No urinary jet – what now?

Posted 11 years ago

For an increasing number of major gynaecological operations guidelines suggest performing a cystoscopy to confirm the intactness of the bladder and the patency of the ureters. In the majority of cases, all will be good – but what are we supposed to do if bilateral urinary jets cannot be seen.

If you wish to think about possible causes yourself – WHAT’S WRONG??!!

Here I am sitting in the operating theatre, having just finished a challenging TLH, wanting to confirm that the urinary collecting system is intact. The cystoscope is inserted, and I can see that the bladder is intact. I can even identify the ureteric orifices (you find them on either end of the inter-ureteric ridge) by swinging the light source from one side to the other when you use a 30-degree cystoscope.

I wait and wait but …. I cannot see a jet form one or the other orifice. I waited now for 5 minutes and still no action. WHAT NEXT?

Check if the bladder is over-distended. You might have forgotten to turn the tap off and you still infuse water into the bladder. In some bladders the ureteric orifices get so compressed by the fluid pressure that urine cannot squirt through. Turn the incoming tap off, empty the bladder and start again. 100 to 200 ml should be plenty to give you sufficient distension.

Make sure that patient is hydrated well enough and receives enough i.v. fluids. Importantly, I always level my patient out or even reverse the Trendelenburg position and have the patient’s head slightly up. If the patient is in a head-down position, you will have hardly any show of urine.

Do you have the right distension medium? If you were given isotonic fluids for a diagnostic cystoscopy you might miss the urinary jet. I try to use water whenever possible. Water is hypotonic fluid and nicely visible as a jet within isotonic urine.

The ureter vermiculates – Is that a good sign? If the ureter would be transected, would it still vermiculate? It certainly does. The innervation of the ureter comes from the autonomous nervous system that encapsulates the ureter as a fine network. As gynaecological oncologists, we sometimes transect ureters and reimplant them into the bladder. I can confirm to you that a transected ureter vermiculates.

Lets go back to my patient. How good is that!!! For the first time I can see a urinary jet nicely blowing from one ureteric orifice. But not from the other. I wait, and wait longer. One is not showing anything. The ureteric orifice retracts, indicating ureteric peristalsis  - but no urine. Bloody hell! What next?

Do you have preoperative imaging (ultrasound, CT scan) of the kidneys available? The patient might have a solitary kidney for congenital reasons or because she had a nephrectomy previously, or she might have an atrophic (afunctional) kidney in which case we will wait for a very long time to see a urinary jet.

I heard of a case last week where a urologist was called into the operating theatre by my friend and colleague. The first thing the urologist did, was a laparotomy. My friend watched in dismay (This is a real case that really happened). “What the …?” At laparotomy, the urologist found that both ureters looked normal and were not transected. The ureters were not caught by a suture either. Lets close up and say “all good, then”. Or not.

The explanation is that a ureter can be suffering from postoperative paralysis, similar to the bowel after extensive dissection and manipulation.

A laparotomy would not be the investigation of my first choice. You should ask your scrub nurse for a ureteric catheter. Lets not confuse a ureteric catheter with a ureteric stent. A catheter is stiff and does not remain in. You can only “probe” a ureter with only minimal risk of perforation. I would only go for a laparotomy if a diagnosis of ureteric injury has been established. It appears to me the above woman had an unnecessary opening of the abdomen.

A ureteric catheter is a stiff catheter that usually is open at both ends. While it can be fiddly to insert it into the ureteric orifice of the bladder you can inject contrast dye for a retrograde pyelogram to visualise the ureters. A contrast stop will indicate a suture that tied off the ureter. If you use one of the vessel sealing devices for surgery you might have sealed and transected the ureter. That will also give you a contrast stop. The ureteric catherter will be removed at the end of the investigative procedure.

By contrast, a ureteric stent is soft, typically curled up at one or two ends (pig-tail) and requires a guide or a glide wire to introduce it into a ureteric orifice through cystoscopy. It can stay within the ureter for weeks. Urologists give me the impression that they are very happy for us gynaecologists to place ureteric catheters but not stents (there is some risk of perforation if you do it without intraoperative imaging).

I remember a patient who had a postoperative hydroureter. We took her to the operating theatre and at retrograde pyelogram (using a ureteric catheter) found that she had a kinking due to an overly long ureter (redundant ureter). There was actually no complication. We placed a ureteric stent, which sorted the problem and was removed after a few weeks..  

Should you not be able to fiddle the ureteric catheter into the ureteric orifices, call a urologist. While your colleague is coming, prepare for intraoperative X-Ray.  

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