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CASE REPORT
Year : 2001  |  Volume : 18  |  Issue : 1  |  Page : 80-82
 

Post hysterectomy vault prolapse - a correctable cause of obstructive uropathy


Department of Urology & Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

Correspondence Address:
Anant Kumar
Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareilly Road, Lucknow- 226014
India
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Source of Support: None, Conflict of Interest: None


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Keywords: Prolapse; Post Hysterectomy


How to cite this article:
Gogoi S, Kumar A, Mandhani A, Bhandari M. Post hysterectomy vault prolapse - a correctable cause of obstructive uropathy. Indian J Urol 2001;18:80-2

How to cite this URL:
Gogoi S, Kumar A, Mandhani A, Bhandari M. Post hysterectomy vault prolapse - a correctable cause of obstructive uropathy. Indian J Urol [serial online] 2001 [cited 2020 May 27];18:80-2. Available from: http://www.indianjurol.com/text.asp?2001/18/1/80/37462



   Case Report Top


A 55-year-old lady presented with recurrent moderate to high grade fever for the last 1 years, & nausea, vomiting and anorexia for 2 weeks. She had normal voiding and urinary output. She had undergone hysterectomy for dysfunctional uterine bleeding 18 years back.

Clinically there was pallor and pitting pedal edema. Pelvic examination revealed complete vault prolapse with grade IV cystocele and grade I rectocele. Her investigations revealed 6.2 gm/dl of hemoglobin, 6.9 mg/dl of serum creatinine, and normal serum electrolyte levels. Ultrasound showed bilateral gross hydroureteronephrosis with thinned out parenchyma.

A provisional diagnosis of obstructive uropathy due to vault prolapse was made. Stents could not be passed so left-sided ultrasound-guided PCN was done. Left nephrostomy drained approximately 2 litres per day and serum creatinine dropped to 3.3 mg/dl over a period of 2 weeks. Antegrade nephrostogram [Figure - 1] showed non-drainage of contrast into the bladder up to 4 hours.

Vault prolapse was repaired through the vaginal route by the four-quadrant suspension as described by Shlomo Raz.' Central vesicopelvic fascial defect (cystocele) was closed by placing a 4 x 5 cm rectangular prolene mesh sutured laterally to the vesicopelvic fascia and posteriorly to the cardinal ligament. Urethral catheter was removed on the first post-operative day and suprapubic catheter (SPC) was maintained for 2 weeks. Left nephrostomy catheter was removed after nephrostogram done on 8th postoperative day revealed prompt drainage into the bladder [Figure - 2]. Postoperative period was uneventful. By 2 weeks she could void well with a minimum post-void residue of 20-30 ml.

In her last follow-up at 6 months she was continent & was voiding to her satisfaction. Her serum creatinine had decreased to 2.2 mg/dl.


   Discussion Top


Incidence of obstructive uropathy in the setting of genital prolapse ranges between 4 and 13 %.[2] First case of posthysterectomy vault prolapse and associated renal failure requiring hemodialysis was reported by Mesler et al[3] in 1991. The incidence of uropathy in various degrees of prolapse was radiologically evaluated (with IVU) by Stabler et al[4] and concluded that IVU was indicated in patients with complete procidentia.

Our experience with this case has emphasized the possibility of obstructive renal failure secondary to vault prolapse. Early recognition and corrective surgical measures can very effectively correct this cause of obstructive uropathy. Four-quadrant repair along with prolene mesh support to the bladder base was found to be effective both functionally and anatomically in managing such high degree (grade IV) of vault prolapse.

 
   References Top

1.Raz S, Little NA. Juma S, Sussman EM. Repair of severe anterior vaginal wall prolapse (grade TV cystourethrocele). J Urol 1991: 146: 988-992.  Back to cited text no. 1    
2.Jorge Catalina A. Bernuy Malfaz C. Obstructive uropathy secondary to genitourinary prolapse. Acta Urol Esp 1995: 19: 247-250.   Back to cited text no. 2    
3.Melser M. Miles BJ. Kastan D. Shetty PC. Anderson W. Chronic renal failure secondary to post-hysterectomy vaginal prolapse. Urology 1991: 38: 361-363.  Back to cited text no. 3    
4.Stabler J. Uterine prolapse and urinary tract obstruction. BrJ Radiol 1977: 50: 493-498.  Back to cited text no. 4    


    Figures

  [Figure - 1], [Figure - 2]



 

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