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A trial placement of a prophylactic ureteral catheter during the excision of a huge pelvic mass with incidental cystotomy.

Warda H - Cent European J Urol (2013)

Bottom Line: They are serious, troublesome, often associated with significant morbidity, and are one of the most common causes for legal action against gynecologic surgeons.We present a case of a 48 year old obese Caucasian female with no significant past medical history who came in with back pain and progressive abdominal swelling for the past three months and was found to have a very large pelvic mass.Patient had an incidental cystotomy during the procedure, which was repaired intra-operatively.

View Article: PubMed Central - PubMed

Affiliation: Department of Obstetrics and Gynecology, Hurley Medical Center, Flint, Michigan, United States.

ABSTRACT
Ureteral injuries are one of the major complications following gynecologic surgeries. They are serious, troublesome, often associated with significant morbidity, and are one of the most common causes for legal action against gynecologic surgeons. The reported rates of injury depend on the vigilance of diagnosis, type of surgery and other risk factors. We present a case of a 48 year old obese Caucasian female with no significant past medical history who came in with back pain and progressive abdominal swelling for the past three months and was found to have a very large pelvic mass. After preoperative evaluation, including: medical history, physical exam, and imaging studies showing a heterogenous mass 24.6 x 33.0 x 43.1, we predicted that the risk of urinary tract injuries was very high. We used preoperative prophylactic bilateral ureteral catheters to prevent injury. A surgical oncologist was consulted and an exploratory laparotomy was performed with removal of the large multi-lobulated pelvic mass + total abdominal hysterectomy, bilateral salpingo-oophorectomy, and appendectomy all performed at the same time. Patient had an incidental cystotomy during the procedure, which was repaired intra-operatively. The ureters remained intact with no injuries. The importance of thorough preoperative identification, evaluation and anticipation of ureteral injuries will be discussed in detail.

No MeSH data available.


Related in: MedlinePlus

Showing inability to access the retroperitoneal space without careful dissection.
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Figure 0003: Showing inability to access the retroperitoneal space without careful dissection.

Mentions: A surgical oncologist was consulted and an exploratory laparotomy with excision of pelvic mass was ordered. Intraoperatively, a urologist was consulted for the bilateral placement of ureteral catheters. The urologist inserted a French #21 scope into the bladder that showed a normal bladder mucosa as it entered the bladder. The bladder examination showed a highly elevated base of the bladder secondary to the retroperitoneal mass. We were able to see the right ureteral orifice and able to insert a right ureteral catheter all the way to about 25 cm. However, we were not able to insert the catheter into the left side because we were not able to see the orifice. During exploration with the oncologist we had to explore the bladder because the huge mass was occupying the whole abdomen and the retroperitoneal space. (Figures 2, 3). After gradual dissection (Figure 4) we were able to find the right ureter with the aid of the ureteric catheter. With a lot of difficulty we were able to find the left ureter. It was kinked and pushed up into the mid pelvic area and attached to the pelvic mass. We were able to separate the ureter away from the mass and able to trace it down to the bladder area. The bladder was highly elevated secondary to the pelvic mass. Finally we were able to separate the bladder and remove the large multi–lobulated pelvic mass + total abdominal hysterectomy, bilateral salpingo–oophorectomy, and appendectomy performed at the same time (Figure 5). We instilled indigo blue into the bladder; found there was an incision on the bladder dome area and we were able to find the edge of the defect. The mucosa was then sutured with 3–0 chromic and the muscle was closed with 3–0 Vicryl. The seromuscular area was closed with 3–0 Vicryl in an interrupted fashion. We repeated a cystoscopy again and were able to find the left ureteral orifice and insert a catheter into the left side. A Foley catheter size French #18 was placed and secured. Ureteral catheters were kept for two days and the Foley catheter was kept for two weeks. The mass came back to be a 9 kg plexiform leiomyoma (49 x 48 cm) with edema, hyaline, and cystic degeneration. The patient had an uneventful postoperative course and was sent home on the fourth postoperative day.


A trial placement of a prophylactic ureteral catheter during the excision of a huge pelvic mass with incidental cystotomy.

Warda H - Cent European J Urol (2013)

Showing inability to access the retroperitoneal space without careful dissection.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3974465&req=5

Figure 0003: Showing inability to access the retroperitoneal space without careful dissection.
Mentions: A surgical oncologist was consulted and an exploratory laparotomy with excision of pelvic mass was ordered. Intraoperatively, a urologist was consulted for the bilateral placement of ureteral catheters. The urologist inserted a French #21 scope into the bladder that showed a normal bladder mucosa as it entered the bladder. The bladder examination showed a highly elevated base of the bladder secondary to the retroperitoneal mass. We were able to see the right ureteral orifice and able to insert a right ureteral catheter all the way to about 25 cm. However, we were not able to insert the catheter into the left side because we were not able to see the orifice. During exploration with the oncologist we had to explore the bladder because the huge mass was occupying the whole abdomen and the retroperitoneal space. (Figures 2, 3). After gradual dissection (Figure 4) we were able to find the right ureter with the aid of the ureteric catheter. With a lot of difficulty we were able to find the left ureter. It was kinked and pushed up into the mid pelvic area and attached to the pelvic mass. We were able to separate the ureter away from the mass and able to trace it down to the bladder area. The bladder was highly elevated secondary to the pelvic mass. Finally we were able to separate the bladder and remove the large multi–lobulated pelvic mass + total abdominal hysterectomy, bilateral salpingo–oophorectomy, and appendectomy performed at the same time (Figure 5). We instilled indigo blue into the bladder; found there was an incision on the bladder dome area and we were able to find the edge of the defect. The mucosa was then sutured with 3–0 chromic and the muscle was closed with 3–0 Vicryl. The seromuscular area was closed with 3–0 Vicryl in an interrupted fashion. We repeated a cystoscopy again and were able to find the left ureteral orifice and insert a catheter into the left side. A Foley catheter size French #18 was placed and secured. Ureteral catheters were kept for two days and the Foley catheter was kept for two weeks. The mass came back to be a 9 kg plexiform leiomyoma (49 x 48 cm) with edema, hyaline, and cystic degeneration. The patient had an uneventful postoperative course and was sent home on the fourth postoperative day.

Bottom Line: They are serious, troublesome, often associated with significant morbidity, and are one of the most common causes for legal action against gynecologic surgeons.We present a case of a 48 year old obese Caucasian female with no significant past medical history who came in with back pain and progressive abdominal swelling for the past three months and was found to have a very large pelvic mass.Patient had an incidental cystotomy during the procedure, which was repaired intra-operatively.

View Article: PubMed Central - PubMed

Affiliation: Department of Obstetrics and Gynecology, Hurley Medical Center, Flint, Michigan, United States.

ABSTRACT
Ureteral injuries are one of the major complications following gynecologic surgeries. They are serious, troublesome, often associated with significant morbidity, and are one of the most common causes for legal action against gynecologic surgeons. The reported rates of injury depend on the vigilance of diagnosis, type of surgery and other risk factors. We present a case of a 48 year old obese Caucasian female with no significant past medical history who came in with back pain and progressive abdominal swelling for the past three months and was found to have a very large pelvic mass. After preoperative evaluation, including: medical history, physical exam, and imaging studies showing a heterogenous mass 24.6 x 33.0 x 43.1, we predicted that the risk of urinary tract injuries was very high. We used preoperative prophylactic bilateral ureteral catheters to prevent injury. A surgical oncologist was consulted and an exploratory laparotomy was performed with removal of the large multi-lobulated pelvic mass + total abdominal hysterectomy, bilateral salpingo-oophorectomy, and appendectomy all performed at the same time. Patient had an incidental cystotomy during the procedure, which was repaired intra-operatively. The ureters remained intact with no injuries. The importance of thorough preoperative identification, evaluation and anticipation of ureteral injuries will be discussed in detail.

No MeSH data available.


Related in: MedlinePlus