Ureteral injuries associated with gynecologic surgery: prevention and management

Gynecologic surgery is responsible for most of the ureteral injuries that occur. The "easy" operation--the "simple" abdominal hysterectomy--and not the technically difficult pelvic one, is responsible for most ureteral injuries. Total abdominal hysterectomy accounts for almost 50% of the genitourinary fistulas and perhaps 80-99% of all surgical ureteral injuries. This problem will persist until a most important surgical axiom is applied routinely during the accomplishment of all pelvic operations: With all dissections, the contiguous structures subject to injury must be exposed. This step not only will avoid injuries to the ureter but also will facilitate an equally important aspect, that is, urinary tract injuries must be recognized at the time of operation. With recognition and adequate repair, problems such as fistula formation and serious morbidity (and litigation) can be avoided almost entirely. Because the gnecologic surgeon frequently will find that urologic consultation is not available at the time of urinary tract injury, he or she must be aware of and familiar with the various ureteral reconstructive procedures that may be required. The gynecologic surgeon must devote time and study to the management of urinary tract injuries before their occurrence. All pelvic surgeons eventually will encounter ureteral problems. The methods of bladder mobilization and ureteroneocystostomy should be within the ability of all who operate within the pelvis. When extensive damage has occurred and a urologist is not available, the gynecologist who is unfamiliar with the more demanding techniques (that is, ureteroureterostomy, bladder flaps, ileal conduits) should avoid additonal damage to the urinary tract and accomplish a simple catheter ureterostomy, deffering the definitive repair for a urologist.     

Assignment1 of human putative tumor suppressor genes ST13 (alias SNC6) and ST14 (alias SNC19) to human chromosome bands 22q13 and 11q24-->q25 by in situ hybridization

OBJECTIVE: Our aim was to describe the indications of repeat caesarean delivery and to determine modifiable practice patterns that might lead to fewer repeat caesarean deliveries. METHOD: Hospital records of all women with previous caesarean sections who delivered between 15 April, 1994-31 December, 1994 at the Princess Badeea Teaching Hospital in North Jordan were reviewed. Three groups were identified: 1) elective repeat caesarean 2) vaginal birth after caesarean 3) failed vaginal birth after caesarean. RESULTS: In this study there were 388 patients. Of these, 208 had a repeat caesarean delivery for the following reasons: failed vaginal birth after caesarean (39, 10.1%) and repeat elective caesarean section (169, 43.5%). The remaining (180, 46.4%) patients had a vaginal birth after caesarean. CONCLUSIONS: Our vaginal birth rate after one previous caesarean section was 82.2%. If this rate can be maintained in patients with 2 or 3 previous caesarean deliveries, we can reduce repeat caesarean rates by at least 14% by allowing more patients with 2 or even 3 previous caesarean deliveries to have a trial of labour under appropriate conditions and also proper management of dystocia.     

Primary non-Hodgkin lymphoma of the ovary

The aim of this study was to investigate the incidence of operative injury to the lower urinary tract after retropubic urethropexy. We prospectively evaluated the incidence of lower urinary tract injury in 97 consecutive patients after pelvic surgery, which included primary Burch retropubic urethropexy. None of the subjects sustained intraoperative injury of the bladder or ureters as evidenced by an intact bladder mucosa and prompt efflux of dye from both ureteral orifices. In our experience, the incidence of lower urinary tract injury with retropubic urethropexy is low. We do not support the routine use of intraoperative cystoscopy with Burch retropubic urethropexy.     

Xenon-133 resorption in urinary bladder: functional diagnosis of bladder epithelium

The examination of resorption from the urinary bladder had previously been restricted almost exclusively to animal research, since, as a rule, a separation of the bladder from the urinary tract is required. If this is not done, the resorbed test substance quickly finds its way back into the bladder. More than 95 per cent of the xenon which has been resorbed from the bladder becomes eliminated through the lungs. The detection and measurement of xenon in the exhaled air enables one to conduct, in a relatively simple fashion, urinary bladder resorption research using human subjects. Studies based on 141 patients showed that the xenon exhalation tests currently represent the most sensitive and exact method for detecting and determining the nature of inflammatory diseases of the urinary bladder. With a number of so-called "irritable bladder" cases it became clear that functional disorders of the bladder epithelium could be present without any evidence of associated morphologic changes. With radiogenic treatment of tumors in the lower pelvic region one experiences an increase in bladder resorption with increased exposure to radiation. There exists, as it were, a linear correlation between the radiation dosage and the degree of resorption from the urinary bladder. Three months after terminating radiotherapy one can detect, as a rule, only a negligible increase in resorption. If at this time the rate of xenon resorption still remains clearly high, one must reckon with permanent radiation damage of the bladder, insofar as it proves unsuccessful to eliminate the cause of cystitis.     

Foreign bodies of the bladder and urethra. Apropos of 2 cases

The bladder and urethra can be the site of various types of foreign bodies. The authors report two cases of low urinary tract foreign bodies. The first case concerned a young man with psychiatric disorders who introduced a condom into his bladder and the second case was an elderly patient with a history of self-dilation who introduced a safety pin into his urethra. In the light of these two cases, the authors review the diagnostic features and management of bladder and urethral foreign bodies.     

The utilization of a paediatric emergency room in a general hospital in Kuwait

The objective of the study was to describe the ultrasonographic findings of urinary bladder urolithiasis and to determine the diagnostic value of the technique in feline lower urinary tract diseases (LUTD). Physical examination of the urinary system and routine clinicopathological analysis of the blood and urine were performed on 32 cats presented with clinical symptoms of LUTD. Cystosonography was done on all of the cats, while plain radiography was performed on 8 and double contrast cystography on 2 cats. Sonography of the bladder provided the following diagnoses: urolithiasis and chronic cystitis: 24 cases, chronic cystitis without urolithiasis: 4 cases, bladder neoplasm: 1 case, negative sonographic finding: 3 cases. Bladder calculi and/or plugs were diagnosed easily, up to a size of 2 mm, according to acoustic shadowing and/or reverberation and gravitation. When the bladder was empty, it was filled up with physiologic saline solution to visualise its contents more easily. Sonography proved to be a useful technique for diagnosing urinary bladder calculi and/or plugs even when they were radiolucent and for distinguishing among the different causes of LUTD. Although ultrasonography is a valuable diagnostic tool, radiography is still necessary to explore lower urinary tract diseases, especially when cystosonography provides negative results or urethral obstruction is suspected.     

A case of ureteral tuberculosis appearing as a ureteral tumor

A 53-year-old female was admitted to our hospital after right hydronephrosis was found on the CT scan taken at another hospital. The urinary cytology and culture findings as well as the urinary culture for acid-fast bacilli results were all negative. At our hospital, CT scan revealed a thickening of the right ureteral wall, and right hydronephrosis. In spite of the fact that retrograde pyeloureterography showed a right ureteric obstruction at the ureterovesical junction, cystoscopic examination demonstrated a normal bladder. Since right lower tract carcinoma was suggested, we performed right nephroureterectomy with bladder cuff. Histopathological diagnosis, however, revealed renal and ureteral tuberculosis.     

Coagulation and fibrinolysis after moderate and very heavy exercise in healthy male subjects

OBJECTIVES To correlate renal function with the site of the ectopic orifice in patients with a single ectopic ureter and to evaluate the role of ureteric reimplantation in the preservation of renal function. PATIENTS AND METHODS: Forty-four patients (41 female, age 1.5 months to 20 years) with a single ectopic ureter have been managed in our institution in the last 21 years. The classical symptom of continuous wetting with intermittent normal micturition was reported in most of the female patients. The investigative evaluation included intravenous urography (i.v.U), cysto-urethroscopy, vaginoscopy with retrograde ureteric catheterization, micturating cysto-urethrography (MCU) and ultrasonography. Diuretic renography was carried out in four patients after it became available in 1992. Renal function was assessed in relation to urinary tract anomalies and with outcome after ureteric re-implantation. RESULTS: Thirty-eight patients (two males) had a unilateral ectopic ureter; the ectopic orifice was vaginal in 12, vestibular in 11, urethral in nine, at the bladder neck in two, the seminal vesicle in one and undetermined in three. Twenty-one patients had renal and/or ureteric abnormalities, with reflux detected on MCU in three ureters. Associated anomalies included hypospadias (two, one female), skeletal anomalies (two), anorectal malformations (three), cryptorchidism (two), and unilateral cystic ovary (one). Two patients had preoperative hypertension. In 15 patients, renal function was considered sufficient to justify ureteric reimplantation, 14 of whom regained continence. One girl had suprapubic leakage from the bladder and died during secondary nephroureterectomy. Another girl had persistent incontinence; she was found to have contralateral duplex ureters with a vestibular ectopic orifice and was cured after upper polar heminephroureterectomy. i.v.U and renography carried out in two patients each within 4 weeks of surgery showed a moderate improvement in renal function. Eight patients reported for follow-up after ureteric reimplantation (mean duration 11 months); none had hypertension or urinary infection. Twenty-three patients with rudimentary kidneys underwent nephroureterectomy. Histopathological examination of the excised kidneys showed moderate to severe dysplasia with chronic pyelonephritis. Six patients (one male) had bilateral single ectopic ureters, with normal renal function in the five females. Unilateral reimplantation in the boy resolved the symptoms; one girl died before surgery and the other four underwent bilateral ureteric reimplantation, after which one was dry for up to 3 h while the other three were incontinent, one of whom subsequently underwent urinary diversion. CONCLUSIONS: There was no clear correlation of renal function with the site of the ectopic ureteric orifice, as most of the patients with a vaginal ectopic ureter had sufficient renal function to justify renal preservation. Ureteric reimplantation preserved renal function, although the improvement after surgery was determined by the degree of renal dysplasia.     

Transitional cell carcinoma of the distal portion of ureter protruding into the sigmoid conduit six years after cystoprostatectomy

Bladder tumors develop after the diagnosis of upper urinary tract carcinoma in approximately 20% of cases, whereas the incidence of upper urinary tract tumor after the diagnosis of bladder cancer is low, approximately 2%. In a 64-year-old man who had undergone cystoprostatectomy treatment of bladder carcinoma 6 years previously, with the sigmoid conduit used for supravesicle diversion, a transitional cell carcinoma that developed in the conduit was not revealed with intravenous pyelography at regular follow-up intervals. The patient had only hematuria. After an obstructed left kidney, left ureteral stricture, and a filling defect in the conduit were observed radiologically and biopsy revealed a transitional cell carcinoma at the ureterosigmoid junction, the patient underwent left nephroureterectomy, partial resection of a third of the sigmoid conduit, and right ureteral reimplantation. The occurrence of upper urinary tract carcinoma after treatment of bladder cancer should be considered even in light of intravenous pyelography that shows no abnormality; and when such carcinomas occur in this situation, disease involving the conduit should be ruled out.     

Effects of liposteroid on skin lesions in autoimmune MRLlpr/lpr mice

Urine leakage from the umbilicus was observed while expressing urine by the Crede manoeuvre in a three-year-old tetraplegic girl with a chronically distended urinary bladder. Intravenous urography (IVU) revealed bilateral hydroureteronephrosis with markedly distended urinary bladder. Regular three hourly intermittent catheterization was advised, and the parents and carers of this child agreed to perform catheterization. There was cessation of urine leak within 48 hours of urethral drainage. Cystography performed two weeks later showed no vesicoureteric reflux; vesicoumbilical fistula was no longer demonstrable. Follow-up IVU, performed after eight and half months of regular intermittent catheterization, showed regression of hydroureteronephrosis. We believe that urine leakage from the umbilicus served two important protective functions in this child, viz. (1) it prevented possible vesical or renal rupture; (2) the striking clinical symptom of urine leak from the umbilicus focussed the attention of the carers to the underlying serious condition of the urinary tract. Further, this case demonstrates that regression of marked hydroureteronephrosis can be achieved by intermittent catheterization performed at regular intervals by devoted parents/carers, in selected cases of spinal cord injury with neuropathic bladder, and vesical outlet obstruction, thus obviating the need for any form of temporary or permanent urinary diversion.     

The use of a multipurpose stent in children

OBJECTIVES: To assess the use of a multipurpose stent (the 'Blue stent', Angiomed Urosoft Pyeloplasty Stent, Bard, UK) in children undergoing pyeloplasty and ureteric reimplantation. PATIENTS AND METHODS: Between August 1994 and August 1996, the Blue stent was used in 50 renal units in 46 children aged 2 months to 12 years and 6 months. Twenty-five children underwent pyeloplasty, 11 had ureteric reimplantation for vesico-ureteric reflux (VUR), eight had ureteric reimplantation with remodelling for obstructed megaureters and in two patients it was used during the removal of stones. The mean follow-up was 18 months (range 6-30 months). RESULTS: After pyeloplasty, 22 patients (88%) had improved renal function and drainage with a decrease in hydronephrosis; two patients had a decrease in hydronephrosis only, one had an anastomotic leak and needed a repeat pyeloplasty and four developed a urinary tract infection (UTI). After ureteric reimplantation, VUR was not detected in any patient. Two patients had no change in drainage after remodelling and reimplantation of a megaureter, one was later diagnosed as having a neuropathic bladder and one child developed a UTI after ureteric reimplantation. The hospital stay was 3 days after pyeloplasty and 5 days after reimplantation. CONCLUSION: The design of the multipurpose Blue stent provides versatility; it can be used as a stent, and both an internal and external drain. Its use does not prolong the hospital stay. Insertion causes minimal trauma to the renal parenchyma, and removal is easy, pain-free and requires no anaesthesia. The complication rates in the present series compare favourably with other reported series.     

NONMEM analysis in determining the tri-exponential disposition of cefotaxime: a method of evaluating serum and urinary phase I data

Good experience with clam cystoplasty is reported for 28 patients (14 female), 89% of whom had a neuropathic bladder. Prolonged conservative treatment had failed in all cases. The efficacy of the operation in terms of continence, increased bladder compliance, and bladder capacity was confirmed. Complications were common and included inability to void (70%) requiring clean intermittent catheterisation (CIC), recurrent urinary tract infection (59%) and stone formation (22%). Due to these complications, further surgery was required for 44% of the patients. Although clam enterocystoplasty is an efficient way to reconstruct a functionally disturbed urinary tract, careful patient selection is essential. Lifetime follow-up and recognition of the most frequent complications is mandatory.     

Three cases of the nephrogenic adenoma of the bladder

Nephrogenic adenoma is a rare, benign tumor of the urinary tract. The origin of this tumor is supposed to be a metaplastic transformation of urothelium in response to stimulation such as recurrent urinary tract infections or surgical trauma. We experienced three cases of nephrogenic adenoma originating in the bladder. The first patient was a 29-year-old man with right vesicoureteral reflux (VUR). When Teflon injection for VUR was performed, a papillary tumor was found on the right wall of the bladder. Transurethral resection of the bladder tumor (TUR-Bt) was performed. The second patient was a 72-year-old woman who was suffering from chronic cystitis. Although she was treated with antibiotics for one year, the symptoms were not improved. Cystoscopy showed multiple papillary tumors at the retrotrigonum of the bladder and TUR-Bt was performed. The third patient was a 75-year-old man who had a history of the left pelvic and bilateral ureteral tumors. Left radical nephroureterectomy and right radical ureterectomy with an ileal graft replacement was performed. Three years later, cystoscopy demonstrated a papillary tumor at the retrotrigonum, which was resected transurethrally. Our cases are the 20th to 22nd cases of the nephrogenic adenoma of the bladder reported in the Japanese literature.     

Diagnosis of urinary tract infections in puerperium

Urinary tract infections (UTI) are the most frequent nosocomial infections of women during puerperium. Since, in these women, diagnostic accuracy is affected by lochial secretion, suprapubic urinary bladder puncture (SPB) is recommended. Between December 1989 and January 1993, we subjected 903 women to suprapubic urinary bladder puncture (SpBP) at the 4th or 5th day after delivery. A urine culture of SpBP was done in all cases. Semiquantitative leukocyte counts (n = 891) and nitrite test (n = 830) were done on mid-stream urine (MSU). Side by side with microbiological investigation for urinary tract pathogens via SpPB, MSU was performed in 246 cases immediately after SpPB had been carried out. Leukocyte counts were also estimated in SpBP urine samples. In 370 (41.1%) of 903 SpBP, one or more microorganisms were cultivated. Only 36 (4.0%) of 903 women showed UTI symptoms. Microorganisms were detectable via SpBP in only 26 (72.7%) of these 36 symptomatic patients. Vaginal-operative or secondary caesarean section are related to an increased UTI rate (p < 0.001). UTI were also significantly (p < 0.0001) more frequent in women subjected to catheterisation sub partu (54.5%) compared to no catheterism (24.4%). No significant differences between the number of leukocytes in MSU sediment and the SpBP findings were seen. Semiquantitative leukocyte counts in SpBP offered a significantly (p < 0.001) increased number of leukocytes in cases with microorganism detection in SpBP irrespective of MSU findings. These results justify the designation of uterine tract infection also in the absence of complaints as "infection" and not common "bacteriuria".(ABSTRACT TRUNCATED AT 250 WORDS)     

Urinary tract cancer and isoniazid

A case control study was conducted in Washington County, Md. to assess the possibility that isoniazid might be associated with the production of malignant neoplasms of the urinary tract. One hundred and forty-two cases of bladder cancer and 48 cases of renal cancer were found in the follow-up of a 1963 census population. Each case was matched to two other persons of the same race, sex, and age enumerated in the census. The tuberculosos register for the county was searched to see whether any case or control subject had ever received isoniazid. Two members of the entire study group had a record of isoniazid administration; both were control subjects. No evidence was found to associate isoniazid with cancers of the urinary tract.     

Bacillus Calmette-Guérin perfusion therapy for carcinoma in situ of the upper urinary tract

OBJECTIVE: To analyse the clinical and therapeutic consequences of bacillus Calmette-Guérin (BCG) perfusion therapy for carcinoma in situ (CIS) of the upper urinary tract. PATIENTS AND METHODS: Eight pyelo-ureteric systems in five patients with cytologically confirmed CIS of the upper urinary tract were treated using perfusion of BCG through a percutaneous nephrostomy tube in five and a retrograde ureteric catheter in three. Follow-up cystoscopy, retrograde pyelography and selective urinary cytology were obtained 4 weeks after the last treatment and every 3 months thereafter. RESULTS: In three patients (five pyelo-ureteric systems) the cytology remained negative for 10-46 months after the treatment was completed. The remaining two patients (three pyelo-ureteric systems) had persistently positive cytology. Of two patients who received BCG therapy through a ureteric catheter, one developed a ureteric stricture and the other developed renal tuberculosis. CONCLUSIONS: Although long-term adaptation to a nephrostomy tube disturbs the quality of life of the patient, percutaneous perfusion therapy through a nephrostomy tube seems to be safer than retrograde perfusion through a ureteric catheter.     

Conservative treatment of a vesicocervical fistula resulting from Shirodkar cervical cerclage

A case of a vesicocervical fistula caused by Shirodkar cervical cerclage and presenting as total urinary incontinence is reported. The patient was managed conservatively by bladder drainage alone with complete resolution of the fistulous tract. This rare complication is avoidable if the bladder is adequately dissected from the cervix during placement of the cerclage suture.     

Ectopic prostatic tissue outside the urinary tract: a case report

A 64-year-old man with a 4-month history of dysuria and urinary frequency had a mass behind the bladder. The preoperative diagnosis was a tumor of the left seminal vesicle, but a histologic examination revealed benign prostatic tissue. This is the seventh reported case of ectopic prostatic tissue situated outside the urinary tract.     

Project management, Part II

OBJECTIVE: Our purpose was to determine the relationship between previous caesarean section and subsequent development of placenta praevia and placenta praevia with accreta. METHOD: A retrospective review of the case records of all women delivered with the diagnosis of placenta praevia during the 2-year period from January 1, 1995, to December 31, 1996, at the tertiary referral centre, Princess Badeea Teaching Hospital, in north Jordan. RESULTS: There were 18, 651 deliveries in the study period. 65 (0.35%) had placenta praevia, 21 (32.3%) of whom had a history of previous caesarean section. The incidence of placenta praevia was significantly increased in those with a previous caesarean section (1.87%) compared with those with an unscarred uterus (0.25%); p < 0.0001). This risk increased as the number of previous caesarean sections increased: 1.78% for one previous section; 2.4% for two, and 2.8% for three or more. The incidence of anterior placenta praevia and placenta accreta was significantly increased in those with previous caesarean scars. In the group without antecedent of caesarean section, accretism risk was 9%, with one section or more 40.8% (p < 0.005). CONCLUSION: There is a high association between anterior placenta praevia, placenta accreta and previous caesarean section. This was enhanced with the increasing number of previous caesarean sections. Patients with an antepartum diagnosis of placenta praevia who have had a previous caesarean section should be considered at high risk of developing placenta praevia and accreta.     

Isolated bladder rupture after minor trauma in a patient with alcohol intoxication

We report the case of an intoxicated male patient who presented with an isolated intraperitoneal urinary bladder rupture, with a history of minor trauma. A review of the literature reveals that isolated bladder rupture after minimal or no trauma in association with alcohol or drug ingestion is an infrequently reported, but recognized, injury. The diagnosis of bladder rupture should be considered in an intoxicated patient with lower abdominal pain, even without a history of trauma. A history of voiding or bladder dysfunction should increase the suspicion for this injury. If suspected, a retrograde cystogram should be obtained promptly. Failure to consider and recognize this injury may lead to significant morbidity.