Early urinary diversion facilitates stent placement and conservative management of surgical ureteric injuries.

To cite: Chaudhary R, Modi JN, Jain N, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014206772 DESCRIPTION A 42-year-old woman presented with continuous urinary discharge from the vagina. She had undergone abdominal hysterectomy for adenomyosis and started leaking urine from the vagina on the 12th postoperative day. On per speculum examination, continuous discharge of clear urine was seen from suture line at vault apex. A three swab test was suggestive of a ureteric fistula as the higher swab was wet but not dye stained. Ultrasonogram revealed moderate hydroureteronephrosis on the right side. A contrast CT scan (figures 1–3) showed a right lower ureteric injury with extravasation of contrast and irregular tract draining freely into the vagina. No dye was seen draining into the urinary bladder from the right ureter. The filling defects seen along the course of the left ureter are artefacts secondary to reconstruction of images. An 8 Fr per cutaneous nephrostomy was performed under ultrasonography guidance without fluoroscopy, and on the postoperative skiagram we realised that the tube was resting in the ureter (figure 4). Though the nephrostomy tube is intended not to traverse the pelviureteric junction, we did not withdraw the tip in the pelvis as we expected it to drain better. Generally, nephrostomy tubes that we employ are of soft material expected to cause minimal or no injury to the ureter. However, there is always a small risk involved and we were lucky not to have experienced any complications even though the curl was resting in the ureter. Subsequent to this the urinary leak from the vagina subsided. After 2 weeks, a nephrostomogram was performed (figure 5). It showed a dilated ureter with abrupt narrowing of the lower segment; however, the dye was passing into the bladder suggestive of a partial ureteric stricture. Although there was slight extravasation at the site of narrowing, no communication with the vagina was seen. This suggested obliteration of the fistula secondary to diversion. In lithotomy position under spinal anaesthesia, an 8×9.8 Fr ureteroscope was introduced in the right ureteric orifice and retrograde pyelography was carried out (figure 6). It showed a lower ureteric stricture about 2 cm proximal to the vesicoureteric junction with the dye passing across. We were unable to negotiate a hydrophilic guide wire (0.03500 Terumo) across the stricture (figure 7). The patient was turned prone and saline was pushed through the nephrostomy tube in an attempt to dilate the stricture. After several attempts we were able to negotiate a 0.03500 Zebra