutaneous nephrostomy with or without placement of a ureteric stent has been of increasing aid in treating both acute and chronic ureteral obstruction in recipients of renal allografts. Eight patients who underwent transplantation, had ureteric obstruction develop and were treated by this means are reported herein. The technique is standard and can be performed in an arteriography suite. Once a catheter is inserted into the allograft collecting system, a nephrostomy tube or a stent, or both, is easily inserted. Three of the patients had acute ureteric obstruction secondary to clot forming after needle biopsy of the transplant kidney. Percutaneous nephrostomy tubes were passed, the renal pelvis and ureter irrigated and the clots lysed. Operation was unnecessary. In five patients with declining renal function secondary to chronic obstruction, percutaneous nephrostomy placement allowed return of renal function to base line levels, while placement of a stent through the ureter into the bladder facilitated location of the ureter at operation for ureteral reimplantation. The technique of percutaneous nephrostomy is simple, convenient and allows patient recovery preoperatively. It has become part of our standard armamentarium in transplant recipients.     

Symptomatic urinary stone disease in pregnancy

BACKGROUND: Symptomatic urinary calculi are rare in pregnancy with an incidence of one per 1500 pregnant women. Calculi may cause ureteric obstruction that can be further complicated by sepsis. This may have a significant morbidity for mother and fetus. OBJECTIVE: To provide an update on the current investigations and management options for pregnant patients with symptomatic urinary calculi. DISCUSSION: We discuss the different imaging modalities available to investigate the renal tract in pregnant women and propose a management pathway. This topic is particularly pertinent to obstetricians in their roles as coordinators of prenatal care.     

Diagnosis and management of adenocarcinoma of the ampulla of Vater during pregnancy

BACKGROUND: Cancer of the biliary tract has a poor prognosis and its association with pregnancy is uncommon. Early diagnosis allowing curative surgical resection offers the only hope of long-term survival. CASE: This report describes the case of a young 26-week-pregnant woman admitted for cholestatis documented by clinical and laboratory examination. Ultrasonography (US) and magnetic resonance cholangiopancreatography (MRCP) were indicative of common bile tract obstruction. Caesarian section was performed at 32 weeks of pregnancy and the tumor was promptly biopsied. Histology demonstrated carcinoma of the ampulla of Vater. The patient underwent a Whipple procedure. Both mother and baby survived. CONCLUSION: Pregnant patients with digestive cancer require careful management. Acute non-invasive assessment and radical surgery improve outcome for both the mother and fetus.     

Primary primitive neuroectodermal tumor of the urinary tract.

Primary primitive neuroectodermal tumor (PNET) of the urinary tract is a rare disease with aggressive behavior and poor prognosis. We analyzed 851 cases of urinary tract malignancies in our hospital between 1984 and 2004. Only three (0.035%) cases with PNET of the urinary tract were identified. Presenting symptoms included flank pain and hematuria. The first case was a 44-year-old man with left renal PNET who underwent hand-assisted laparoscopic radical nephrectomy and adjuvant chemotherapy. There was no recurrent tumor at the 4-year follow-up. The second case was a 75-year-old woman with right renal PNET with inferior vena cava (IVC) thrombosis extending to the right atrium. The patient underwent right radical nephroureterectomy and IVC thrombectomy with cardiopulmonary bypass. She died of metastatic disease 7 months later. The third case was a 45-year-old man with left ureteral PNET. Left ureteral segmental resection and partial cystectomy were performed. Tumor recurrence was noted 7 years later. The patient died of disseminated disease 1 year after the discovery of recurrence. Urinary tract PNET appears to be an aggressive malignancy. Long-term survival is possible if complete resection is performed at an early stage.     

Ureteric obstruction after radical hysterectomy

Two patients with invasive carcinoma of the cervix treated with radical hysterectomy developed total unilateral ureteric obstruction postoperatively. A temporary percutaneous nephrostomy was inserted. Because both patients needed adjuvant radiotherapy, intended reimplantation of the ureter was postponed. During this period spontaneous passage through the ureter was observed after 5 and 14 weeks, respectively. It is emphasized that a 'wait and see' policy may be justifiable in the case of ureteric obstruction of unclear etiology after radical hysterectomy for at least 3 months, as long as renal function is preserved by percutaneous nephrostomy drainage of the affected kidney side.     

Ureteric obstruction in pregnancy--diagnosis and management.

OBJECTIVE--To discuss the aetiology, diagnosis and management of ureteric obstruction in pregnancy and to describe the use of double-pigtail ureteric stents in a series of 10 patients. DESIGN--Retrospective study of women presenting to a maternity unit in whom the diagnosis of ureteric obstruction is reached. SETTING--Southmead Hospital in Bristol; a large district general hospital with a throughput of around 6000 maternity patients per year. SUBJECTS--10 women (8 in their first pregnancy, 1 in her second and 1 in her third; mean age 29.2 years (range 18-31 years). INTERVENTIONS--Double-pigtail ureteric stents were electively passed after a diagnosis of ureteric obstruction. Stents remained in situ for a mean 15.5 weeks (range 8-25 weeks) and were electively removed 4-6 weeks post partum. RESULTS--Nine women progressed uneventfully through the remainder of their pregnancy. One developed strangury, haematuria and discomfort after stent insertion. Seven women had normal vaginal deliveries, two assisted vaginal deliveries and one was delivered by caesarean section. None required to have external urinary drainage. CONCLUSIONS--Double-pigtail ureteric stents are easy to place and remove and are well tolerated. They provide a simple, safe and effective method of internal upper urinary tract drainage in ureteric obstruction in pregnancy.     

Clinical and radiological findings for early diagnosis of Herlyn–Werner–Wunderlich syndrome in pediatric age: experience of a single center

Objective: The authors present their experience in the management of pediatric patients with Herlyn–Werner–Wunderlich syndrome (HWWS) considering clinical classification and anatomical characteristics of the malformation.

Methods: All the data of the patient presented at our Pediatric Surgery Unit from February 2010 to August 2015 were collected. According to the type of malformations, patients were divided in 3 groups: A (completely obstructed hemivagina), B (incompletely obstructed hemivagina), and C (communication between the duplicated cervices).

Results: Six patients were treated in the study period. The mean age was 9?years (2?months–15?years). According to the characteristics of the HWWS, we had 5 patients in group A, 1 in group B, and none in group C. One-stage surgical treatment was performed in all cases of complete obstruction, but in one case a second look was necessary for a better resection of the septum. At a mean follow-up of 18?months all patients were symptoms free.

Conclusions: Prognosis of this malformation is good in case of early diagnosis and treatment. We suggest that when a renal agenesia is diagnosed, the patient needs an ultrasonographic follow-up of the contralateral kidney but also of the genital tract to find each minimal abnormalities, furthermore, a MRI scanning before the onset of menstruation can be necessary.     

In utero therapy for lower urinary tract obstruction.

Lower urinary tract obstruction has a significant impact on neonatal and child health. Pulmonary hyperplasia and renal impairment could be direct or indirect consequences of this condition leading to significant morbidity and mortality. Evaluation of fetuses with suspected lower urinary tract obstruction is performed not only to confirm the diagnosis but also to assess renal prognosis. Ultrasound examination and urinary analysis aid in the evaluation of these fetuses. The decision to perform fetal intervention in these cases is a difficult one. Vesico-amniotic fetal shunting, open fetal surgery and more recently endoscopic fetal surgery for this condition are available as possible modalities of fetal intervention. Case selection for fetal intervention is extremely important in order to both avoid unnecessary intervention in those unlikely to survive, and also to avoid procedure related complications in fetuses likely to do well without intervention. Vesico-amniotic shunting has the advantage of bypassing the obstruction, however it is often associated with complications. Open fetal surgery is not usually recommended because of the complications and high fetal loss rate. Endoscopic surgery to visualise and treat the cause of lower urinary tract obstruction has been tried. Fetal endoscopic surgery is in its infancy and endoscopic procedures are limited to a few groups. This current review addresses evaluation, case selection and therapeutic options for lower urinary tract obstruction in utero. It also discusses the limited data against which the efficacy of the various options can be assessed. The current state of fetal intervention is detailed in the present review.     

冠状动脉异常分布对小儿复杂先心病右室流出道重建的影响

目的总结法洛四联症和右室双出口合并冠状动脉畸形手术治疗经验，探讨冠状动脉畸形对右室流出道重建的影响。方法1989年4月至2004年5月治疗合并冠状动脉畸形的法洛四联症和右室双出口患儿20例，其中单支冠状动脉畸形11例，左前降支起自右冠状动脉6例，右冠状动脉 肺动脉瘘2例，左右冠状动脉交通支形成蔓状血管丛1例。行姑息手术1例，根治术19例。结果根治术早期死亡1例，18例随访10个月至8年，残余漏2例，残余梗阻3例，余结果满意。结论根据畸形冠状动脉走行特点，选择手术切口，避免损伤异常冠状动脉。有些术中被迫使用异体材料或无法行根治术，影响了中远期效果，应引起足够重视。     

A study of mild fetal pyelectasia - outcome and proposed strategy of management

Mild fetal pyelectasia, defined as a renal pelvic anteroposterior (AP) diameter of 4-10 mm, has become a frequent finding on fetal ultrasonography. The natural history of such dilatation is unclear, resulting in confusion as to appropriate postnatal investigation and management. The aim of this study was to examine the urinary tract outcome of a series of infants with mild fetal pyelectasia demonstrated on routine morphology ultrasonogram between 16 and 21 weeks' gestation. Of the 37 cases identified, 13 (35%) went on to require medical or surgical intervention for significant urinary tract anomalies. These anomalies included pelvi-ureteric junction obstruction, dysplastic kidney, vesicoureteric reflux and posterior urethral valves. On initial scan all cases had an AP diameter of 4-8 mm and did not predict those infants who would go on to require intervention. An AP diameter of greater than 7 mm on repeat scans performed after 27 weeks' gestation had a positive predictive value of 0.92 and a negative predictive value of 0.76 for significant urinary tract anomaly requiring intervention. The specificity was 0. 94 and sensitivity 0.70. A protocol of one repeat antenatal ultrasound at 28-34 weeks' gestation would be able to identify those infants who would require postnatal investigation, using a measurement of >/=7 mm. The fetus with a normal repeat ultrasound would not require postnatal follow-up.     

Discordant lower urinary tract obstruction in early twin gestations: management and outcome

OBJECTIVE: To report our experience with the management of twin pregnancies discordant for lower urinary tract obstruction. METHODS: Cases of twin pregnancies discordant for lower urinary tract obstruction were identified from our fetal medicine database. Information on ultrasonographic findings, antenatal course, pregnancy complications, and perinatal outcome was obtained by reviewing medical records or contacting the referring obstetricians. RESULTS: Five twin pregnancies discordant for lower urinary tract obstruction were diagnosed between 11 and 15 weeks of gestation. There were 3 dichorionic and 2 monochorionic pregnancies (1 diamniotic and 1 monoamniotic). The dichorionic pregnancies were managed conservatively, resulting in a pregnancy loss of both twins in 1 case, a single fetal death at 29 weeks in 1 case, and an early neonatal death due to lung hypoplasia of the affected twin in 1 case. On the other hand, both monochorionic twin pregnancies were managed with serial vesicocenteses. In both cases, the prenatal course was complicated, 1 by premature rupture of the membranes and the other by cord entanglement, requiring delivery at 29 and 31 weeks, respectively. Among the 4 continuing pregnancies with complete perinatal outcome, none of the affected twins survived, and the structurally normal twins were delivered between 29 and 36 weeks and discharged from the hospital in good condition. CONCLUSION: Twin pregnancies discordant for lower urinary tract obstruction are at high risk of perinatal death and premature delivery. Prenatal intervention seems not to be associated with an improved perinatal outcome of the affected twin, but it may be beneficial in selected cases to attain viability of the unaffected twin.     

Ultrasound-guided fine needle aspiration of ovarian cysts during pregnancy

OBJECTIVE: To evaluate the safety and efficacy of ultrasound-guided fine needle aspiration in the treatment of ovarian cysts during pregnancy. STUDY DESIGN: Nine out of twenty-nine patients between the 6th and the 16th week of gestation with unilateral ovarian cysts ranging between 65 and 540 cm3 in volume were selected for sonographically-guided fine needle aspiration. RESULTS: No complications were observed at either short or long-term follow-up; all patients delivered healthy infants at term. Clinical and sonographic post-partum follow-up was uneventful in all cases. In three cases it was necessary to repeat the procedure once and in one case twice during pregnancy. In one case a recurrent serous cyst was excised at operative laparoscopy performed 3 months after delivery. CONCLUSIONS: Ultrasound-guided fine needle aspiration was safely performed in nine patients as an alternative treatment to surgery when persistent monolateral and unilocular ovarian cysts with regular borders and completely anechoic structure are detected during pregnancy.     

Can flexible sigmoidoscopy predict need for colorectal surgery in ovarian carcinoma?

INTRODUCTION: It is difficult to predict which patients with ovarian cancer will require bowel surgery. We propose that sigmoidoscopy performed by an experienced colorectal surgeon could predict the need for bowel resection as part of optimum cytoreduction by assessment of rigidity and encasement of the rectosigmoid colon or mucosal involvement. Laparotomy may then be performed electively in collaboration with a colorectal surgeon after administration of bowel preparation. METHODS: In a prospective study 30 patients undergoing surgery for a high suspicion of ovarian malignancy and with at least two of either a complex pelvic mass on ultrasound, elevated CA125 or ascites were studied. Flexible sigmoidoscopy performed at time of admission was reported as "clear bowel", "external compression only" or "mucosal involvement" with the recommendation to "avoid resection" or "may need resection". RESULTS: Sigmoidoscopy was completed in all patients and was well tolerated. Satisfactory preparation and evaluation was possible in 70% and did not delay definitive surgery. 67% (20/30) of cases proved to have ovarian carcinoma. Overall prediction to avoid resection was correct in 21/25 and to resect in 5/9 with accurate prediction in those with ovarian cancer of 17/20 cases. This included 3/4 sigmoid colectomies for ovarian malignancy as part of an optimum debulking procedure. Sigmoidoscopy was more accurate than relying on a history of change in bowel habit alone in predicting the need for bowel resection. CONCLUSIONS: Sigmoidoscopy was shown to be a practical procedure, causing no significant morbidity in patients with ovarian carcinoma. In evaluating a pelvic mass it can exclude primary colorectal pathology and impending obstruction. Flexible sigmoidoscopy correctly identified the majority of cases which required colorectal surgery and allowed an optimal resection to take place as a planned procedure.     

The usefulness of cystoscopy in the staging of cervical cancer

OBJECTIVE: The aim of this study was to clarify the usefulness of cystoscopy in the staging of cervical cancer and to evaluate the clinical indications for performing ureteric catheterization to rule out ureteral obstruction in cervical cancer. METHODS: Both rigid cystoscopy and CT were performed before treatment in patients with cervical cancer of FIGO stage IB or greater. Cystoscopically directed biopsy specimens were taken from all areas in the bladder which were suspected of cancerous development. If a jet of urine spurting from each ureteral orifice was not found, a ureteric catheter was inserted into the orifice to rule out ureteral obstruction. The cystoscopic findings were compared with a CT examination. RESULTS: A total of 100 patients were included in the study (mean age 59 years). There were 30 stage IB cancers, 20 stage IIA, 17 stage IIB, 5 stage IIIA, 18 stage IIIB, and 10 stage IV. A total of 90 patients had squamous cell carcinomas and 10 had adenocarcinomas. Cystoscopy identified 8 patients with bladder invasion including 1 stage IIIA, 2 stage IIIB, and 5 stage IV. All of these patients had CT indication of possible invasion. CT indication of possible invasion was proved to be false by cystoscopy in 2 patients. Both the sensitivity and the negative predictive value of CT for bladder invasion were 100%. Of the 14 patients in whom ureteral obstruction was diagnosed by ureteric catheterization, 11 cases were indicated by CT scan, but for the other 3 patients CT found no significant ureteral obstruction. CONCLUSIONS: The results of this study suggest that cystoscopy is indicated only in cervical cancer patients for whom CT examination indicates possible bladder invasion. In addition, the results suggest that placement of ureteric catheterization using cystoscopy to rule out ureteral obstruction is not indicated in the staging of cervical cancer.