A ureter obstruction after modified Manchester Fothergill operation description of a rare complication
IUGA Academy. van Zon-Rabelink I. Jun 30, 2018; 212806; 486 Topic: Pelvic Organ Prolapse
Ingrid van Zon-Rabelink
Ingrid van Zon-Rabelink

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486

A ureter obstruction after modified Manchester Fothergill operation; description of a rare complication

van Zon-Rabelink, I1

1: Medisch Spectrum Twente

Objective: To share a rare complication after prolapse operation and make pelvic organ surgeons more aware of this acute developed and possibly dangerous complication.

Methods: This is a case report of a rare postoperative complication after prolapse surgery with native tissue. A 67 year old woman had a pessary for 5 years to redress her prolapse (cystocele grade 2, descending uterus grade 2, rectocele grade 1 by the quantification system of Baden-Walker). She developed vaginal bloodloss due to decubitus in posterior fornix. It was decided to have surgery to correct the prolapse with native tissue. The modified Manchester Fothergill operation was combined with an anterior and posterior colporrhaphy without a cervical amputation, because there was no elongation of the cervix. The first day after pelvic organ prolapse surgery the indwelling catheter and vaginal tampon were removed. Micturation was without residu and the patient was discharged from hospital stay on the first day after surgery.

Results: During postoperative period patient had very painful episodes located at the left side of the abdomen, without symptoms of a fever. Her laboratory results showed hematuria and leucuria > 150/ml, infection CRP 116 mg/l, leucocytosis 12.1 x 109./l, diminished kidney function: GFR 42 ml/min and serum creatine 112 mmol/l. At the 6th day postoperatively a CT scan showed hydronefrosis and a mild hydroureter on the left side. Our diffential diagnosis pointed to an acute obstruction of the left distal ureter, near the insertion of ureter to the bladder. A percutaneous nefrostomy gave good pain relief and restored the kidney function to completely normal. The placement of the nefrostomy was complicated by venous bleeding and infectious periods due to retroperitoneal abcess formation treated by antibiotics and abcess drainage. It was not possibly to pass the stenose retrograde or antegrade with a JJ stent. After 3 months a successful reimplantation of the left ureter in the bladderwall was performed. The ureter was stenotic for 2 cm on the distal part close to the bladder wall. Suture material was not found at this stenotic area. A JJ stent was placed perioperatively. The ureter obstruction was fully restored after removal of this stent 2 month after the reimplantion of the ureter.

Figure 1. Pyelogram with distal stop of left ureter postoperatively after modified Manchester Fothergill operation

Conclusions: Although the modified Manchester Fothergill operation is a very successful operation to restore pelvic organ prolapse, there are complications which are very rare. This case demonstrated a delay in the diagnosis of acute obstruction of the distal ureter probably due to kinking of the ureter by one of the proximating sutures of the sacro-uterine or cardinal ligaments.

References:

-Urologic complications from pelvic and vaginal surgery; how to diagnose and manage

2011, Washington University Department of surgery

http://urology.wustl.edu/en/Patient-Care/ReconstructiveSurgery/Urologic-Complications-from-Surgery

-The modified Manchester operation

Oral presentation and poster at ICS /IUGA annual meeting 2010 Toronto

van Zon-Rabelink I., Everhardt E., Dony J.

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Work supported by industry: no, by -.

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