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Ureteral Obstruction Secondary to Ovarian Remnants: A Case Report
Vol. 108, September Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
URETERAL OBSTRUCTION SECONDARY TO OVARIAN REMNANTS: A CASE REPORT JAN E. BERNIE
Fm. 1. A, plain film of kidneys, ureters and bladder. B, 2-hour IVP. C, retrograde film
Retained ovarian remnant causing ureteral obstruction occurs rarely. Six cases have been reported.1-3 Herein is described a case of left ureteral obstruction secondary to a retained retroperitoneal corpus luteum. CASE REPORT
T. N., a 40-year-old white married woman, was hospitalized on August 16, 1971 with left lower quadrant and side pain for 12 to 18 hours. The pain seemed to be steady and radiated to the left flank, and the patient suffered some nausea and vomiting. A similar pain had occurred on and off for the past 8 months but there was no history of stone, recurrent infection or fever. No other urogenital symptoms were noted. The medical history was significant. The patient had undergone left salpingo-oophorectomy in April 1966 for pelvic pain. Adhesions involving the left tube and ovary were described at that time. Total abdominal hysterectomy and right salpingo-oophorectomy were done in December 1969 Accepted for publication December 10, 1971. Kaufman, J. J.: Unusual causes of extrinsic ureteral obstruction, part I. J. Urol., 87: 319, 1962. 2 Horowitz, M. I. and Elguezabal, A.: Obstruction of the ureter by recent corpus luteum located in the retroperitoneum: report of 2 cases. J. Urol., 95: 706, 1966. 3 Major, F. J.: Retained ovarian remnant causing ureteral obstruction. Report of two cases. Obst. Gynec., 32: 748, 1968. 1
FIG. 2. Postoperative IVP
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Fro. 3. A, theca-lutein cells (left border) surrounding hemorrhagic area. B, ovarian stroma because of intractable pelvic pain. Pathological examination revealed a fibroid uterus. Physical examination at the current hospitalization revealed that the blood pressure was 130/80, pulse 80 and temperature 98.6 degrees. The patient had mild lower quadrant pain and mild left costovertebral angle tenderness. A mass of golfball size was palpated in the left adnexa. Sigmoidoscopy and barium enema were essentially within normal limits. An excretory urogram (IVP) showed no abnormal calcification (fig. 1, A) nor obstructive nephrogram effect on the 2-hour delay film (fig. 1, B). An electrocardiogram, chest x-ray and lumbosacral spinal film were negative. Laboratory data revealed blood urea nitrogen 14, fasting blood sugar 110, hematocrit 38 and white blood cells 7,800. Urinalysis re-
vealed specific gravity 1.026, zero albumin, zero sugar, 8 to 10 white blood cells per high power field, creatinine 1.1 and urine culture negative. On August 21 the patient underwent cystoscopy and a left retrograde pyelogram. A No. 5 ureteral catheter easily passed to the left renal pelvis but pull out film revealed an obstruction at the bony pelvic brim (fig. 1, G). The adnexal mass was again palpated while the patient was under anesthesia. Because of the mass lesion which we thought may have been tumor, small bowel adhesions, endometrioma or abscess, surgical exploration was carried out on August 26. Preoperative insertion of a No. 6 ureteral catheter was instituted. A midline transperitoneal approach disclosed the bluish cystic mass overlying the left
URETERAL OBSTRUCTION SECONDARY TO OVARIAN REMNANTS
ureter just below the hypogastric vessels. A frozen section biopsy showed a benign lesion and the mass was excised. The posterior aspect of the cystic mass was adherent to the ureter and vessels and required some tedious dissection to free it from the underlying ureter. The ureter distal to the mass was freed from the surrounding adhesions. Omentum was used to cover the ureter over the area of dissection to prevent further adhesions. The wound was closed without drains and the ureteral catheter was removed 5 days postoperatively. An IVP, 9 days postoperatively, showed good function (fig. 2) and the patient was discharged from the hospital doing well 10 days postoperatively. Incomplete removal of the ovary and extraperitoneal implantation with regeneration of the residual
~I
::,
401
ovarian remnant can occur. Corpus luteum formation can then give rise to ureteral obstruction and pain (fig. 3). Ureteral obstruction caused by ovarian remnant should be considered in women in whom there. is no history of calculi and a pelvic operation has been done. SUMMARY
The seventh case of ureteral obstruction secondary to retained ovarian remnant is reported. This entity should be suspected in women who have undergone previous pelvic operations and suffer recurrent pyelonephritis or ureteral obstruction. Drs. Paul Stauffer and Walter Reiling, Jr. assisted in the operating room. 700-08 Reibald Building, Dayton, Ohio 45402
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
URETERAL OBSTRUCTION SECONDARY TO OVARIAN REMNANTS: A CASE REPORT JAN E. BERNIE
Fm. 1. A, plain film of kidneys, ureters and bladder. B, 2-hour IVP. C, retrograde film
Retained ovarian remnant causing ureteral obstruction occurs rarely. Six cases have been reported.1-3 Herein is described a case of left ureteral obstruction secondary to a retained retroperitoneal corpus luteum. CASE REPORT
T. N., a 40-year-old white married woman, was hospitalized on August 16, 1971 with left lower quadrant and side pain for 12 to 18 hours. The pain seemed to be steady and radiated to the left flank, and the patient suffered some nausea and vomiting. A similar pain had occurred on and off for the past 8 months but there was no history of stone, recurrent infection or fever. No other urogenital symptoms were noted. The medical history was significant. The patient had undergone left salpingo-oophorectomy in April 1966 for pelvic pain. Adhesions involving the left tube and ovary were described at that time. Total abdominal hysterectomy and right salpingo-oophorectomy were done in December 1969 Accepted for publication December 10, 1971. Kaufman, J. J.: Unusual causes of extrinsic ureteral obstruction, part I. J. Urol., 87: 319, 1962. 2 Horowitz, M. I. and Elguezabal, A.: Obstruction of the ureter by recent corpus luteum located in the retroperitoneum: report of 2 cases. J. Urol., 95: 706, 1966. 3 Major, F. J.: Retained ovarian remnant causing ureteral obstruction. Report of two cases. Obst. Gynec., 32: 748, 1968. 1
FIG. 2. Postoperative IVP
399
400
BERNIE
Fro. 3. A, theca-lutein cells (left border) surrounding hemorrhagic area. B, ovarian stroma because of intractable pelvic pain. Pathological examination revealed a fibroid uterus. Physical examination at the current hospitalization revealed that the blood pressure was 130/80, pulse 80 and temperature 98.6 degrees. The patient had mild lower quadrant pain and mild left costovertebral angle tenderness. A mass of golfball size was palpated in the left adnexa. Sigmoidoscopy and barium enema were essentially within normal limits. An excretory urogram (IVP) showed no abnormal calcification (fig. 1, A) nor obstructive nephrogram effect on the 2-hour delay film (fig. 1, B). An electrocardiogram, chest x-ray and lumbosacral spinal film were negative. Laboratory data revealed blood urea nitrogen 14, fasting blood sugar 110, hematocrit 38 and white blood cells 7,800. Urinalysis re-
vealed specific gravity 1.026, zero albumin, zero sugar, 8 to 10 white blood cells per high power field, creatinine 1.1 and urine culture negative. On August 21 the patient underwent cystoscopy and a left retrograde pyelogram. A No. 5 ureteral catheter easily passed to the left renal pelvis but pull out film revealed an obstruction at the bony pelvic brim (fig. 1, G). The adnexal mass was again palpated while the patient was under anesthesia. Because of the mass lesion which we thought may have been tumor, small bowel adhesions, endometrioma or abscess, surgical exploration was carried out on August 26. Preoperative insertion of a No. 6 ureteral catheter was instituted. A midline transperitoneal approach disclosed the bluish cystic mass overlying the left
URETERAL OBSTRUCTION SECONDARY TO OVARIAN REMNANTS
ureter just below the hypogastric vessels. A frozen section biopsy showed a benign lesion and the mass was excised. The posterior aspect of the cystic mass was adherent to the ureter and vessels and required some tedious dissection to free it from the underlying ureter. The ureter distal to the mass was freed from the surrounding adhesions. Omentum was used to cover the ureter over the area of dissection to prevent further adhesions. The wound was closed without drains and the ureteral catheter was removed 5 days postoperatively. An IVP, 9 days postoperatively, showed good function (fig. 2) and the patient was discharged from the hospital doing well 10 days postoperatively. Incomplete removal of the ovary and extraperitoneal implantation with regeneration of the residual
~I
::,
401
ovarian remnant can occur. Corpus luteum formation can then give rise to ureteral obstruction and pain (fig. 3). Ureteral obstruction caused by ovarian remnant should be considered in women in whom there. is no history of calculi and a pelvic operation has been done. SUMMARY
The seventh case of ureteral obstruction secondary to retained ovarian remnant is reported. This entity should be suspected in women who have undergone previous pelvic operations and suffer recurrent pyelonephritis or ureteral obstruction. Drs. Paul Stauffer and Walter Reiling, Jr. assisted in the operating room. 700-08 Reibald Building, Dayton, Ohio 45402