“Dr. Rahman, this is the nurse in OR 12, Dr. H is doing a robotic/laparoscopic hysterectomy, he thinks he’s injured the ureter, and is requesting help. Are you available?” There was a surge of adrenaline in my system as I answered this call in my office, as I know what came next was going to be complex — challenging surgically, disruptive to my schedule, and potentially risky. I told the nurse that I would be over in about 10 minutes and my staff to reschedule my morning patients in the office. As I walked over the OR and changed into scrubs, I prepared a mental list of things I would need including sutures, instruments, cystoscopic instruments and called over to the nurses to have these available.
I walked into the OR, re-introduced myself to Dr. H and he filled me on the details of the case. Under anesthesia was Melanie C, a 46 year old African American female who was undergoing a hysterectomy for heavy vaginal bleeding from fibroids. The patient was overweight with a BMI of 48, which made the case more challenging. Dr. H had managed to remove the uterus. The uterus is intimately associated with the urinary system, including the bladder and the ureters, the tubes which bring urine to the bladder from the kidneys. He had given dye which turns the urine deep yellow/green, noting some spillage in the pelvis near the bladder and left ureter. I asked that he first introduce me to the family, so they knew why I was suddenly involved in their loved one’s care.
In the OR, I looked into the surgical field, and I could see the dye spilling indicating that there had been some injury to the urinary system. I was not sure whether it was the bladder or the very distal part of the left ureter (as it enters into the bladder). I than performed a cystoscopy (placing a fiber-optic scope within the bladder) to visually inspect the bladder. As I did this, I did not see any evidence of a bladder tear. I could see urine coming out of the right sided ureter (there are small openings on the right and left side of the bladder representing where each ureter tunnels into the bladder and projects its urine), but did not clearly see urine coming out of the left side. I placed a wire into the opening of the left ureter and was happy that I did not feel any resistance, and I could easily pass a catheter into the left ureter without difficulty. I felt reassured by these findings because it meant that the ureter had not been completely divided.
Now I could see that the catheter I had placed in the left ureter was indeed exposed, indicating a small tear in the ureter (1cm, less than ½ inch). I had a decision to make: I could place a few stitches to fix this small tear or I could divide the ureter, make a new opening in the bladder and re-suture it into place. They both had their advantages and disadvantages – suturing it close would be simpler and easier, but the blood supply to the ureter in this region could be tenuous and result in poor healing. Dividing the ureter and re-implanting the ureter would result in better healing, but would require a longer, more complex and tedious surgery, with the added risk of causing indefinite pain in the bladder and kidney when the bladder is full. The natural course of the ureter into the bladder creates a one-way flap mechanism which prevents urine from going back to the kidney; disrupting this to re-implant the ureter increases the chance urine will reflux back into the kidney with the bladder full, creating discomfort and pain.
After discussing with a few of my urology colleagues, I decided to place a few sutures close the tear, and then replace the ureteral catheter with an indwelling ureteral stent (catheter that has coils at both ends, one in the kidney and the other in bladder, thereby insuring that the stent stays in place) which would stay in for a few weeks, allowing the ureter to fully heal.
Despite the added surgery, Melanie did well and was discharged home the next day. I saw her again 6 weeks later, found out she was a NY state auditor, and removed her stent in the office uneventfully.
She called the office the next day crying and in a panic, as she was draining fluid from her vagina continuously since the stent had been removed. She was going through 1-2 pads per hour. I had her come to the office immediately, and confirmed that she was draining urine (I had asked her to take a pill that would stain her urine orange, and I did see orange staining urine dripping from her vaginal cuff). I presumed it was from the left ureter but I wasn’t completely sure where it was coming from.
Back in the OR the same day, I first placed blue dye into her bladder to see if there was any communication between the bladder and vagina. I placed a clean white pad in her vagina and only saw the orange tinged drainage, no blue, which all but confirmed the drainage was from the ureter. I than placed a ureteroscope through the opening in her left ureter, saw scar tissue from my previous repair as opposed to healthy pink tissue. There was an open communication through which I passed a wire, which came out through her vagina, confirming what I knew viscerally from her first panic stricken call; she had indeed developed a ureterovaginal fistula. I replaced a stent back into the ureter and completed the case. I had a long discussion with Melanie and her family in the recovery room, explaining the findings, and that I had temporized things by placing a stent (she would not leak with the stent in place), but she was going to need another operation, the ureteral re-implant that I had debated doing at the original surgery.
Three days later l scheduled Melanie for a robotic assisted laparoscopic left ureteral reimplant. In the preop area, I reiterated to Melanie and her family that as she just had major surgery, there was chance I would not be able to do the surgery robotically due to scarring, and that I may need to do a standard open surgery to do the operation, which would significantly lengthen her hospital stay and recovery. As we began her surgery, it was obvious that there was previous scarring, and her entire lower colon was draped over her bladder and ureter, obscuring them from the surgical field. Proceeding slowly and with the assistance of a colo-rectal surgeon, I was able to mobilize the colon away and fully visualize the bladder and left ureter, all still robotically. I was able to then divide the ureter just before the fistula, and after over 3 hours of surgery, re-attach it to the dome of the bladder. She recovered well, and was discharged home the next day. Four weeks later, I removed her stent and she had no recurrences or any urinary leakage, which I confirmed by several phone calls over the next few days. I just saw Melanie for her 6 month follow-up recently. Her left kidney looks normal without swelling, and she has only mild pain in her bladder when it is full (just in the morning upon awakening), no incontinence. She leads a full and active life.
There are many valuable lessons derived from Melanie’s story. First, medicine and surgery are human endeavors, fraught with mistakes with mishaps. Split second decisions have to be made and sometimes need to be revisited. Secondly, excellent surgeons and clinicians aren’t those who’ve never made mistakes, but those who are quick to recognize them, seek help when needed and quick to remedy their mistakes. Dr. H is an excellent GYN oncologist with a great surgical record and experience. He had a tough case and encountered a problem, but sought out help immediately. In hindsight, despite seeking other opinions, re-implanting her ureter at the outset would have prevented Melanie’s second surgery (I would likely do this now if faced with a similar episode). However, I quickly recognized it and was skilled enough to fix the problem quickly with a minimally invasive technique. Thirdly, sometimes success takes a circuitous path rather than a straight line. Despite her ordeal, Melanie’s health is better now than when she started the process, and in the end, that’s what matters most.