Obstructive uropathy secondary to accidental ureteric placement of indwelling urinary catheter at time of caesarean section

doi:10.21203/rs.3.rs-4287574/v1

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Case Report

Obstructive uropathy secondary to accidental ureteric placement of indwelling urinary catheter at time of caesarean section

https://doi.org/10.21203/rs.3.rs-4287574/v1

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This case describes a rare complication of Foley catheter insertion where accidental instrumentation of a ureter occurred at time of caesarean section with subsequent development of bladder obstruction and acute kidney injury. This has only been documented in literature a handful of times however rapid identification and management can minimise associated long term implications. As such this necessitates greater awareness of this possible complication and risk factors such as pregnancy that may predispose patients.

“Caesarean” “ureteric instrumentation” “obstructive uropathy” “bladder obstruction” “kidney injury”

Foley catheter insertion is routine practice both at time of caesarean section and in labour for certain indications. We describe a case where a catheter was inserted at time of caesarean section where it was accidentally placed and inflated in the left ureteric orifice, a complication not discovered until the following day. On review of the literature there is a potential of increased risk of misplacement into the ureters in the context of the gravid uterus altering the position of the uretero-vesical orifices and physiologic hydronephrosis associated with pregnancy. We also explore methods of identifying potential aberrant catheter placement to allow for earlier diagnosis which is particularly important in this population who often have altered sensation in the context of epidural or spinal analgesia.

A 31-year-old female underwent an uncomplicated lower segment caesarean section (LSCS) at term for DCDA twins where an indwelling catheter (IDC) was placed after administration of spinal anaesthesia for an elective LSCS. The following morning a medical review was requested for urine output of 0.2ml/kg/hr of dark concentrated urine which had not improved overnight despite significant fluid resuscitation. Biochemical analysis showed a significant acute kidney injury with a creatinine of 120. Throughout the proceeding hour she developed significant abdominal pain and CT confirmed IDC tip was protruding 5cm into the left ureter with bilateral hydronephrosis. Retraction of the catheter resulted in decompression of the bladder and resolution of the obstructive uropathy. Subsequent follow-up ultrasound confirmed no evidence of long term complication.

This is a notably rare complication of urinary catheter placement however of the small number of known cases the identified risk factors tend to be female sex and neurogenic bladder (1).

On review of the literature, we have found five other cases documented in pregnant or immediately postpartum patients (2–6). Physiological changes in pelvic anatomy in pregnancy such as hydronephrosis may contribute to the risk of this complication (2, 4). Of these cases, majority in pregnancy are involving the right ureter rather than the left. Dilation of the right ureter in pregnancy is a known phenomenon and may explain the higher incidence of accidental instrumentation however interestingly the contralateral side was instrumented in this case (7, 8). Furthermore, females are deemed at higher risk due to a shorter urethra (9). The gravid uterus in the setting of twin pregnancy may have caused protrusion of the ureteric orifices in line with the urethral orifice thus leading to the accidental instrumentation. Proposed methods of identification include recognition of increased length of catheter inside the patient, reduced urine output non-responsive to fluid resuscitation and acute kidney injury (2, 9). Our patient also had pain secondary to bladder distension despite a draining catheter. A significant proportion of patients also developed pyelonephritis however of this group none were pregnant or postpartum, presumably due to need for longer term catheterisation in order to predispose them to this complication than typically seen in the post-operative or postpartum population (7).

Whilst this is an exceedingly rare complication practitioners should consider this in addition to other causes in patients who are oliguric post caesarean section and further investigate with thorough examination, biochemical analysis and imaging if indicated.

This case underscores the importance of vigilance during catheter placement, particularly in the context of caesarean sections due the anatomical shift to pelvic organs caused by a gravid uterus. Although an exceedingly rare complication, obstructive uropathy due to ureteric catheter misplacement demands consideration in the differential diagnosis of postoperative oliguria. A heightened awareness among practitioners can facilitate early identification, prompt intervention, and prevention of potential long-term complications.

Indwelling catheter (IDC)

Lower Segment Caesarean Section (LSCS)

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Consent to participate: written consent was attained for publication from the patient concerned.

Availability of data and materials: Not Applicable

Competing interests: The authors declare they have no competing interests

Funding: No funding declared

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All authors read and approved the manuscript

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No competing interests reported.

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Obstructive uropathy secondary to accidental ureteric placement of indwelling urinary catheter at time of caesarean section

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