Case Reports in Women’s Health 36 (2022) e00439 Contents lists available at ScienceDirect Case Reports in Women's Health journal homepage: www.elsevier.com/locate/crwh Solitary kidney functional damage due to caesarean ureteric injury monitored for 2 years after acute management: A case report Mahamudu Ayamba Ali a,*, Mawuenyo Attawa Oyortey a, Raymond Saa-Eru Maalman a, Yaw Otchere Donkor a, Kekeli Kodjo Adanu a, Mathew Yamoah Kyei b a Departments of Surgery and Basic Medical Science, School of Medicine, University of Health and Allied Science, Ho, Volta Region, Ghana. b Department of Surgery, University of Ghana Medical School, Accra, Ghana. A R T I C L E I N F O A B S T R A C T Keywords: Caesarean section with associated ureteric injuries that damage kidney function is uncommon. Such injury in Solitary kidney women with a solitary kidney has far-reaching effects if the diagnosis is delayed. The case report describes the Acute kidney injury successful acute management with stenting of ureteric damage after caesarean section in a woman with a solitary Ureteric injury kidney. Caesarean section A 29-year-old woman presented with anuria, hypertension (174/101 mmHg) and flank pain 3 days after caesarean section. Physical examination was significant for peri-orbital oedema, left flank tenderness, pallor and delirium. A diagnosis of acute kidney injury was confirmed by elevated blood urea and creatinine levels. An ultrasound scan revealed a solitary hydronephrotic left kidney. She had successful acute management at a resource-deprived facility, with normal renal function at a 2-year follow-up. Proteinuria lasted for about three months after surgery. Recovery of solitary kidney function with acute kidney injury due to caesarean section ureteric injury may be associated with prolonged proteinuria without evidence of further functional deterioration. 1. Introduction 2. Case Presentation Solitary kidney damage following an iatrogenic ureteric injury (IUI), A healthy 29-year-old woman, gravida 4, para 3, with 1 previous CS, although extremely rare, can have far-reaching consequences and be life presented for antenatal care at 13 weeks of gestation at a peripheral threatening if diagnosed late [1,2]. Over 70% of ureteric injuries (UIs) health facility. Her booking laboratory test results and obstetric ultra- are diagnosed late [2]. Lack of clear management guidelines and lack of sound scan were reported as normal. The pregnancy progressed un- facilities in low-resource settings are further challenges to successful eventfully. A term obstetric ultrasound scan documented an estimated management. The presence of a solitary kidney is independently asso- fetal weight (EFW) of 3.6 kg. ciated with an increased risk of chronic kidney disease (CKD) after The patient went into spontaneous labour, for which she was unilateral nephrectomy or congenital renal agenesis [3]. Thus acute admitted. Full blood count (FBC), blood urea, electrolytes, and creati- kidney injury following caesarean section (CS) ureteric injury in women nine (BUE & Cr) test indices were normal. The labour lasted over 16 h with a solitary kidney is a serious complication in obstetric practice. The without significant progress. A caesarean section was therefore per- reported increased incidence of CS ureteric injuries in parts of sub- formed and a live, normal male child with a birthweight of 4.1 kg was Saharan Africa and the high cost of treatment after delayed diagnosis delivered. Lower uterine segment adhesions were noted, and estimated [4–6] make reporting these cases important. blood loss was 800mls. Post-operatively, she was anuric and remained so for over 48 h despite a 5 L intravenous infusion (3 L crystalloids, 2 L blood) and administration of 260 mg of intravenous frusemide. She Abbreviations: IUI, Iatrogenic Ureteric Injury; UI, Ureteric Injury; CKD, Chronic Kidney Disease; CS, Caesarean Section; EFW, Estimated Fetal Weight.; FBC, Full Blood Count; BUE & Cr, Blood Urea, Electrolytes & Creatinine; URA, Unilateral Renal Agenesis; VBAC, Vaginal Delivery After Caesarean. * Corresponding author. E-mail address: aayamba@uhas.edu.gh (M.A. Ali). https://doi.org/10.1016/j.crwh.2022.e00439 Received 19 June 2022; Received in revised form 3 August 2022; Accepted 8 August 2022 Available online 10 August 2022 2214-9112/© 2022 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). M.A. Ali et al. C a s e R e p o r t s i n W o m e n ’s H e a l th 36 (2022) e00439 complained of left flank pain and intermittent breathlessness, necessi- tating her referral to a tertiary centre. On admission she was pale, febrile (temperature 38.3 ◦C), and had peri-orbital and bilateral pitting pedal oedema. The pulse rate was 110 beats/min, blood pressure 170/101 mmHg, and respiratory rate 31 cy- cles/min. She had coarse bi-basal crepitations, and SPO2–90% on at- mospheric air. The CS wound dressing was clean and dry. The uterine size was about 22 weeks and well contracted. The abdomen had signs of peritonism, tender with rebound tenderness. The urine bag contained less than 50mls of straw-coloured urine. Speculum examination revealed no urine leakage per vaginum. The initial investigations revealed a haemoglobin of 6.7 g/dL, White blood cell count 18.2 x 109/L, platelets count 224 x 109/L, urea 16.1 mmol/L, creatinine 367 umol/L, with negative hepatitis B, C, and retroviral screening tests. An ultrasound scan showed a hydronephrotic left kidney. The right kidney was not visualised (Fig. 1). A diagnosis of obstructive uropathy of a solitary kidney due to CS ureteric injury and intraabdominal sepsis was made. Preoperative resuscitation included intra-nasal oxygen, intravenous fluids (150mls/h over 3 h), metronidazole, ceftriaxone, and paraceta- Fig. 2. Distal 3rd right ureterostomy exposing a solid mass (benign by histo- mol. The lung bases were frequently auscultated to detect any worsening pathology) and flexible feeding tube insertion to localise ureteric orifice. bi-basal crepitations. No pre-operative dialysis was instituted though it was available. She was counseled for exploratory laparotomy to which both written and verbal informed consent were obtained. The procedure was done within 3 h of admission under general anaesthesia with endotracheal intubation. The findings at laparotomy were a dilated left ureter with kinking at the distal third near a traction suture in the parametrium. The left kidney was palpable. The right kidney was absent. There was a right ureteric stump that had an intra- luminal mass at the distal part (Fig. 2) and ended blindly with no right ureteric orifice in the bladder (Fig. 3). There was minimal intra- abdominal fluid. Release of the traction suture, cystostomy, J-J stent placement, and right ureterectomy was done. Intraoperatively, she had intravenous fluids infused at 375 ml/h over 4 h and a 1 L whole-blood transfusion. Her urine production improved after the ureteric obstruction was relieved. The immediate post-operative treatment included intravenous fluids, antibiotics, and analgesia. She had another 1 L blood transfusion at 48 h and was continued on oral antibiotics for 5 days. Her blood pressure and temperature normalised. Renal function improved within 2 weeks and she was discharged. She continued with a scheduled follow-up that included monitoring renal function over 2 years. (Table 1). Renal function remained normal at 2 years of follow up. 3. Discussion Adults living with undiagnosed solitary kidney are rare. Unilateral Fig. 3. Cystostomy with left double pig-tail stenting of left ureter after release of suture and absent right ureteric orifice at the bladder trigone. renal agenesis (URA), nephrectomy for disease control, and kidney donation are the common reasons why adults have a solitary kidney. With an estimated incidence of about 1 in 2000, renal agenesis is the commonest cause, with males being more affected [7]. The diagnosis of URA using ultrasound scan requires expertise and equipment which may be lacking in low-resource settings. Vaginal delivery after caesarean section (VBAC) frequently fails when the birthweight is >3.5 kg [8]. The EFW, which was 3.6 kg, was, therefore, an indication for a planned CS. The decision that led to attempted VBAC was probably drawn from practices in isolated centres where ultrasound EFW >3.5 kg is accepted for trial of labour after caesarean section [9,10]. As the actual birthweight was 4.1 kg we sug- gest that specialist ultrasound training should be encouraged in low- resource settings to improve obstetric care. During caesarean delivery, urine output of 0.5 ml/kg/h or greater is expected following a crystalloid infusion rate of 250mls/h for patients Fig. 1. CDU showing liver, psoas muscle and absent right kidney. 2 M.A. Ali et al. C a s e R e p o r t s i n W o m e n ’s H e a l th 36 (2022) e00439 Table 1 Presentation and follow-up parameters. Parameter Presentation Discharge 3 months 6 months 12 months 18 months 24 months Blood pressure(mmHg) 170/101 132/84 138/88 112/78 126/82 118/80 125/86 Urea(mmol/L) 16.1 7.2 5.4 6.1 5.8 4.3 4.8 Creatinine/umols/L 367 144 98 111.2 117.6 108 94.2 Proteinuria N/A ++ + nil nil nil nil Leucocytosis N/A nil nil ++ nil nil + References value: urea [2.1–7.1], creatinine[45.0–115.0]. with stable vital signs peri-operatively. The infusion of 3 L of crystalloid committee of the Ho Teaching Hospital with reference HTHREC (15) FC- and 2 L of blood, which failed to produce urine despite 260 mg fruse- 2022 was granted. mide administration, at the primary facility was a departure from the standard management. Such clinical progression was sufficient to trigger Provenance and peer review early recognition and referral of a possible ureteric injury. Anuria and left flank pains were consistent with iatrogenic ureteric ligation and This article was not commissioned and was peer reviewed. were further suggestive of unilateral involvement [2]. Most caesarean ureteric injuries occur at the distal third segment due Conflict of interest statement to haemostatic suture placement in an extended uterine incision to control bleeding within the broad ligament [11–13]. Previous caesarean The authors declare that they have no conflict of interest regarding section scar and adhesions made dissection difficult in this case [2]. the publication of this case report. Recovery was characterised by transient proteinuria during the follow- up period (Table 1). We initially believed this proteinuria was an early References sign of a possible progression of renal impairment since the pregnancy period urinalysis was normal. It resolved within three months, however. [1] G. Lucarelli, P. Ditonno, C. Bettocchi, G. Grandaliano, L. Gesualdo, F.P. Selvaggi, et Even though renal function was normal after 2 years, there are still al., Delayed relief of ureteral obstruction is implicated in the long-term development of renal damage and arterial hypertension in patients with unilateral concerns about development of CKD in the future. ureteral injury, J. Urol. 189 (2013) 960–965. [2] J. Mensah, G. Klufio, F. Ahiaku, C. Osafo, S. Gepi-Attee, Delayed recognition of 4. Conclusion bilateral ureteral injury after gyneacological surgery, Ghana Med. J. 42 (4) (2008) 133–136. [3] S. Kim, Y. Chang, Y.R. Lee, H.S. Jung, Y.Y. Hyun, K.B. Lee, K.J. Joo, K.E. Yun, Anuria with unilateral flank pain after CS should alert health care H. Shin, S. Ryu, Solitary kidney and risk of chronic kidney disease, Eur. J. practitioners to the possibility of ureteric injury. Recovery of solitary Epidemiol. 34 (9) (2019 Sep) 879–888, https://doi.org/10.1007/s10654-019- 00520-7. Epub 2019 Apr 25. PMID: 31025238. kidney function due acute CS ureteric injury may be associated with [4] S.M. Eisenkop, R. Richman, L.D. Platt, R.H. Paul, Urinary tract injury during prolonged proteinuria without evidence of further functional cesarean section, Obstet. Gynecol. 60 (5) (1982 Nov) 591–596. PMID: 7145252. deterioration. [5] A. Field, R. Haloob, Complications of caesarean section, Obstet. Gynaecol. 18 (2016) 265–272, https://doi.org/10.1111/tog.12280. [6] O. Lawal, O. Bello, I. Morhason-Bello, R. Abdus-Salam, O. Ojengbede, Our Contributors experience with iatrogenic ureteric injuries among women presenting to university college hospital, Ibadan: a call to action on trigger factors, Obstet. Gynecol. Int. 2019 (2019 Feb 10) 6456141, https://doi.org/10.1155/2019/6456141. PMID: Mahamudu Ayamba Ali contributed to patient management and data 30881457; PMCID: PMC6387707. collection, and drafted and edited the manuscript. [7] Rik Westland, Michiel F. Schreuder, Johannes C.F. Ket, Joanna A.E. van Wijk, Mawuenyo Attawa Oyortey contributed to patient management and Unilateral renal agenesis: a systematic review on associated anomalies and renal data collection, and edited the manuscript. injury, Nephrol. Dial. Transplant. 28 (7) (July 2013) 1844–1855. [8] J.D. Seffah, K. Adu-Bonsaffoh, Vaginal birth after a previous caesarean section: Raymond Saa-Eru Maalman contributed to the literature review and current trends and outlook in Ghana, J. West Afr. Coll. Surg. 4 (2) (2014 Apr-Jun) drafted the manuscript. 1–25. Yaw Otchere Donkor contributed to the literature review and drafted [9] E. Nkwabong, J.N. Fomulu, F.L. Djomkam Youmsi, Trial of labor after cesarean section among women with unique lower segment scarred uterus and fetal weight the manuscript. >3500 g: prognostic factors for a safe vaginal delivery, J. Obstet. Gynaecol. India Kekeli Kodjo Adanu contributed to patient management and data 66 (Suppl. 1) (2016 Oct) 202–206, https://doi.org/10.1007/s13224-015-0835-1. collection, and edited the manuscript. Epub 2016 Mar 3. PMID: 27651604; PMCID: PMC5016442. [10] Society of Obstetricians and Gynaecologists of Canada, SOGC clinical practice Mathew Yamoah Kyei helped shape the concept, and contributed to guidelines. Guidelines for vaginal birth after previous caesarean birth. Number 155 manuscript review. (Replaces guideline Number 147), February 2005, Int. J. Gynaecol. Obstet. 89 (3) All authors approved the final submitted manuscript. (2005 Jun) 319–331, https://doi.org/10.1016/j.ijgo.2005.03.015. PMID: 16001462. [11] T. Basturk, Y. Koc, Z. Ucar, T. Sakaci, E. Ahbap, E. Kara, F. Bayraktar, M. Sevinc, Funding T. Sahutoglu, A. Kayalar, A. Sinangil, C. Akgol, A. Unsal, Renal damage frequency in patients with solitary kidney and factors that affect progression, Int. J. Nephrol. 2015 (2015), https://doi.org/10.1155/2015/876907. Article ID 876907, 7 pages. This work did not receive any specific grant from funding agencies in [12] C.T. Yeong, T.L. Lim, K.H. Tan, Ureteral injuries in an obstetric and gynaecology the public, commercial, or not-for-profit sectors. teaching hospital, Med J Malaysia 53 (1) (1998 Mar) 51–58. PMID: 10968138. [13] P.L. Chalya, A.N. Massinde, A. Kihunrwa, et al., Iatrogenic ureteric injuries Patient consent following abdomino-pelvic operations: a 10-year tertiary care hospital experience in Tanzania, World J. Emerg. Surg. 10 (2015) 17, https://doi.org/10.1186/ s13017-015-0011-z. The patient consented to the publication of the report and any accompanying images. Ethical approval from the research and ethics 3