Dilatation and curettage of urinary bladder: A rarity
Twenty-eight-year-old female, G4 P3 0 1 3, presented with a progressive decline in urine output for one month, fever, nausea and vomiting for two weeks. Detailed questionnaire revealed that she underwent medical termination of pregnancy by dilatation and curettage by quack, three months ago followed by profuse urethro-vaginal bleeding, urinary ascites and shock for which she was managed conservatively with parenteral fluid, blood component therapy, per cutaneous abdominal tube drainage in a local nursing home. After recovery from shock, the patient noticed a continuous leakage of urine per vaginam for two months followed by progressive decline in urine output for which she consulted various nursing homes with no relief and then she was referred to us. Since first surgery was done by untrained para-medical person, details of which was not available. Available records and frequent questionnaire from attendants could reveal that she had incurred massive vesico-urethral trauma during MTP.\nOn examination, the patient was pale, no pedal edema. Bilateral kidneys were palpable with mild tenderness and the bladder was not palpable. Locally, only vaginal opening with scarred area at the site of urethral orifice seen, anterior vaginal wall was lacerated. Cystoscopy, even with pediatric scope was not feasible.\nHer hemoglobin was 7.2 gm%, TLC-8800/cmm, P67%, L27%, M4% E2%, blood sugar-84 mg%, blood urea-108 mg%, serum creatine-3.9 mg%, serum Na-134 mEq/l and K-5.8 mEq/l. USG-abdomen showed bilateral kidneys enlarged with gross hydronephrosis and both ureters dilated till lower end and a small fibrotic bladder. Plain X-ray of KUB Kidney,Ureter,Bladder region and Electrocardiogram showed no abnormality. Bilateral Percutaneous nephrostomy (PCN were done under local anesthesia. Urine from bilateral PCN was cloudy, sent for culture sensitivity and the patient was put on antibiotic accordingly. When PCN urine culture report revealed no growth, 24 hour urine creatinine clearance from right kidney was 42 mg/ml/minute and from left kidney was 49 mg/ml/minute. After improving the general condition of the patient and when serum creatinine had returned to 1.2 mg%, bilateral antegrade pyelogram was done which showed the blind ending of ureters at lower end and no contrast in the bladder. Repeat sonography of KUB region showed that right kidney measures 10.2 × 4.5 cm in size and parenchymal thickness- 14 mm while left kidney measures 10.5 × 4.8 cm and parenchymal thickness- 15 mm. Both kidneys showed normal cortico-medullary differentiation. Moreover, there was good creatinine clearance from both kidneys, so intravenous urography IVU was omitted. Since there was no urethral opening, only scarring was present and further, bladder was a fibrotic remnant and non distensible on sonography, so voiding cysto-urethrography VCUG was not feasible. The patient was counselled for urinary diversion. She was neither willing to accept any kind of stoma, nor willing to perform clean intermittent catheterization CIC. She was planned for MAINZ II pouch. Pre-operatively, colonoscopy was done to exclude any bowel disease. She was given 300 cc saline enema to check for integrity of anal sphincter and one day prior to surgery, she received poly-ethylene glycol lavage. Under general anesthesia, she received single dose third generation cephalosporin just before induction and was explored through infraumbilical midline approach. Intra-operatively, both ureters were dilated and a fibrotic remnant of the bladder was present and anterior wall uterus was partially injured []. After identifying the rectosigmoid junction, colon was folded on itself, tagged with stay suture, detubularized by making inverted U-shaped incision (20 cm long) along antimesenteric border using cutting diathermy and posterior wall of the pouch was formed by closing in two layers. After making an incision in posterior peritoneum, right ureter was mobilized almost up to its midpoint. Left ureter was mobilized by incising along the line of toldt. Both ureters were reimplanted on posterior wall lateral to midline, via a 4 cm long submucosal tunnel using 5-0 Vicryl suture and were anchored on the posterior wall of the pouch. Both ureters were stented over 10F infant feeding tubes and brought out through anus by side of 30F flatus tube. After closing anterior walls of reservoir, pouch was fixed to periosteum of sacral promontory. Abdominal tube drain was inserted in pelvis. Flatus tube and infant feeding tubes were sutured to perianal skin. Post-op period remained uneventful. Abdominal tube drain and flatus tubes were removed on 4th post-op day. Infant feeding tubes were removed on 10th post-op day. Initially, she used to pass urine every 2-4 h, gradually day time frequency improved and she developed no nocturnal incontinence. At 3-year follow-up, serum electrolytes are normal and USG-KUB showed no dilatation of upper tract.