Incidental Kidney Stone Diagnosed During Laparoscopy-Assisted Vaginal Hysterectomy

Abstract

Objectives: BACKGROUND: Approximately 600, 000 hysterectomies are performed annually in the US, making it the second most common major surgery amongst reproductive aged women. Morbidity risks with pelvic surgery include infection, hemorrhage, thromboembolism, and potential damage to bowel, bladder, and ureters. Mortality is a rare outcome. Morbidities associated with ureteral injury or obstruction includes pain, loss of kidney function, anxiety, depression, poor quality of life, and additional surgeries. Intraoperative cystoscopy used to detect injury during pelvic surgery remains controversial. A 5-times higher detection rate of ureteral injury has been reported with routine use of cystoscopy, allowing earlier injury detection and prompt repair. Intraoperative cystoscopy suggests injury or obstruction with an absence of indigo carmine dye spilling from the ureteral orifice after an intravenous infusion. This finding can be associated with a suture or another type of iatrogenic blockage. However, an additional etiology of obstruction, albeit rare, is an incidental finding of an obstructing kidney stone. We present such a case. Methods: CASE Medical History A 40-year-old female presented with 8 months of menometrorrhagia, with bleeding almost daily. She was otherwise healthy, with a past medical and surgical history significant for asthma, two cesarean deliveries and a tubal ligation. Evaluation and Exam Pelvic exam revealed a 10 week sized uterus with a normal appearing cervix. An endometrial biopsy and pap smear were both negative for malignancy, and a transvaginal ultrasound confirmed a fibroid uterus measuring 10 x 7 x 6 cm. Results: Treatment After failed conservativemedical treatment of non-steroidal anti-inflammatory medications and progesterone therapy, the patient desired surgical management via laparoscopic assisted vaginal hysterectomy (LAVH). The LAVH was successfully completed. Intravenous indigo carmine was injected and a cystoscopy revealed a grossly normal bladder with adequate flowof dye from the right ostia. The left ureter did not spill any dye. An unsuccessful attempt was made to introduce a whistle-tip catheter. Urology was consulted and when a Glidewire and 5-French Pollock catheter were used in combination, he was able to pass the catheter to a depth of 20 cm. A pyelogram revealed a 1.5 cm defect in the proximal ureter, and a stent was placed. Due to concern for ureteral injury, the surgery was converted to an open laparotomy. The left ureter palpated normal. At the junction of the renal pelvis and ureter, a firm mass was noted. The ureter was incised and a stone was visualized, removed and the ureter repaired. The patient had an uneventful postoperative course and was discharged with the stent. Conclusions: COMMENT Renal stones are a relatively common condition. The estimated prevalence was 3.8% in 1980, rising to 5.2% by 1994, increasing regardless of gender or race. A systematic search of PubMed yielded no published cases on a presentation of an incidental finding of a kidney stone during a cystoscopy status-post gynecologic surgery. While the chance of ureteral obstruction secondary to kidney stone is small either during or after gynecologic surgery, this case suggests that it should remain on the list of differential diagnoses.