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337 - ORIGINAL FLOW CHART FOR THE MANAGEMENT OF HYDROURETERONEPHROSIS AFTER PESSARY PLACEMENT

337

ORIGINAL FLOW CHART FOR THEMANAGEMENT OF HYDROURETERONEPHROSIS AFTER PESSARY PLACEMENT

M. BALZARRO, E. RUBILOTTA, A.PORCARO, N. TRABACCHIN, M. CERRUTO, W. ARTIBANI;
Urology, AOUIVerona, Verona, Italy.

Introduction: The use of apessary to treat a pelvic organ prolapse (POP) is a validnon-invasive option that can improve quality of life with minorcomplications. Hydroureteronephrosis (HUN) is a potentially severecomplication in complete uterine prolapse due to concurrent ureteralmechanical compression and kinking, with the possibility of renalfailure. The reduction of a POP by pessary placement can resolve HUN.Pessaries have a reported complication rate of approximately 57.7%,with the main complications being vaginal abrasion and erosion, pain,vaginal discharge and constipation. Nevertheless, HUN, a rare butvery severe complication, can occur due to obstruction at thevesico-ureteric junction caused by the pessary.
Objective:We propose an original flow chart based on a review of the Literaturecoupled with our experience in the management of HUN as a consequenceof pessary placement. A Literature search showed that in the fewreported cases, management was mostly similar but some importantdifferences existed. We attempted to identify the most relevant andcommonly adopted steps in the diagnosis and management of these caseswith the aim of developing an original flow chart.
Methods:Literature search on pub-med was performed using the followingkeywords: pessary, pelvic organ prolapse, hydroureteronephrosis,renal failure, non-invasive intra-vaginal administration, computertomography scan, flow chart, complication.
Results: Areview of the Literature showed only four case reports1-2documenting a HUN secondary to pessary (Table I). All patients werein critical condition, with symptoms suggestive of uremia and/orurosepsis. All patients were old women with a history of pessary use.In all cases, the first imaging tool was Ultrasound Scan (US). Onlyin one case was a Computed Tomography (CT) scan conducted after US.Others diagnostic tests were: cystoscopy (Cysto), urine culture(UCX), intravenous pyelogram (IVP), percutaneous nephrostomy tube(PNT), and retrograde pyelogram (RGPG). In the Literature, we foundtwo more cases of neglected pessaries associated with a significantincrease of serum creatinine and urosepsis. In both patients, thepessaries were discovered accidentally and removed. In one case, thepessary was detected during bladder catheterization, and in theother, it was detected on abdominal radiography. The authors did notevaluate the patients with imaging tools, which would have beenuseful to exclude the presence of HUN3. In our experience,we were able to demonstrate by proper imaging how the pessary couldcreate an extrinsic compression, causing obstruction. Moreover, weevidenced for the first time the blockage of the distal ureter levelusing a 3D-CT scan. As in the other cases, HUN was associated withacute urinary failure. Due to the lack of urosepsis, it was possibleto apply conservative management consisting of the substitution ofthe device with a more appropriate one. Therefore, unlike in theother cases, we were able to identify the cause of the obstructionwith a 3D CT scan.
Conclusions: The suspicion of thepessary as the culprit is recommended in patients with a history oflong-term pessary placement, symptoms of urosepsis and/or uremia, andevidence of HUN. Based on Literature data and our experience, wepropose an original flow chart for the management of these patients(Figure 1)
References:

  1. ANZ J Surg.2015 Jan 12. doi: 10.1111/ans.12960.

  2. Scand JUrol Nephrol. 1993;27(3):419-20.

  3. Ann EmergMed. 1999 May;33(5):581-3.


TableI: Different management of HUN secondary to pessary in theLiterature.

Author,Year

MeinhardtW. 1992

DasguptaP. 1995

DuncanL.E. 1997

McGeeM. 2015

Ourdata 2016

Symptoms

anuria,urosepsis symptoms

uremiasymptoms

uremiasymptoms, urosepsis symptoms

urosepsissymptoms

none

Patientage

86

81

85

78

87

Serumcreatinine

166μmol/L

886μmol/L

141μmol/L

n.a.

122μmol/L

Leukocytes

18000/mm3

n.a.

17600/mm3

n.a.

10000/mm3

Urineculture

E.Coli

n.a.

ProteusMirabilis

KlebsiellaOxytoca

Negative

Antibioticuse

Yes

n.a.

Yes

Yes

No

HUN-Pfind

  • Blood test

  • UCX

  • US

  • CYSTO

  • IVP

  • RGPG

  • CTScan

  • Yes

  • Yes

  • No

  • No

  • Yes

  • No

  • No

  • Yes

  • No

  • Yes

  • Yes

  • Yes

  • No

  • No

  • Yes

  • Yes

  • Yes

  • Yes

  • No

  • Yes

  • No

  • n.a.

  • Yes

  • Yes

  • Yes

  • No

  • Yes

  • Yes

  • Yes

  • Yes

  • Yes

  • No

  • No

  • No

  • Yes

Sideof HUN

Bilateral

Leftsolitary kidney

Leftkidney

Rightkidney

Rightkidney

Pessary

Neglected

Neglected

Neglected

Misplaced

Misplaced

Treatment

  • Antibiotics

  • Cut of vaginalintroitus

  • Pessary Removal

  • Ureteraldilation

  • JJ stentplacement

  • PNT

  • Yes

  • Yes

  • Yes

  • No

  • No

  • No

  • No

  • No

  • Yes

  • No

  • Yes

  • Yes

  • Yes

  • No

  • Yes

  • Yes

  • Yes

  • No

  • Yes

  • No

  • Yes

  • No

  • Yes

  • No

  • No

  • No

  • Yes

  • No

  • No

  • No