Endoscopic Management of Iatrogenic Ureteral Injury: A Case Report and Review of the Literature.

Iatrogenic ureteral injury represents an uncommon, but significant, complication of gynecologic surgery. Endoscopy has typically played little to no role in the treatment of these injuries, which are traditionally managed with re-exploration or delayed repair. Delayed repair with temporary urinary diversion exposes the patient to significant morbidity. We present a case in which iatrogenic ureteral injury is managed definitively with endoscopy alone. We present a 32-year-old female who developed a delayed postpartum hemorrhage following cesarean section, necessitating emergent hysterectomy. Postoperatively, there was concern for right ureteral injury. A computed tomography (CT) urogram was obtained showing right-sided hydronephrosis, but no obvious ureteral injury. After developing right flank pain, the patient was taken to the operating room for further evaluation. On semirigid ureteroscopy, a suture was identified within the lumen of the ureter and incised with the holmium laser, effectively treating the obstruction. At a 10-week follow-up, a renal ultrasound showed no hydronephrosis. At 8 months, the patient reports she is doing well with no flank pain. We present, to the best of our knowledge, the first published report in the United States of an iatrogenic ureteral ligation managed effectively in an acute postoperative setting with endoscopic holmium laser release, without balloon dilation, sparing the patient from delayed surgical intervention and the potentially associated morbidity. It is our belief that an initial retrograde pyelogram followed by a ureteroscopic evaluation should be performed as this allows for proper characterization of the injury, and may allow one to attempt definitive endoscopic management.