Extensive Cellulitis as the First Symptom of Ureter Lesion After Laparoscopic Hysterectomy

Introduction

Increasingly, more specialists convert their practice of open surgery to a laparoscopic approach. Advantages of laparoscopic hysterectomy are less pain, quicker recovery, and better short-term quality of life. ¹ Otherwise, the incidence of postoperative ureter lesion is increased to rates between 0.3% and 4%.^2,3 Symptoms of ureter lesion present within 48–72 hours postoperatively and consist of fever, abdominal pain and/or pain in the flank, hematuria, ascites, peritonitis, leukocytosis, and/or rising creatinine. ² We present a case with extensive cellulitis of the first symptom of ureter lesion after a total laparoscopic hysterectomy.

Case Presentation

A 53-year-old woman presented at the outpatient clinic with dyspareunia, urinary incontinence, and pollakisuria. She previously underwent a laparoscopic adhesiolysis. Gynecological examination and transvaginal sonography demonstrated an enlarged uterus with myomas in both the anterior and posterior wall of 4 cm in diameter with insufficient descent for a vaginal hysterectomy. A total laparoscopic hysterectomy was performed to relieve patient's mechanical complaints. The procedure was uneventful. Both ureters were identified and prepared outside the working field. The bladder was dissected using monopolar coagulation and hampered by the anterior located myoma 3 × 4 cm in diameter. Additionally, the left ovary as well as the left tube were adhesive to the posterior wall of the uterus, but could be dissected easily. On the second postoperative day, the patient presented with a bulge of 10 × 4 cm around the right trocar incision and problems with micturition. After expectative management, the right side of the abdomen appeared red, tender, and swollen on the third postoperative day. Clindamycin was administrated intravenously because of the clinical suspicion of a urinary tract infection based on the urine sediment and the rise in C-reactive protein (183 mg/L). Urine culture demonstrated a Escherichia coli colonization of >10⁵. Additional abdominal sonography demonstrated minimal dilatation of left extrarenal pyelum, without dilatation of the ureter, and intra-abdominal free fluid. Serum creatinine was elevated till 110 μmol/L (normal range: 55–100 μmol/L). Subsequently, on computed tomography, leakage from the distal left ureter nearby the ureterovesical junction was observed. A nephrostomy catheter was placed, since the insertion of a Double-J catheter failed. In addition, an intraperitoneal drain was placed in Douglas pouch to withdraw the purulent free fluid. Twelve days after surgery, the patient recovered, serum creatinine returned to normal value, and the skin rash resolved. Six weeks after primary surgery, the patient underwent a re-anastomosis of the ureter by laparotomy. The postoperative period was uneventful, and she recovered completely 3 months after primary surgery. On final pathology, two myoma's were identified, the largest one of 3.8 cm in diameter, without other abnormalities. The total weight of the uterus was 220 g.

Discussion

To our knowledge, this is the first reported case of extensive cellulitis as the initial symptom of ureter lesion after total laparoscopic hysterectomy. It was suspected that the cellulitis was caused by E. coli, which was colonized out of the patients' urine. Recently, one other case report was published of an E. coli cellulitis as a complication after radical prostatectomy. It was speculated that because of insufflation of CO₂ in the abdomen, skin layers are cleaved and easily expand infections through all tissue layers. ⁴ E. coli bacteria are present in the gastrointestinal tract of healthy humans. Patients are more vulnerable because of decreased activity of the immune system, which can be exacerbated by operative procedures.

There is a discrepancy between the side of the lesion of the left ureter and the cellulitis at the right trocar incision. This could be explained by the patients' position in bed. As a result of the cleavage of the skin layers in all directions, the infection can be migrated to the right side even if originally from the left ureter leakage. Unfortunately, ureter lesions are more common in laparoscopic hysterectomies than in open and vaginal procedures. ¹ In the current case, thermal injury is most likely because there was some delay in the presentation of the symptoms, which is known to be characteristic for thermal and mainly monopolar damage. ⁵ When dissection of tissue is hampered during laparoscopic surgery, sharp dissection may be preferential to electro surgery to reduce the risk of thermal injury.

Conclusion

In this case report, we describe cellulitis as the first symptom of extended urinary tract infection in the abdomen caused by thermal ureter injury. Cellulitis should be treated with susceptible antibiotics, and additional imaging is necessary to rule out any urinary tract injury.