assess the size of the cervical varices. In conclusion, we propose that in the setting of cervical varices and other risk factors for postprocedure hemorrhage, prophylactic uterine artery embolization can be considered before second-trimester dilation and evacuation.
7. Yoshimura K, Hirsch E, Kitano R, Kashimura M. Cervical varix accompanied by placenta previa in twin pregnancy. J Obstet Gynaecol Res 2004;30:323–5. 8. Kumazawa Y, Shimizu D, Hosoya N, Hirano H, Ishiyama K, Tanaka T. Cervical varix with placenta previa totalis. J Obstet Gynaecol Res 2007;33:536–8. 9. Follen MM, Fox HE, Levine RU. Cervical vascular malformation as a cause of antepartum and intrapartum bleeding in three diethylstilbestrol-exposed progeny. Am J Obstet Gynecol 1985;153:890–1.
REFERENCES 1. Dindelli M, Parazzini F, Basellini A, Rabaiotti E, Corsi G, Ferrari A. Risk factors for varicose disease before and during pregnancy. Angiology 1993;44:361–7. 2. Evans CJ, Allan PL, Lee AJ, Bradbury AW, Ruckley CV, Fowkes FG. Prevalence of venous reflux in the general population on duplex scanning: the Edinburgh vein study. J Vasc Surg 1998;28:767–76.
10. Fleming AD, Anderson TL. Cervical AV malformation with in utero DES exposure. Nebr Med J 1993;78:138–9. 11. Gizzo S, Saccardi C, Patrelli TS, Di Gangi S, Breda E, Fagherazzi S, et al. Fertility rate and subsequent pregnancy outcomes after conservative surgical techniques in postpartum hemorrhage: 15 years of literature. Fertil Steril 2013;99:2097–107.
3. Hurton T, Morrill H, Mascola M, York C, Bromley B. Cervical varices: an unusual etiology for third-trimester bleeding. J Clin Ultrasound 1998;26:317–9.
12. Pron G, Mocarski E, Bennett J, Vilos G, Common A, Vanderburgh L, et al. Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial. Obstet Gynecol 2005;105:67–76.
4. Kusanovic JP, Soto E, Espinoza J, Stites S, Goncalves LF, Santolaya J, et al. Cervical varix as a cause of vaginal bleeding during pregnancy: prenatal diagnosis by color Doppler ultrasonography. J Ultrasound Med 2006;25:545–9.
13. Borgatta L, Chen AY, Reid SK, Stubblefield PG, Christensen DD, Rashbaum WK. Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion. Am J Obstet Gynecol 2001;185:530–6.
5. Sammour RN, Gonen R, Ohel G, Leibovitz Z. Cervical varices complicated by thrombosis in pregnancy. Ultrasound Obstet Gynecol 2011;37:614–6.
14. Steinauer JE, Diedrich JT, Wilson MW, Darney PD, Vargas JE, Drey EA. Uterine artery embolization in postabortion hemorrhage. Obstet Gynecol 2008;111:881–9.
6. Sukur YE, Yalcin I, Kahraman K, Soylemez F. Cervical varix complicating marginal placenta previa: a unique coexistence. J Obstet Gynaecol Res 2011;37:1515–7.
15. Haddad L, Delli-Bovi L. Uterine artery embolization to treat hemorrhage following second-trimester abortion by dilatation and surgical evacuation. Contraception 2009;79:452–5.
Ureteral Transection Due to Intraperitoneal Course of Ureter After Pediatric Ureteral Reimplantation
Two fibrous bands attached a segment of small bowel to the abdominal wall. One band was transected and ligated. Postoperative suspicion that the bands represented ureter prompted computed tomography imaging, showing high-grade ureteral obstruction. Retrograde pyelogram revealed urinary extravasation and no continuity with the ureter. Reoperation with ureteroneocystotomy confirmed the bands were ureter coursing through bowel, consistent with injury during ureteral reimplantation.
Jessica M.B. Ritch, MD, and Nicole L. Heidemann,
MD
BACKGROUND: Traditional pediatric ureteral reimplantation involved blindly passing a clamp behind the bladder to guide the ureter into a new hiatal opening, potentially resulting in an intraperitoneal ureter.
CONCLUSION: Review of previous surgeries, a high index of suspicion, and prompt urologic consultation are recommended to identify and repair ureter injuries in abnormal anatomy cases.
CASE: A 44-year-old woman with previous ureteral reimplantation underwent gynecologic laparoscopy.
(Obstet Gynecol 2014;123:462–5)
From the Baptist Hospital, Nashville, Tennessee. Corresponding author: Jessica M.B. Ritch, Center for Pelvic Health, 4601 Carothers Parkway, Suite 350, Franklin, TN 37067; e-mail: ritch.jessica@ gmail.com. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
462
Ritch and Heidemann
Injury of Intraperitoneal Ureter
DOI: 10.1097/AOG.0b013e3182a9cab6
H
istorically, the most common surgical treatment of pediatric vesicoureteral reflux had been the Politano-Leadbetter technique of ureteral reimplantation, which involved blind creation of a new ureteral hiatus. A right-angle clamp was passed from the original hiatus behind the bladder, puncturing the posterior wall of the bladder to create a new hiatal opening. A second right-angle clamp followed the path of the first in reverse, through the new hiatus, out behind the
OBSTETRICS & GYNECOLOGY
Fig. 1. Fibrous band attaching the small bowel to peritoneum of anterior abdominal wall near the bladder. Ritch. Injury of Intraperitoneal Ureter. Obstet Gynecol 2014.
Fig. 3. Fibrous band originating from left pelvic sidewall and extending to small bowel.
bladder and into the original hiatus, grasping the ureter, and pulling it along this path into the new hiatus. This blind maneuver is discouraged in contemporary urology because of significant complications, including routing of the ureter intraperitoneally and a 0.5% rate of damage to the bowel and other structures.1,2 The purpose of this case is to present a ureteral injury during gynecologic laparoscopy attributable to abnormal anatomy in a patient with previous pediatric ureteral reimplantation. Awareness of potential abnormal anatomy, rapid identification of the injury, and prompt urologic consultation led to a quick and uncomplicated resolution.
Ritch. Injury of Intraperitoneal Ureter. Obstet Gynecol 2014.
CASE A 44-year-old woman with a surgical history of ureteral reimplantation at age 4 years for vesicoureteral reflux underwent diagnostic hysteroscopy, endometrial ablation, diagnostic laparoscopy with lysis of adhesions, and excision of endometriosis for pelvic pain, dysfunctional uterine bleeding, and suspected endometriosis.
On diagnostic laparoscopy, endometrial implants and dense adhesions were noted throughout the pelvis. The left ovary was densely adhered to the left pelvic sidewall with an endometrioma extending retroperitoneally. The ureters were visualized with peristalsis in the pelvic sidewalls bilaterally, and this was confirmed with intraoperative consult. The left ureter appeared to be running retroperitoneally under the left ovary. Because of confidence with visualization of the ureters, ureterolysis was not performed. A fibrous band that appeared to be a dense adhesion was noted between the small bowel and the left pelvic sidewall, coursing over the infundibulopelvic ligament at the pelvic brim. A second fibrous band attached from the same section of small bowel to the peritoneum of the anterior abdominal wall near the bladder (Fig. 1). There appeared to be a well-defined plane between the anterior adhesion and the small bowel; therefore, the adhesion was transected at the level of the peritoneum. Suspicion of scant serous fluid arising from the central
Fig. 2. Transected and ligated fibrous band protruding from small bowel, previously attached to anterior abdominal wall.
Fig. 4. Computed tomographic image showing left hydronephrosis. Arrow indicates dilated renal pelvis.
Ritch. Injury of Intraperitoneal Ureter. Obstet Gynecol 2014.
Ritch. Injury of Intraperitoneal Ureter. Obstet Gynecol 2014.
VOL. 123, NO. 2 PART 2, FEBRUARY 2014
Ritch and Heidemann
Injury of Intraperitoneal Ureter
463
Fig. 5. Computed tomographic image showing dilated left ureter to level of pelvic brim consistent with high-grade left ureteral obstruction with presumed ligation of the ureter. Arrow indicates dilated ureter. Ritch. Injury of Intraperitoneal Ureter. Obstet Gynecol 2014.
portion of the base of the adhesion led to intraoperative surgical consult and the determination the tissue may represent a deep Meckel diverticulum. As a precaution, the base was ligated with two Endoloops and the abdomen and pelvis were copiously irrigated (Fig. 2). Attention was then turned to the fibrotic band originating from the left pelvic sidewall. The peritoneum surrounding the suspected adhesion was skeletonized to reveal a tubular-appearing structure leading directly into the small bowel (Fig. 3). This structure was left in place. The left ovary was carefully dissected from the pelvic sidewall and the endometrioma was excised. The procedure concluded with careful excision and fulgeration of multiple endometriosis implants. Postoperative review of the case images raised concern that the fibrous bands were an aberrantly coursing intraperitoneal left ureter. Therefore, the patient was admitted for observation and further evaluation. Computed tomography imaging with contrast on postoperative day 1 showed moderate to severe left hydronephrosis (Fig. 4) and dilation of the left ureter to the level of the left adnexa, at which point the ureter appeared to blend into a loop of small bowel (Fig. 5). A focus of hyperdensity at the distal end of the ureter was thought to potentially represent suture material. These findings were consistent with acute high-grade left ureteral obstruction and presumed ligation of the ureter. The patient’s creatinine increased from 0.7 to 1.3. The urology department was consulted.
464
Ritch and Heidemann
Injury of Intraperitoneal Ureter
Fig. 6. Fluoroscopy image taken at the time of percutaneous nephrostomy tube placement shows dilated ureter, which appears to end near a loop of small bowel. Arrow indicates point of obstruction of ureter. Ritch. Injury of Intraperitoneal Ureter. Obstet Gynecol 2014.
The patient underwent cystoscopy and left retrograde pyelogram, which demonstrated urinary extravasation from the distal left ureter into the pelvis and no continuity with the proximal segment of the left ureter. A percutaneous nephrostomy tube was placed to relieve the severe hydroureteronephrosis (Fig. 6). The patient underwent exploratory laparotomy with urology. The previously noted thick fibrous band adhered to a loop of small bowel to the pelvic sidewall was identified. Frozen-section pathology of a portion of this fibrous band confirmed the tissue to be ureter. At that point, it was determined that the ureter coursed directly through the center of the small bowel. This was consistent with a remote through-and-through injury of the small bowel during childhood ureteral reimplantation. The ureteral stumps emanating from the bowel were oversewn. There was no evidence of compromise to the integrity of the small bowel. The left ureter was dissected from the retroperitoneum, the bladder was mobilized, and
OBSTETRICS & GYNECOLOGY
ureteroneocystotomy was performed without tension. A double-J ureteral stent was left in place for 3 weeks. The patient’s recovery was uncomplicated.
COMMENT Ureteral injuries occur in 0.03–13 per 1,000 cases of benign gynecologic surgery.3,4 Approximately 4% of these injuries occur in cases with the primary diagnosis of endometriosis.4 Many patients undergoing gynecologic surgery have distorted anatomy secondary to previous surgical procedures, adhesions, and endometriosis. Awareness of the patient’s surgical history and understanding of previous procedures and associated complications all have a critical effect on the safety and efficacy of the currently planned surgical interventions. Iatrogenic ureteral injury can be minimized through judicious intraoperative decision-making and routine identification of the ureters through direct visualization, ureterolysis, or temporary ureteral stenting. In this case, understanding of the PolitanoLeadbetter technique led to concern that the transected
Elevated Human Chorionic Gonadotropin and Hyperandrogenemia in a Woman With Mu¨llerian Agenesis Robyn L. Schickler, MD, Mitchel S. Hoffman, MD, and Shayne M. Plosker, MD BACKGROUND: Mu¨llerian agenesis is a congenital malformation characterized by absence of the uterus, cervix, and upper vagina. A positive home pregnancy test in
From the Department of Obstetrics and Gynecology and the Divisions of Gynecologic Oncology and Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine and Tampa General Hospital, Tampa, Florida. Corresponding author: Shayne M. Plosker, MD, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, South Treatment Center, 2 Tampa General Circle, 6th floor, Tampa, FL 33606; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
VOL. 123, NO. 2 PART 2, FEBRUARY 2014
band represented ureter running a highly aberrant path. Evaluation resulted in rapid identification of the surgical complication and primary ureteral repair. A high index of suspicion, close follow-up, and prompt urologic consultation are recommended to quickly identify ureteral injuries in cases of abnormal anatomy. From that point, appropriate and timely treatment and repair can be undertaken.
REFERENCES 1. Khoury A, Bagli D. Reflux and megaureter. In: Wein A, Kavoussi L, Novick A, Partin A, Peters C, editors. Campbell-Walsh urology. Vol 4. 9th ed. Philadelphia (PA): Saunders Elsevier; 2007. p. 3423–81. 2. Heidenreich A, Ozgur E, Becker T, Haupt G. Surgical management of vesicoureteral reflux in pediatric patients. World J Urol 2004;22:96–106. 3. Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol 2006;107:1366–72. 4. Frankman EA, Wang L, Bunker CH, Lowder JL. Lower urinary tract injury in women in the United States, 1979-2006. Am J Obstet Gynecol 2010;202:495.e1–5.
a woman with Mu¨llerian agenesis mandated evaluation for malignancy. CASE: A woman with Mu¨llerian agenesis presented with elevated levels of human chorionic gonadotropin (hCG), testosterone, and dehydroepiandrosterone sulfate. Pelvic magnetic resonance imaging (MRI), abdominal and pelvic computed tomography scan, chest computed tomography scan, brain MRI, and body positron emission tomography scan did not identify a malignancy. Human chorionic gonadotropin characterization revealed 74% hyperglycosylated and 1.6% free b-hCG, suggesting a trophoblast-containing tumor. Interventional ovarian venous sampling and repeat pelvic MRI suggested a right adnexal source. After laparoscopic removal of a stage 1C right ovarian dysgerminoma, hCG and testosterone returned to normal. CONCLUSION: A dysgerminoma coincident with Mu¨llerian agenesis expressed hCG before detection by MRI. Human chorionic gonadotropin molecular characterization, ovarian vein sampling, and repeat pelvic MRI led to successful treatment. (Obstet Gynecol 2014;123:465–8) DOI: 10.1097/AOG.0000000000000004
M
üllerian agenesis is a congenital malformation characterized by absence of the uterus, cervix, and upper vagina.1 The presence of human chorionic gonadotropin (hCG) in women with Müllerian agenesis requires consideration of hCG-secreting malignant
Schickler et al
Elevated hCG and Mu¨llerian Agenesis
465
7. Yoshimura K, Hirsch E, Kitano R, Kashimura M. Cervical varix accompanied by placenta previa in twin pregnancy. J Obstet Gynaecol Res 2004;30:323–5. 8. Kumazawa Y, Shimizu D, Hosoya N, Hirano H, Ishiyama K, Tanaka T. Cervical varix with placenta previa totalis. J Obstet Gynaecol Res 2007;33:536–8. 9. Follen MM, Fox HE, Levine RU. Cervical vascular malformation as a cause of antepartum and intrapartum bleeding in three diethylstilbestrol-exposed progeny. Am J Obstet Gynecol 1985;153:890–1.
REFERENCES 1. Dindelli M, Parazzini F, Basellini A, Rabaiotti E, Corsi G, Ferrari A. Risk factors for varicose disease before and during pregnancy. Angiology 1993;44:361–7. 2. Evans CJ, Allan PL, Lee AJ, Bradbury AW, Ruckley CV, Fowkes FG. Prevalence of venous reflux in the general population on duplex scanning: the Edinburgh vein study. J Vasc Surg 1998;28:767–76.
10. Fleming AD, Anderson TL. Cervical AV malformation with in utero DES exposure. Nebr Med J 1993;78:138–9. 11. Gizzo S, Saccardi C, Patrelli TS, Di Gangi S, Breda E, Fagherazzi S, et al. Fertility rate and subsequent pregnancy outcomes after conservative surgical techniques in postpartum hemorrhage: 15 years of literature. Fertil Steril 2013;99:2097–107.
3. Hurton T, Morrill H, Mascola M, York C, Bromley B. Cervical varices: an unusual etiology for third-trimester bleeding. J Clin Ultrasound 1998;26:317–9.
12. Pron G, Mocarski E, Bennett J, Vilos G, Common A, Vanderburgh L, et al. Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial. Obstet Gynecol 2005;105:67–76.
4. Kusanovic JP, Soto E, Espinoza J, Stites S, Goncalves LF, Santolaya J, et al. Cervical varix as a cause of vaginal bleeding during pregnancy: prenatal diagnosis by color Doppler ultrasonography. J Ultrasound Med 2006;25:545–9.
13. Borgatta L, Chen AY, Reid SK, Stubblefield PG, Christensen DD, Rashbaum WK. Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion. Am J Obstet Gynecol 2001;185:530–6.
5. Sammour RN, Gonen R, Ohel G, Leibovitz Z. Cervical varices complicated by thrombosis in pregnancy. Ultrasound Obstet Gynecol 2011;37:614–6.
14. Steinauer JE, Diedrich JT, Wilson MW, Darney PD, Vargas JE, Drey EA. Uterine artery embolization in postabortion hemorrhage. Obstet Gynecol 2008;111:881–9.
6. Sukur YE, Yalcin I, Kahraman K, Soylemez F. Cervical varix complicating marginal placenta previa: a unique coexistence. J Obstet Gynaecol Res 2011;37:1515–7.
15. Haddad L, Delli-Bovi L. Uterine artery embolization to treat hemorrhage following second-trimester abortion by dilatation and surgical evacuation. Contraception 2009;79:452–5.
Ureteral Transection Due to Intraperitoneal Course of Ureter After Pediatric Ureteral Reimplantation
Two fibrous bands attached a segment of small bowel to the abdominal wall. One band was transected and ligated. Postoperative suspicion that the bands represented ureter prompted computed tomography imaging, showing high-grade ureteral obstruction. Retrograde pyelogram revealed urinary extravasation and no continuity with the ureter. Reoperation with ureteroneocystotomy confirmed the bands were ureter coursing through bowel, consistent with injury during ureteral reimplantation.
Jessica M.B. Ritch, MD, and Nicole L. Heidemann,
MD
BACKGROUND: Traditional pediatric ureteral reimplantation involved blindly passing a clamp behind the bladder to guide the ureter into a new hiatal opening, potentially resulting in an intraperitoneal ureter.
CONCLUSION: Review of previous surgeries, a high index of suspicion, and prompt urologic consultation are recommended to identify and repair ureter injuries in abnormal anatomy cases.
CASE: A 44-year-old woman with previous ureteral reimplantation underwent gynecologic laparoscopy.
(Obstet Gynecol 2014;123:462–5)
From the Baptist Hospital, Nashville, Tennessee. Corresponding author: Jessica M.B. Ritch, Center for Pelvic Health, 4601 Carothers Parkway, Suite 350, Franklin, TN 37067; e-mail: ritch.jessica@ gmail.com. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
462
Ritch and Heidemann
Injury of Intraperitoneal Ureter
DOI: 10.1097/AOG.0b013e3182a9cab6
H
istorically, the most common surgical treatment of pediatric vesicoureteral reflux had been the Politano-Leadbetter technique of ureteral reimplantation, which involved blind creation of a new ureteral hiatus. A right-angle clamp was passed from the original hiatus behind the bladder, puncturing the posterior wall of the bladder to create a new hiatal opening. A second right-angle clamp followed the path of the first in reverse, through the new hiatus, out behind the
OBSTETRICS & GYNECOLOGY
Fig. 1. Fibrous band attaching the small bowel to peritoneum of anterior abdominal wall near the bladder. Ritch. Injury of Intraperitoneal Ureter. Obstet Gynecol 2014.
Fig. 3. Fibrous band originating from left pelvic sidewall and extending to small bowel.
bladder and into the original hiatus, grasping the ureter, and pulling it along this path into the new hiatus. This blind maneuver is discouraged in contemporary urology because of significant complications, including routing of the ureter intraperitoneally and a 0.5% rate of damage to the bowel and other structures.1,2 The purpose of this case is to present a ureteral injury during gynecologic laparoscopy attributable to abnormal anatomy in a patient with previous pediatric ureteral reimplantation. Awareness of potential abnormal anatomy, rapid identification of the injury, and prompt urologic consultation led to a quick and uncomplicated resolution.
Ritch. Injury of Intraperitoneal Ureter. Obstet Gynecol 2014.
CASE A 44-year-old woman with a surgical history of ureteral reimplantation at age 4 years for vesicoureteral reflux underwent diagnostic hysteroscopy, endometrial ablation, diagnostic laparoscopy with lysis of adhesions, and excision of endometriosis for pelvic pain, dysfunctional uterine bleeding, and suspected endometriosis.
On diagnostic laparoscopy, endometrial implants and dense adhesions were noted throughout the pelvis. The left ovary was densely adhered to the left pelvic sidewall with an endometrioma extending retroperitoneally. The ureters were visualized with peristalsis in the pelvic sidewalls bilaterally, and this was confirmed with intraoperative consult. The left ureter appeared to be running retroperitoneally under the left ovary. Because of confidence with visualization of the ureters, ureterolysis was not performed. A fibrous band that appeared to be a dense adhesion was noted between the small bowel and the left pelvic sidewall, coursing over the infundibulopelvic ligament at the pelvic brim. A second fibrous band attached from the same section of small bowel to the peritoneum of the anterior abdominal wall near the bladder (Fig. 1). There appeared to be a well-defined plane between the anterior adhesion and the small bowel; therefore, the adhesion was transected at the level of the peritoneum. Suspicion of scant serous fluid arising from the central
Fig. 2. Transected and ligated fibrous band protruding from small bowel, previously attached to anterior abdominal wall.
Fig. 4. Computed tomographic image showing left hydronephrosis. Arrow indicates dilated renal pelvis.
Ritch. Injury of Intraperitoneal Ureter. Obstet Gynecol 2014.
Ritch. Injury of Intraperitoneal Ureter. Obstet Gynecol 2014.
VOL. 123, NO. 2 PART 2, FEBRUARY 2014
Ritch and Heidemann
Injury of Intraperitoneal Ureter
463
Fig. 5. Computed tomographic image showing dilated left ureter to level of pelvic brim consistent with high-grade left ureteral obstruction with presumed ligation of the ureter. Arrow indicates dilated ureter. Ritch. Injury of Intraperitoneal Ureter. Obstet Gynecol 2014.
portion of the base of the adhesion led to intraoperative surgical consult and the determination the tissue may represent a deep Meckel diverticulum. As a precaution, the base was ligated with two Endoloops and the abdomen and pelvis were copiously irrigated (Fig. 2). Attention was then turned to the fibrotic band originating from the left pelvic sidewall. The peritoneum surrounding the suspected adhesion was skeletonized to reveal a tubular-appearing structure leading directly into the small bowel (Fig. 3). This structure was left in place. The left ovary was carefully dissected from the pelvic sidewall and the endometrioma was excised. The procedure concluded with careful excision and fulgeration of multiple endometriosis implants. Postoperative review of the case images raised concern that the fibrous bands were an aberrantly coursing intraperitoneal left ureter. Therefore, the patient was admitted for observation and further evaluation. Computed tomography imaging with contrast on postoperative day 1 showed moderate to severe left hydronephrosis (Fig. 4) and dilation of the left ureter to the level of the left adnexa, at which point the ureter appeared to blend into a loop of small bowel (Fig. 5). A focus of hyperdensity at the distal end of the ureter was thought to potentially represent suture material. These findings were consistent with acute high-grade left ureteral obstruction and presumed ligation of the ureter. The patient’s creatinine increased from 0.7 to 1.3. The urology department was consulted.
464
Ritch and Heidemann
Injury of Intraperitoneal Ureter
Fig. 6. Fluoroscopy image taken at the time of percutaneous nephrostomy tube placement shows dilated ureter, which appears to end near a loop of small bowel. Arrow indicates point of obstruction of ureter. Ritch. Injury of Intraperitoneal Ureter. Obstet Gynecol 2014.
The patient underwent cystoscopy and left retrograde pyelogram, which demonstrated urinary extravasation from the distal left ureter into the pelvis and no continuity with the proximal segment of the left ureter. A percutaneous nephrostomy tube was placed to relieve the severe hydroureteronephrosis (Fig. 6). The patient underwent exploratory laparotomy with urology. The previously noted thick fibrous band adhered to a loop of small bowel to the pelvic sidewall was identified. Frozen-section pathology of a portion of this fibrous band confirmed the tissue to be ureter. At that point, it was determined that the ureter coursed directly through the center of the small bowel. This was consistent with a remote through-and-through injury of the small bowel during childhood ureteral reimplantation. The ureteral stumps emanating from the bowel were oversewn. There was no evidence of compromise to the integrity of the small bowel. The left ureter was dissected from the retroperitoneum, the bladder was mobilized, and
OBSTETRICS & GYNECOLOGY
ureteroneocystotomy was performed without tension. A double-J ureteral stent was left in place for 3 weeks. The patient’s recovery was uncomplicated.
COMMENT Ureteral injuries occur in 0.03–13 per 1,000 cases of benign gynecologic surgery.3,4 Approximately 4% of these injuries occur in cases with the primary diagnosis of endometriosis.4 Many patients undergoing gynecologic surgery have distorted anatomy secondary to previous surgical procedures, adhesions, and endometriosis. Awareness of the patient’s surgical history and understanding of previous procedures and associated complications all have a critical effect on the safety and efficacy of the currently planned surgical interventions. Iatrogenic ureteral injury can be minimized through judicious intraoperative decision-making and routine identification of the ureters through direct visualization, ureterolysis, or temporary ureteral stenting. In this case, understanding of the PolitanoLeadbetter technique led to concern that the transected
Elevated Human Chorionic Gonadotropin and Hyperandrogenemia in a Woman With Mu¨llerian Agenesis Robyn L. Schickler, MD, Mitchel S. Hoffman, MD, and Shayne M. Plosker, MD BACKGROUND: Mu¨llerian agenesis is a congenital malformation characterized by absence of the uterus, cervix, and upper vagina. A positive home pregnancy test in
From the Department of Obstetrics and Gynecology and the Divisions of Gynecologic Oncology and Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine and Tampa General Hospital, Tampa, Florida. Corresponding author: Shayne M. Plosker, MD, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, South Treatment Center, 2 Tampa General Circle, 6th floor, Tampa, FL 33606; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
VOL. 123, NO. 2 PART 2, FEBRUARY 2014
band represented ureter running a highly aberrant path. Evaluation resulted in rapid identification of the surgical complication and primary ureteral repair. A high index of suspicion, close follow-up, and prompt urologic consultation are recommended to quickly identify ureteral injuries in cases of abnormal anatomy. From that point, appropriate and timely treatment and repair can be undertaken.
REFERENCES 1. Khoury A, Bagli D. Reflux and megaureter. In: Wein A, Kavoussi L, Novick A, Partin A, Peters C, editors. Campbell-Walsh urology. Vol 4. 9th ed. Philadelphia (PA): Saunders Elsevier; 2007. p. 3423–81. 2. Heidenreich A, Ozgur E, Becker T, Haupt G. Surgical management of vesicoureteral reflux in pediatric patients. World J Urol 2004;22:96–106. 3. Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol 2006;107:1366–72. 4. Frankman EA, Wang L, Bunker CH, Lowder JL. Lower urinary tract injury in women in the United States, 1979-2006. Am J Obstet Gynecol 2010;202:495.e1–5.
a woman with Mu¨llerian agenesis mandated evaluation for malignancy. CASE: A woman with Mu¨llerian agenesis presented with elevated levels of human chorionic gonadotropin (hCG), testosterone, and dehydroepiandrosterone sulfate. Pelvic magnetic resonance imaging (MRI), abdominal and pelvic computed tomography scan, chest computed tomography scan, brain MRI, and body positron emission tomography scan did not identify a malignancy. Human chorionic gonadotropin characterization revealed 74% hyperglycosylated and 1.6% free b-hCG, suggesting a trophoblast-containing tumor. Interventional ovarian venous sampling and repeat pelvic MRI suggested a right adnexal source. After laparoscopic removal of a stage 1C right ovarian dysgerminoma, hCG and testosterone returned to normal. CONCLUSION: A dysgerminoma coincident with Mu¨llerian agenesis expressed hCG before detection by MRI. Human chorionic gonadotropin molecular characterization, ovarian vein sampling, and repeat pelvic MRI led to successful treatment. (Obstet Gynecol 2014;123:465–8) DOI: 10.1097/AOG.0000000000000004
M
üllerian agenesis is a congenital malformation characterized by absence of the uterus, cervix, and upper vagina.1 The presence of human chorionic gonadotropin (hCG) in women with Müllerian agenesis requires consideration of hCG-secreting malignant
Schickler et al
Elevated hCG and Mu¨llerian Agenesis
465
