Spontaneous Healing of Iatrogenic Complete Ureteric Transection Injury

Abstract

Iatrogenic ureteric injury is the most common cause of ureteric injury. It is usually caused by either gynecological or urological surgical procedures. Iatrogenic ureteric injury repair depends mainly on the time of diagnosis. We represent here a case of iatrogenic complete transection ureteric injury resulted from laparoscopic bilateral salpingo-oophorectomy. The patient had a history of abdominal hysterectomy causing adhesions that resulted in challenging surgery. One week later, the patient presented to the emergency department with abdominal pain, and contrast CT showed left hydronephrosis with extravasation of the contrast at the left renal pelvis. The patient was treated initially with left nephrostomy and an antegrade nephrostogram confirmed the diagnosis of complete transection ureteric injury. Surprisingly, left retrograde study, which was done 11 weeks after the operative injury, showed healing of the ureteric injury with a small annular stricture. The stricture was dilated and a stent was inserted. We concluded that conservative waiting and delayed ureteric repair might be advised in similar injuries allowing time for resolution of the postoperative inflammatory reaction and spontaneous healing.

Case Details

Disease Location

Ureter

Personal Characteristics

56-year-old woman. History of total abdominal hysterectomy 20 years prior for endometriosis.

Clinical Characteristics

Underwent laparoscopic bilateral salpingo-oophorectomy. In the early postoperative days, there was mild pain at the left iliac fossa, which was managed with paracetamol and oral morphine. One week later, the patient presented to the emergency department with severe left iliac fossa pain associated with nausea and vomiting. Contrast CT showed extravasation of the contrast at the level of the left renal pelvis and ureteric dilatation down to the pelvic ureter. Left ureteric iatrogenic injury was concluded, and the patient was managed initially with urgent CT-guided nephrostomy insertion. Three weeks posttraumatic injury, the patient underwent a proper antegrade nephrostogram. The contrast extravasated into the peritoneal cavity and there was no contrast passing into the distal left ureter. A diagnosis of complete transection of the ureteric injury was suspected. The nephrostomy was left in situ and the patient was planned for reconstructive surgery. Eleven weeks posttraumatic injury, the patient was admitted for her planned surgery.

Remission Characteristics

Prior to the surgery, left retrograde study was performed and surprisingly the contrast went up to the left kidney with only annular stricture at the level of the injury. Ureteroscopy showed a small annular stricture, less than 0.5 cm, that was passed easily over the safety guidewire and a ureteric stent

Treatment & Mechanisms

Proposed Remission Mechanisms

Bridging epithelial or even adventitial ureteric tissue between the edges of the defect might help the healing process

Clinical Treatment

Paracetamol, morphine, nephrostomy, ureteroscopy