Bilateral Retrograde Ureteric Passage of Contrast Medium During Hysterosalpingography: a Case Report

J Cases Obstet Gynecol, 2016;3(2):45-49

J o u r n a l o f C a s e s i n Obs tetrics & G ynecology

Case Report

Bilateral retrograde ureteric passage of contrast medium during hysterosalpingography: A case report

Dinçer Sümer1,*, Muhammed Emin Öz2, Gülizar Özer2, Ali Yanik2

1Bitlis State Hospital, Bitlis, Turkey 2Cumhuriyet University Faculty Of Medicine Department of Obstetrics and Gynecology, Sivas, Turkey

Abstract

A 30-year-old patient, has not been conceived for fifteen years, was evaluating for infertility via hysterosalpingography. In the course- ofexam ination after inserting the canulla to the external cervical ostium, medium performed gently through cervical canal. Cervical canal, uterine cavity and bilaterally fallopian tubes distended by medium, respectively. Contrast medium poured onto peritoneum and as soon as pouring, suddenly, ascended bilaterally and synchoronously, enlarged and branched at the level of second lumbal vertebral silhuette which is indicating the kidneys. Bilateral linear, thin and sharp contoured images were ureters. We reported this unusual case whom intravenous-pyelogram, magnetic resonance imaging and intraoperative findings were inefficient for explaining of this retrograde passage of medium.

Key Words:

Retrograde, ureter, hysterosalpingography

Introduction Case Presentation

Hysterosalpingography (HSG) is the most commonly A 30-year-old, gravida 0, para 0 patient admitted to clinic used technique for evaluating infertility and used to assess for infertility for fifteen years. There was only tiroidectomy the anatomy of the uterus and the patency of the fallopian operation, and any other operation or instrumentation was tubes [1]. Occasionally, during performing HSG contrast not notable at her medical history. Uterus was found en- medium transudes into the venous and lymphatic canals larged at pelvic examination. Transvaginal ultrasonography and thereby to the systemic circulation and known as in- showed 60x55 mm sized hypoechogenity suggesting an travasation. The presence of contrast within the bladder intramural leiomyoma arising from posterolateral portio of and ureters after a time later, indicates the clearance of me- uterus and normally ovaries with 6-7 antral folicules. There dium from the vascular circulation [2]. Here we report an was not ascites or fluid at posterior cul de sac. She had reg- extraordinary passase of contrast into ureters and thereby ular menstruation periods and serum follicle stimulating kidneys, a retrograde cruise, in an infertile patient and has hormone (FSH), luteinising hormone (LH) and estradiol not associated with intravasation or vascular clearence. (E2) levels were with normal range at third day of cycle.

Article History: A cervical Papanicolaou test taken and revealed normally. Received: 03/04/2015 HSG was planned at early proliferative period of menstrual Accepted: 21/04/2015 cycle. In the course of procedure at dorsal lithotomy po- *Correspondence: Dr. Dincer Sumer sition, after inserting sterile speculum, cervix hold by one Address: Bitlis State Hospital, Bitlis, Turkey Tel: 05073432971 E-mail: [email protected] 45 Journal of Cases in Obstetrics & Gynecology J o u r n a l o f C a s e s i n Obs tetrics & G ynecology teeth tenaculum. The canulla inserted to the external cervi- Patient turned side to right decubitis position and sco- cal ostium then contrast medium performed gently through py studied again. The echogenity was beginning from the cervical canal. Hydrosoluble iodized contrast medium posterior cul de sac, curving and ascending at anteri- (Omnipaque; Nycomed, Amersham, UK) 20 mL was slow- or of uterus in the pelvis minor, and became closer to ly administered with fluoroscopic guidance. Cervical canal the silhuette of vertebras on pelvis major (Figure 2). and uterine cavity distended respectively at the scopy. Mini- mal filling defect at fundus was suggesting subseptus. Irreg- Figure 2. ular, reticular, round like contour appeared at right posterolateral side of uterus, due to intravasation, pointed out the leiomyoma demonstrated by ultrasonography before simul- taneously passage of medium through the fallopian tubes bilaterally, slowly at left side, and pouring into the peritoneum. As soon as pouring, the hypoechoic image of contrast medium, ascended as a thin line originating from the lateral borders of fallopian tubes bilaterally, curved to the medial and became closer to the lumbal vertebras symmetrically, than enlarged and branched synchronously and terminated at the level of first-second lumbal vertebra silhuette in few seconds. The hypoechogenity of contrast medium was distending cervical canal, uterus, fallopian tubes and was pointing out the leiomyoma, peritoneum and the unusual bilateral ascending image at the sametime (Figure 1).

Figure 1.

Right lateral decubitis graphy showing contrast medium ascending at posterolateral abdominal wall

Total duration up to this moment starting from performing the medium though the cervical canal was approximately ten seconds. Half an hour later the hypoechogenity of medium demonstrated at the distending bladder compatable with vasculer clearence (Figure 3). The procedure was terminated and further in- vestigation planned electively. Intravenous-pyelogram and voiding cystography performed for evaluating the urinary system and graphies showed kidneys at their well-known location, ureters and bladder, without duplication or leak- Contrast medium presenting at uterine cavity, fallo- age of medium (Figure 4). Reflux was not determined at pian tubes and bilateral ureters at the same time

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voiding cystography. There was only 6x6x7 cm heteroge- Diagnostic hysteroscopy and myomectomy via laparato- nous hypointence mass as pathologic finding at right pos- my planned for assessment of endometrial cavity and sus- terolateral side of uterus at Magnetic Resonance Imaging. picious filling defect of subseptus and enucluation of the Endometrial sampling revealed proliferative endometrium. posterolateral located leiomyoma causing enlargement and distortion of uterus and for restoration of the uterine anat- Figure 3. omy but patient was lost for follow- up. Approximately two years later, patient preparated for operation. During hysteroscopy cervical canal and left tubal ostium seemed normally, right tubal ostium was deplaced and endometrial cavity was distortioned by external compression. Intramu- ral leiomyoma, 8x8cm sized at posterolateral side of uterus, found at laparotomy. Fallopian tubes were adherent to posterior cul de sac but ovaries were normally. There was not any visible endometriotic implants or ascitic fluid. Figure 4.

Distending bladder 30 minutes after performing medium competible with retardation of vascular clearence mechanism

Normally Intravenous-pyelogram of patient

47 Journal of Cases in Obstetrics & Gynecology J o u r n a l o f C a s e s i n Obs tetrics & G ynecology

Methilene blue was applied from cervix, for chromo-per- cular clearence mechanism. This unusual periton-ureteral tubation, but it was inefficacious. Although myomectomy, passage may be a cause of infertility via discomposing the adhesiolysis and distal salpingoplasty established, minimal peritoneal habitus and may misdiagnosed as intravasation. dye hardly passed through fallopian tubes. Biopsy has been Patient was given doksisiklin medication for infection taken from peritoneum for pathological examination. A drain profilaxis due to intravasation via leiomyoma [3]. Al- with negative pressure placed at posterior cul de sac and op- though embolism due to oil soluble contrast medium eration was terminated. Postoperative at third hour the color has been reported there was not any reports about em- of urine was bluish-green. There was 130 mililiter serous bolism due to water soluble media so anticoagulant liquid in drain at morning after. Creatinine level of incoming use for such indication is not clear [4]. Patient was not analised and it was similar with blood serum. Any medical given anticoagulant medication with subsequent data. or surgical complication has occured and patient discharged Deep infiltrating endometriosis (DIE) - usu at postoperative third day. Final pathologic examination ally involves the uterosacral ligaments, the revealed endosalpingiosis and degenerating leiomyoma. rectovaginal space, the upper third of the posterior vaginal wall, the bowel, and the urinary tract. Chapron et al. report- Discussion ed ureteric DIE at 2.1% of their 426 patients suffering from pelvic pain [5]. There was not narrowing segments at ureter- HSG is the only radiologic procedure routinely performed ic image at intravenous-pyelogram and visible endometriot- in the initial evaluation of the infertile woman and used to ic implants on peritoneum at laparatomy. Also peritoneal assess the anatomy of the uterus and the patency of the fal- biopsies did not revealed histological proved endometriosis. lopian tubes [1]. The venous and lymphatic intravasation in Endosalpingiosis refers to the presence of ectopic tub- uterine and adnexal vessels is acomplicated disorder which al-type ciliated glandular epithelium which resembles the occurs due to progressive destruction and ulceration of en- normal endosalpinx [6]. Lesions of endosalpingiosis have dometrium. The most important cause of intravasation is been found to involve pelvic parietal and visceral peritone- the transudation of contrast medium into the venous and um, omentum , pelvic lymph nodes, the appendix, intestine, lymphatic canals through unprotected vessels. The pres- uterine corpus skin and urinary bladder [7,8]. Li et al. re- ence of contrast within the bladder and ureters indicates ported ureteric involvement of endosalpingiosis [9]. Clem- the clearance of contrast from the vascular circulation so it ent et al. reported transmural involvement of the uterine get times after the process [2]. In this unusual case contrast cervix and lower uterine segment and contiguous corpus in medium distended and pointed out cervical canal, uterine the two cases with uterine involvement [10]. The capability cavity, leiomyoma, fallopian tubes respectively. Meanwhile of transmural involvement at endosalpingiosis lesions sug- the medium poured into the posterior cul de sac and as- gests potential role at passage of medium but unilateral pas- cended, branched and terminated at the level of kidneys. sage, confirmed by patency of ureters at IVP and analysis The medium was presented at uterine cavity, leiomyoma, of incoming of abdominal drain, refutates this suggestion. fallopian tubes, posterior cul de sac, ascending thin line Lymphatic stomatas are small openings of lymphatic cap- ‘ureters’ and kidneys at the sametime. The duration was illaries on the free surface of the mesothelium. The perito- only few seconds up to this moment. The retrograde cruise neal cavity is connected with lymphatic system via these of contrast, which is not compatable with pelvic veins, and small openings, which have the function of active absorp- occurance in a few seconds rules out the vascular clearence tion. The ultrastructure of the lymphatic stomata and their mechanism and confirms the passage of medium into the absorption from the body cavities are important clinically, ureters directly from peritoneum. The hypoechogenity of such as ascites elimination, neoplasm metastasis, and in- medium was seen as distending the bladder half an hour flammatory reaction [11]. Lymphatic stomata may -be as later which was compatable with retardation of the vas- sociated with peritoneal absorption but it is insufficient for explanation of passage of medium into the ureters.

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The location, origin and cruise of contrast medium sug- Acknowledgement gests the ureteric association, enlarging and branching None at terminal, like renal pelvis supported this suggestion. Conflict of Interest Statement There was not abnormality at imaging studies about uri- The authors declare no conflict of interest nary system and any pathologic findings except leiomyoma at laparatomy. Creatinine level of drain incoming rules out fistulas. As a result we suggest the contrast medium passed through peritoneum into ureters and thereby kidneys via retrograde cruise but we couldn’t ex- plain the occurance of this situation with our knowledge.

References

1. Stovall DW. The role of hysterosalpin- trast medium. Respirology. 2004 Mar;9(1):134-6 chemistry. Int J Surg Pathol. 2010 Oct;18(5):381-3 gography in the evaluation of infertil- 5. Chapron C, Chopin N, Borghese B, Foulot H, Dousset 9. Li WM, Yang SF, Lin HC, Juan HC, Wu WJ, Huang ity. Am Fam Physician. 1997;55:621-28 B, Vacher-Lavenu MC,et al. Deeply infiltrating endo- CH,et al. Müllerianosis of ureter: a rare cause of hy- 2. Ahmadi F, Zafarani F, Shahrzad GS. Hystero- metriosis: pathogenetic implications of the anatomi- dronephrosis. Urology. 2007 Jun;69(6):1208.e9-11 salpingographic Appearances of Female Genital cal distribution. Hum Reprod. 2006 Jul;21(7):1839-45 10. Clement PB, Young RH. Florid cystic en- Tract Tuberculosis: Part II: Uterus. Int J Fertil Ster- 6. Heinig J, Gottschalk I, Cirkel U, Diallo R. Endosalpingio- dosalpingiosis with tumor-like manifestations: il. 2014 Apr;8(1):13-20. Epub 2014 Mar 9. Review sis—an underestimated cause of chronic pelvic pain or a report of four cases including the first report- 3. Lindequist S, Justesen P, Larsen C, Rasmus- an accidental finding? A retrospective study of 16 cas- ed cases of transmural endosalpingiosis of the sen F. Diagnostic quality and complications of es. Eur J Obstet Gynaecol Reprod Biol 2002;103:75–8.). uterus. Am J Surg Pathol. 1999 Feb;23(2):166-75 hysterosalpingography: oil- versus water-sol- 7. Hesseling M, de Wilde R. Endosalpingiosis in lapa- 11. Wang ZB, Li M, Li JC. Recent advanc- uble contrast media--a randomized prospec- roscopy. J Am Assoc Gynaecol Laparosc 2000;7:215–8. es in the research of lymphatic stomata. Anat tive study. Radiology. 1991 Apr;179(1):69-74. 8. Maniar KP, Kalir TL, Palese MA, Unger PD. En- Rec (Hoboken). 2010 May;293(5):754-61 4. Uzun O, Findik S, Danaci M, Katar D, Erkan dosalpingiosis of the urinary bladder: a case of L. Pulmonary and cerebral oil embolism after probable implantative origin with characteri- hysterosalpingography with oil soluble con- zation of benign Fallopian tube immunohisto-

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