Ureteric Recovery Without Stenting After Intraoperative De-ligation During Cesarean Section: A Case Report

Urinary tract injury during cesarean section is uncommon, but the risk is much higher in the case of multiple sections due to dense adhesions. Bladder injury is the most frequent. Accidental ureteric injury is also rare; however, the combination of bladder rupture, ureteric ligation, and massive uterine artery hemorrhage in a single operation is what happened in our case. Current guidelines recommend the placement of a ureteric stent after de-ligation, but this is a situation in which stenting was not technically achievable. We report a case of a 36-year-old woman, gravida 4 para 2, with two previous cesarean sections, who underwent emergency lower segment caesarean section at 39+1 weeks of gestation. During the operation, she had a complete bladder rupture, with additional retractor-related injury to the left posterior bladder wall near the trigone; suture ligation of the left distal ureter in three places during attempted control of broad-ligament bleeding; and severe hemorrhage from a torn left uterine artery. The intraoperative hemoglobin fell to 5.43 g/dL. The urology team controlled the bleeding, removed the three ureteric sutures and confirmed ureteric continuity, and repaired the bladder in two layers over a suprapubic catheter. A leak test was done after the repair and was negative for leakage. A ureteric stent could not be placed during the operation for several reasons. The priority was to stabilize the unstable patient and finish the operation as quickly as possible, since she had already lost more than 3 liters of blood, and there was a delay in providing blood products from the blood bank. At the index operation, no ureteric stents, ureteric catheters, or guidewires were available in theatre, and urological endoscopic equipment was not immediately accessible. In addition, the retractor injury had obscured the left ureteric orifice, so even a small Nelaton ureteric catheter could not be placed retrogradely. Accordingly, the urologist decided to finish the procedure with a plan to place a stent or nephrostomy after resuscitation, after discussing the case in MDT. The patient received four units of packed red cells, two units of fresh frozen plasma, one unit of platelets, cryoprecipitate, and tranexamic acid, and her hemoglobin recovered to 11.5 g/dL by day 9. Two post-op contrast CT urograms (day 2 and day 11) showed no contrast extravasation and no hydronephrosis. Renal-bladder ultrasound at six months showed normal kidneys, normal cortical thickness on the de-ligated side, and no significant post-void residual urine. Serum creatinine remained normal throughout follow-up. This case shows that a distal ureter that is recognized and de-ligated early may recover function without ureteric stenting, even after major bladder injury and significant blood loss. Early urological involvement, immediate de-ligation, direct inspection of the ureter, and careful bladder repair were the key elements of a good outcome. The case may be useful for surgeons working in settings of limited resources.