JAOA • Vol 105 • No 11 • November 2005 • 521-522
Report of Case: Partial Ureteral Obstruction Masked by Diuretics During Intraoperative Cystoscopy
Joseph M. Novi, DO;
Beth H. K. Mulvihill, DO
Previously from the Division of Urogynecology and Reconstructive Pelvic
Surgery at the University of Pennsylvania in Philadelphia, Dr Novi is
currently at Riverside Methodist Hospital in Columbus, Ohio. Dr Mulvihill is a
clinical associate in the Department of Obstetrics and Gynecology at the
Philadelphia College of Osteopathic Medicine in Pa.
Address correspondence to Joseph M. Novi, DO, Director of Urogynecology and
Reconstructive Pelvic Surgery, Riverside Methodist Hospital, 3545 Olentangy
River Rd, Ste 501, Columbus, OH 43214-3907. E-mail:
jnovi{at}ohiohealth.com
Injury to the lower urinary tract is a potential complication in all major
vaginal and urogynecologic surgical procedures. Several authors have
recommended the routine use of intraoperative cystoscopy during urogynecologic
procedures. To evaluate possible injury to the lower urinary tract during
intraoperative cystoscopy, the concomitant use of diuretics with indigo
carmine dye has been advocated; efflux of dye is hypothesized to indicate
functional patency of the urinary tract. This report describes a case in which
a partial ureteral obstruction was present at the time of intraoperative
cystoscopy—despite the observation of diuresis caused by furosemide.
This case indicates that the efflux of indigo carmine-stained urine from both
ureteral orifices is not conclusive evidence of the absence of ureteral insult
during intraoperative cystoscopy.
Injury to the lower urinary tract complicates 2.9% to 5.3% of all major
vaginal and urogynecologic surgical
procedures.1 Several
authors have recommended the routine use of intraoperative
cystoscopy—with intravenous indigo carmine dye contrast—during
urogynecologic
procedures.1,2
Furthermore, the addition of an intravenous diuretic has been advocated to
reduce the time from administration of the dye to its visualization in the
bladder, particularly in cases in which more than 10 minutes have elapsed
since intravenous injection of the
dye.3 We found that
a partial ureteral obstruction can be present at the time of intraoperative
cystoscopy, but it may go undetected because of the diuresis caused by
furosemide.
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Report of Case
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A 65-year-old woman reported to a urogynecology office with a protruding
vaginal mass. The clinical examination revealed cystocele, enterocele, and
uterine prolapse of grade III, based on the Baden-Walker halfway system. The
patient subsequently underwent vaginal hysterectomy and bilateral
salpingo-oophorectomy, enterocele repair, sacrospinous ligament fixation,
perineorrhaphy, and cystoscopy. The enterocele was repaired using 2-0
polypropylene suture (Prolene; Ethicon Inc, Somerville, NJ). The suture
incorporated bilateral uterosacral ligaments, cul-de-sac peritoneum, and the
endopelvic fascia of the vagina. Two additional 2-0 sutures (Maxon; United
States Surgical Corp, Norwalk, Conn) were similarly placed.
A cystoscopy was performed using a 70-degree cystoscope (Karl Storz
Endoscopy, Culver City, Calif). Following the intravenous administration of
indigo carmine dye, a diuretic— furosemide—was administered
intravenously to enhance the excretion of the dye. Among our findings at this
stage of the procedure were normal bladder mucosa, as well as efflux of indigo
carmine-stained urine from the left
(Figure 1) and right
(Figure 2) ureteral
orifices. Sacrospinous ligament fixation and perineorrhaphy were accomplished
by use of methods similar to those described by
Nichols.4
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Figure 1. Intraoperative cystoscopic image of the left ureteral orifice after the
intravenous administration of indigo carmine dye and furosemide diuretic. The
arrow indicates the efflux of indigo carmine-stained urine. Although the flow
appears strong, the lumen of this ureter was subsequently found to be
compromised by culdeplasty sutures.
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Figure 2. Intraoperative cystoscopic image of the right ureteral orifice after
the intravenous administration of indigo carmine dye and furosemide diuretic.
The arrow indicates the efflux of a strong stream of indigo carmine-stained
urine.
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On postoperative day 2, the patient complained of chills and was noted to
have a temperature of 102.7°F (39.3°C). Blood and urine cultures were
negative, and the patient's white blood cell count was
6.2x103/µL. Her serum creatinine level increased from 0.8
mg/dL on postoperative day 1 to 1.5 mg/dL on postoperative day 3. A computed
tomographic scan of the abdominopelvic region revealed mild left-sided
hydronephrosis.
The patient was taken to the operating room, where a retrograde pyelogram
was performed. Complete obstruction of the lower third of the left ureter was
noted. Attempts to pass a double-J ureteral stent into the left ureter were
unsuccessful. The right kidney and ureter were normal.
Next, the vaginal cuff was opened to allow the removal of the enterocele
sutures. The stent was then easily passed into the left ureter and renal
pelvis. Subsequently, the patient's fever resolved, and tests indicated that
her renal function returned to normal. The patient had an intravenous
pyelogram (IVP) performed six weeks later, when the stent was removed. A final
IVP two months after stent removal revealed a normal left kidney and
ureter.
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Comment
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According to Jabs and
Drutz,2 injuries to
the lower urinary tract are reported to be as high as 5.3% during pelvic and
urogynecologic surgical procedures. These and other researchers have also
noted that routine use of intraoperative cystoscopy to evaluate ureteral
integrity has been shown to effectively reduce the sequelae of operative
injury to the lower urinary
tract.1,2
A cystoscopic finding of efflux of urine from both ureteral orifices and the
absence of bladder trauma are generally regarded as eliminating the
possibility of iatrogenic lower urinary tract
injury.5
Unfortunately, as seen in the current case, the efflux of indigo
carmine-stained urine following the concomitant administration of a diuretic
does not guarantee normal ureteral patency. A partially obstructed ureter may
appear to have normal patency in such a scenario. Possibly as the result of
the progression of inflammation and scarring in the immediate postoperative
period, the partial obstruction may progress to complete
obstruction.6
We believe that the partial obstruction of the ureter in the current case
was caused by placement of the culdoplasty sutures in too lateral of a
position. Placement of these sutures either lateral to, or distal on, the
uterosacral ligament will result in greater likelihood of kinking of the
ureter.
A search of the literature through the US National Library of Medicine's
MEDLINE database (using the keywords intraoperative cystoscopy,
cystoscopy, pelvic surgery, vaginal surgery, and ureter) failed
to identify any citation regarding the use of diuretics concomitantly with
intravenous dye during intraoperative cystoscopy. We found one reference to
the use of intravenous dye and diuretics in the obstetrics/gynecology
literature.3
Consequently, there is little supportive evidence to guide decision making
during intraoperative cystoscopy when both intravenous dye and diuretics are
used.
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Conclusion
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The current case leads us to discourage the use of diuretics during
intraoperative cystoscopy. In addition, we recommend careful interpretation of
results from intraoperative cystoscopy when spillage of dye is observed from
both ureteral orifices.
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References
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1. Kwon CH, Goldberg RP, Koduri S, Sand PK. The use of intraoperative
cystoscopy in major vaginal and urogynecologic surgeries. Am J
Obstet Gynecol. 2002;187:1466
-1471.[Medline]2. Jabs CF, Drutz HP. The role of intraoperative cystoscopy in
prolapse and incontinence surgery. Am J Obstet
Gynecol. 2001;185:1368
-1373.[Medline]
3. Walters MD. Ureteral obstruction after vaginal repair of advanced
prolapse. In: Walters MD, Karram MM, eds. Urogynecology and
Reconstructive Pelvic Surgery. 2nd ed. Philadelphia, Pa: Mosby
Publishing Co; 1999: 448.
4. Nichols DH. Massive eversion of the vagina. In: Nichols DH, ed.Vaginal Surgery. 4th ed.
Philadelphia, Pa: Williams
& Wilkins; 1996:366
-378.
5. Pettit PD, Petrou SP. The value of cystoscopy in major vaginal
surgery. Obstet Gynecol.1994; 84:318
-320.[Abstract/Free Full Text]
6. Steele AC, Goldwasser S, Karram M. Failure of intraoperative
cystoscopy to identify partial ureteral obstruction. Obstet
Gynecol. 2000;96:847
.[Free Full Text]
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