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An incidental finding
Images in Gynecology
www. AJOG.org
An incidental finding Routine cystoscopy after pelvic floor reconstruction surgery revealed a bladder mass Mitchell B. Berger, MD, PhD; Kindra A. Larson, MD; John O. L. DeLancey, MD
Case notes A 51 year old woman (gravida 3, para 2) presented to the urogynecology clinic for evaluation of symptomatic pelvic organ prolapse. She had no urinary or defecatory symptoms. Her surgical history was notable for an uncomplicated laparoscopic supracervical hysterectomy performed 18 months previously for symptomatic uterine fibroids. On examination, her anterior vaginal wall and cervix prolapsed 3 cm beyond the hymen, and her posterior fornix and posterior vaginal wall were well supported. She consented to undergo trachelectomy with sacrospinous ligament suspension and anterior colporrhaphy. Intravenous indigo carmine was administered at the completion of an uncomplicated pelvic floor reconstruction, and routine cystoscopy was performed. Bilateral ureteral efflux was noted. The bladder mucosa appeared normal with the exception of a raised mass involving the left ureteral orifice (Figure and Video). Conclusions An intraoperative consultation with the Urology Department confirmed that the mass was a ureterocele. Follow-up renal ultrasound was recommended. It has been suggested that cystoscopy be performed at the time of hysterectomy or pelvic floor reconstructive surgery to identify lower urinary tract injuries.1,2 Gynecologists who adopt this practice are therefore likely to identify urologic pathology with increasing frequency. Continued training in cystoscopy and intraoperative urology consultations will permit suitable patient care when such findings are encountered. Ureteroceles, cystic dilations of the terminal ureters, are generally identified in newborns or young children but are rare in adults.3 They affect females more commonly than men, with a 3-4 to 1 predominance.4 Most often they are found on the left From the Pelvic Floor Research Group, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI. Received May 20, 2010; revised July 7, 2010; accepted Aug. 16, 2010. Cite this article as: Berger MB, Larson KA, DeLancey JOL. An incidental finding: routine cystoscopy after pelvic floor reconstruction surgery revealed a bladder mass. Am J Obstet Gynecol 2010;203:518.e1. 0002-9378/$36.00 © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.08.016
VIDEO
518.e1
Click Supplementary Content under the article title in the online Table of Contents
American Journal of Obstetrics & Gynecology NOVEMBER 2010
FIGURE
The left ureteral orifice was noted to be raised and dilated during routine cystoscopy. Note the efflux of indigo carmine-stained urine from the orifice and the visibility of the blue color through the thin wall of an apparent mass. Recorded footage from this cystoscopy demonstrating ureteral efflux from the ureterocele can be viewed in the Supplementary Content. Berger. An incidental finding. Am J Obstet Gynecol 2010.
side, and in adults, they are generally located entirely within the bladder.4,5 Hydronephrosis or stones frequently complicate ureteroceles, so intravenous pyelography or ultrasound are helpful for evaluation and long-term follow-up.5 Our patient had a renal ultrasound performed on the same day as her surgery. It was unremarkable with no evidence of collecting system dilatation, calculi, or abnormal calcification. f REFERENCES 1. Ibeanu OA, Chesson RR, Echols KT, Nieves M, Busangu F, Nolan TE. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol 2009;113:6-10. 2. Gustilo-Ashby AM, Jelovsek JE, Barber MD, Yoo EH, Paraiso MF, Walters MD. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol 2006;194:1478-85. 3. Fletcher SG, Lemack GE. Benign masses of the female periurethral tissues and anterior vaginal wall. Curr Urol Rep 2008;9:389-96. 4. Decter RM. Renal duplication and fusion anomalies. Pediatr Clin North Am 1997;44:1323-41. 5. Halachmi S, Pillar G. Congenital urological anomalies diagnosed in adulthood—management considerations. J Pediatr Urol. 2008;4:2-7.
www. AJOG.org
An incidental finding Routine cystoscopy after pelvic floor reconstruction surgery revealed a bladder mass Mitchell B. Berger, MD, PhD; Kindra A. Larson, MD; John O. L. DeLancey, MD
Case notes A 51 year old woman (gravida 3, para 2) presented to the urogynecology clinic for evaluation of symptomatic pelvic organ prolapse. She had no urinary or defecatory symptoms. Her surgical history was notable for an uncomplicated laparoscopic supracervical hysterectomy performed 18 months previously for symptomatic uterine fibroids. On examination, her anterior vaginal wall and cervix prolapsed 3 cm beyond the hymen, and her posterior fornix and posterior vaginal wall were well supported. She consented to undergo trachelectomy with sacrospinous ligament suspension and anterior colporrhaphy. Intravenous indigo carmine was administered at the completion of an uncomplicated pelvic floor reconstruction, and routine cystoscopy was performed. Bilateral ureteral efflux was noted. The bladder mucosa appeared normal with the exception of a raised mass involving the left ureteral orifice (Figure and Video). Conclusions An intraoperative consultation with the Urology Department confirmed that the mass was a ureterocele. Follow-up renal ultrasound was recommended. It has been suggested that cystoscopy be performed at the time of hysterectomy or pelvic floor reconstructive surgery to identify lower urinary tract injuries.1,2 Gynecologists who adopt this practice are therefore likely to identify urologic pathology with increasing frequency. Continued training in cystoscopy and intraoperative urology consultations will permit suitable patient care when such findings are encountered. Ureteroceles, cystic dilations of the terminal ureters, are generally identified in newborns or young children but are rare in adults.3 They affect females more commonly than men, with a 3-4 to 1 predominance.4 Most often they are found on the left From the Pelvic Floor Research Group, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI. Received May 20, 2010; revised July 7, 2010; accepted Aug. 16, 2010. Cite this article as: Berger MB, Larson KA, DeLancey JOL. An incidental finding: routine cystoscopy after pelvic floor reconstruction surgery revealed a bladder mass. Am J Obstet Gynecol 2010;203:518.e1. 0002-9378/$36.00 © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.08.016
VIDEO
518.e1
Click Supplementary Content under the article title in the online Table of Contents
American Journal of Obstetrics & Gynecology NOVEMBER 2010
FIGURE
The left ureteral orifice was noted to be raised and dilated during routine cystoscopy. Note the efflux of indigo carmine-stained urine from the orifice and the visibility of the blue color through the thin wall of an apparent mass. Recorded footage from this cystoscopy demonstrating ureteral efflux from the ureterocele can be viewed in the Supplementary Content. Berger. An incidental finding. Am J Obstet Gynecol 2010.
side, and in adults, they are generally located entirely within the bladder.4,5 Hydronephrosis or stones frequently complicate ureteroceles, so intravenous pyelography or ultrasound are helpful for evaluation and long-term follow-up.5 Our patient had a renal ultrasound performed on the same day as her surgery. It was unremarkable with no evidence of collecting system dilatation, calculi, or abnormal calcification. f REFERENCES 1. Ibeanu OA, Chesson RR, Echols KT, Nieves M, Busangu F, Nolan TE. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol 2009;113:6-10. 2. Gustilo-Ashby AM, Jelovsek JE, Barber MD, Yoo EH, Paraiso MF, Walters MD. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol 2006;194:1478-85. 3. Fletcher SG, Lemack GE. Benign masses of the female periurethral tissues and anterior vaginal wall. Curr Urol Rep 2008;9:389-96. 4. Decter RM. Renal duplication and fusion anomalies. Pediatr Clin North Am 1997;44:1323-41. 5. Halachmi S, Pillar G. Congenital urological anomalies diagnosed in adulthood—management considerations. J Pediatr Urol. 2008;4:2-7.