Black pearl in urology: Inadvertent anastomosis of gonadal vein to ureter leading to malpostioning of stent into the inferior vena cava

Double-J Stent Misplacement in the Inferior Vena Cava and Right Atrium: A Urovascular Nightmare

Ureteral injury may occur during abdominopelvic surgery given its anatomic path and proximity to surrounding organs. We present a case in which a patient required ureteral reimplantation following injury during a hysterectomy. The patient underwent a seemingly uncomplicated robotic ureteral reimplantation with ureteral stent placement. However, postoperative imaging demonstrated extension of the stent from the bladder to the right atrium. It appeared that the gonadal vein was reimplanted rather than the ureter. In a combined urology-vascular surgery case, gonadal vein implantation into the bladder was confirmed. Through-and-through access from the right internal jugular vein to the urethra was established. The ureteral stent was removed and the gonadal vein was embolized, with urology follow-up for planning and scheduling of ureteral reimplantation. Vascular involvement by ureteral stents has considerable risks and often requires further surgery. Ureteral injury can occur even in the hands of experienced surgeons and has a considerable impact on patients. Recognizing important anatomy and using operative techniques to differentiate from nearby structures, such as the gonadal vein, may help in preventing ureteral injury and assisting with repair of ureteral injury.

Patient summary

We describe a case in which a patient had an injury to her ureter, the tube that transports urine from the kidney to the bladder. When trying to repair this, a blood vessel (the gonadal vein) instead of the ureter was accidentally connected to the bladder. We discuss the resulting complications and management, similar cases, and important anatomy concepts and surgical techniques to prevent this type of injury.