FEMALE UROLOGY

The natural history of hydronephrosis after radical hysterectomy with no intraoperatively recognizable injury to the ureter: a prospective study
Paick SH, Oh SJ, Song YS, Kim HH
Departments of Urology and Obstetrics and Gynaecology, Seoul National University College of Medicine, Seoul, Korea
BJU Int. 2003; 92: 748-50

• Objective: To investigate, in a prospective study, the natural history of hydronephrosis of the urinary tract after radical hysterectomy.
• Patients and Methods: From December 1997 to March 2001, 34 patients with localized cervical cancer underwent radical hysterectomy by one gynaecologist, with no intraoperatively identifiable injury to the ureter. Intravenous urography was used routinely before and at 2 and 4 weeks after surgery. The degree of hydronephrosis was graded I - IV.
• Results: Urography before surgery showed no abnormal finding in any of the patients, except in one with a unilateral duplex kidney. Hydronephrosis was found in 10 units in the upper tract (grade II in eight, III in one and IV in one) in seven patients (21%) 2 weeks after surgery (one right, three left and three bilateral). All the ureteric narrowing was in the distal ureter. The hydronephrosis disappeared in four units in three patients, but became worse in two units in two patients with bilateral pathology in the fourth week. At 3 months after surgery no hydronephrosis had deteriorated and the hydronephrosis in all units had disappeared by 6 months. The presence of hydronephrosis was significantly correlated with pathological stage and age (P < 0.05).
• Conclusion: Hydronephrosis was detected after radical hysterectomy even with no intraoperatively recognizable injury to the ureter, but in most the hydronephrosis improved spontaneously and needed no ureteric stenting or surgical intervention.
  
  
• Editorial Comment
  The authors perform a prospective study on the natural history of hydronephrosis after radical hysterectomy. The population was limited to patients who had undergone radical hysterectomy by a single gynecologist with no intraoperative injury to the ureter. The patients were followed by radiographic imaging using intravenous urography preoperatively then again at 2 and 4 weeks postoperatively. Findings included the presence of hydronephrosis in 10 renal units out of the 34 patients who were included in the study. There was no serial increase in any noted hydronephrosis at the 3 month postoperative check-up and there was radiographic resolution all affected kidneys by 6 months. The value of this study lies in its assisting the urologist in understanding the natural history of incidental hydronephrosis after hysterectomy. Many times the consulting urologist noting this radiographic finding must make the diagnostic and clinical decision to perform ureteric stenting versus percutaneous nephrostomy tube or allow for watchful waiting. This study emboldens those urologists who wish to follow an asymptomatic patient conservatively. The authors should be commended on their study. The paper’s value may have been potentially increased if a comment could have been made on whether the patients had undergone cystourethroscopy after intravenous indigo carmine injection during the operation (1) to delineate ureteral patency; in addition, a description of the postoperative urinalysis and serum creatinine in all patients postoperatively with special emphasis on the patients with abnormal radiographic findings and a brief commentary on the patient’s symptoms and clinical examination would have been enlightening. One wonders based on this study, what the rate of incidental and clinically significant post operative hydronephrosis would be in patients with patent ureters checked intraoperatively with intravenous indigo carmine.

Reference
1. Pettit PD, Petrou SP: The value of cystoscopy in major vaginal surgery. Obst Gynecol. 1994; 84: 318-20.

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Medical School
Jacksonville, Florida, USA