What is the management of post cesarean section (CS) ureteric obstruction?

From the Guidelines

Management of post-cesarean section ureteric obstruction requires prompt intervention with a stepwise approach, starting with placement of a ureteral stent or percutaneous nephrostomy to relieve the obstruction and preserve renal function, as recommended by the 2023 WSES guidelines 1. Initial management should be guided by the severity and cause of the obstruction, with supportive care including pain management with NSAIDs like ketorolac 30mg IV every 6 hours or oral analgesics, adequate hydration, and monitoring of renal function through serum creatinine and electrolytes. Antibiotics are necessary if infection is present, typically with broad-spectrum coverage such as ceftriaxone 1-2g IV daily or piperacillin-tazobactam 3.375g IV every 6 hours until culture results guide targeted therapy. Some key points to consider in the management of post-cesarean section ureteric obstruction include:

• The use of CT urography with both nephrographic and excretory phases as the gold standard technique for diagnosing ureteral injuries 1
• The importance of early intervention to prevent permanent renal damage, with the best outcomes achieved when treatment begins within 2-3 weeks of injury
• The role of minimally invasive techniques, such as percutaneous nephrostomy tube placement and wire recanalization of the ureteral lumen, in the management of ureteral injuries 1
• The need for close follow-up with serial imaging to ensure resolution of the obstruction and preservation of renal function
• The potential for surgical intervention, including ureterolysis, ureteral reimplantation, or ureteroneocystostomy, in severe cases involving suture entrapment or thermal injury 1.

From the Research

Management of Post Cesarean Section (CS) Ureteric Obstruction

• The management of post CS ureteric obstruction involves early recognition and immediate repair of damage 2.
• Ureteral catheterization via a cystoscope or directly through the orifices should be considered the modality of choice to assess ureteral intactness 2.
• Continuous urinary leakage and acute abdominal distention associated with fluid accumulation after emergency CS should be considered as "red flag" symptoms of ureteral injury and ureterouterine fistulae complications 3.
• Delayed management for ureteral repair may not be associated with bad outcomes for management of ureterouterine fistula, and may be associated with less blood loss, less operating time, and acceptable outcome among patients with ureterouterine fistulae when the renal function is not compromised 3.

Treatment Options

• Treatment options for post CS ureteric obstruction include ureteroneocystostomy, ureteroneocystostomy with Boari flap, transureteroureterostomy, and ureteral stenting via ureterocystoscopy 3.
• Percutaneous nephrostomy (PCN) and retrograde ureteral stenting (RUS) are also effective for the decompression of an obstructed urinary system, with no significant difference in most outcomes 4.
• PCN is preferable to RUS because of its reduced impact on the patient's post-operative quality of life due to haematuria and dysuria, although it is associated with slightly longer hospitalisation duration 4.

Risk Factors and Prevention

• Surgeon inexperience is the prime risk factor for urological injury during CS and hysterectomy 5.
• Improved anatomical knowledge is the leading preventative strategy for urological injury during CS and hysterectomy 5.
• Physiological changes in pregnancy may also act as a significant risk factor for accidental instrumentation of a ureter during Foley catheter insertion at the time of CS 6.