Introduction
Ureteric injuries, when recognised post-operatively, may involve returning to theatre for laparotomy and ureteric re-implantation surgery. The following case describes the management of ureteric injury through the use of minimally invasive techniques.
Clinical description
A 48-year-old woman presented with severe menorrhagia on the background of a multi-fibroid uterus. She had been admitted on numerous occasions for severe anaemia which required repeated blood transfusions, and her menorrhagia was refractory to medical management. An urgent total abdominal hysterectomy and bilateral salpingectomy was performed. She recovered well initially but was noted to have a rising creatinine post operatively. A CT scan of the urinary tract showed a right-sided ureteric obstruction. Multidisciplinary management involved consultation with the Urology team and insertion of a percutaneous nephrostomy tube by Interventional Radiology. However, anterograde guide-wire insertion for stenting was unsuccessful. She was subsequently discharged home and returned the following week for cysto-ureteroscopy and retrograde pyelogram. Intra-operatively the ureteric obstruction was found to be secondary to a suture, which was treated ureteroscopically with laser to relieve the obstruction and allow stent insertion. She recovered well from the procedure and was discharged home. Follow up plan was for nephrostogram in four weeks and for cystoscopy and right ureteric stent exchange in three months.
Discussion
Ureteric injuries can occur in up to 10% of pelvic surgeries. In hysterectomies, rates of up to 5% have been described, depending on the route of surgery. The usual method of repair for ureteric injury is through ureteric reimplantation if discovered intra-operatively. When discovered in the post-operative period, it can be managed via stenting or reimplantation. Endo-ureteric repair of iatrogenic injuries has not been widely described in the literature. Through the use of a minimally invasive approach, the overall morbidity to the patient can be reduced.
Conclusion
Ureteric injury can be successfully managed via a minimally invasive approach. While the method described had significant benefits for this patient, further research is required to better evaluate the feasibility of such a technique as standard management.