A 65-year-old woman reported to a urogynecology office with a protruding vaginal mass. The clinical examination revealed cystocele, enterocele, and uterine prolapse of grade III, based on the Baden-Walker halfway system. The patient subsequently underwent vaginal hysterectomy and bilateral salpingo-oophorectomy, enterocele repair, sacrospinous ligament fixation, perineorrhaphy, and cystoscopy. The enterocele was repaired using 2-0 polypropylene suture (Prolene; Ethicon Inc, Somerville, NJ). The suture incorporated bilateral uterosacral ligaments, cul-de-sac peritoneum, and the endopelvic fascia of the vagina. Two additional 2-0 sutures (Maxon; United States Surgical Corp, Norwalk, Conn) were similarly placed.
A cystoscopy was performed using a 70-degree cystoscope (Karl Storz Endoscopy, Culver City, Calif). Following the intravenous administration of indigo carmine dye, a diuretic— furosemide—was administered intravenously to enhance the excretion of the dye. Among our findings at this stage of the procedure were normal bladder mucosa, as well as efflux of indigo carmine-stained urine from the left (
Figure 1) and right (
Figure 2) ureteral orifices. Sacrospinous ligament fixation and perineorrhaphy were accomplished by use of methods similar to those described by Nichols.
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On postoperative day 2, the patient complained of chills and was noted to have a temperature of 102.7°F (39.3°C). Blood and urine cultures were negative, and the patient's white blood cell count was 6.2×103/μL. Her serum creatinine level increased from 0.8 mg/dL on postoperative day 1 to 1.5 mg/dL on postoperative day 3. A computed tomographic scan of the abdominopelvic region revealed mild left-sided hydronephrosis.
The patient was taken to the operating room, where a retrograde pyelogram was performed. Complete obstruction of the lower third of the left ureter was noted. Attempts to pass a double-J ureteral stent into the left ureter were unsuccessful. The right kidney and ureter were normal.
Next, the vaginal cuff was opened to allow the removal of the enterocele sutures. The stent was then easily passed into the left ureter and renal pelvis. Subsequently, the patient's fever resolved, and tests indicated that her renal function returned to normal. The patient had an intravenous pyelogram (IVP) performed six weeks later, when the stent was removed. A final IVP two months after stent removal revealed a normal left kidney and ureter.