Cobra head sign of adult-type ureterocele incidentally discovered during pre-operative evaluation for fibroid uterus before abdominal hysterectomy

The female genital and urinary tracts are closely related, and there is potential risk of injury to one when operating on the other [1].
The risk of damage increases when the normal anatomy is altered by primary pathology or adhesions or when the normal anatomy is insufficiently identified intraoperatively during severe bleeding [1]. There are certain conditions that increase the risk of ureteral injuries as endometriosis, large ovarian masses, pelvic inflammatory disease (PID), pelvic malignancy, irradiation, adhesions, previous pelvic surgery, and broad ligament fibroids [2, 3]. Urinary tract injury complicates 0.2–1% of all gynaecological and pelvic operations [4]. Eighty-two percent of ureter injuries occur during pelvic surgery, and 75% of urinary tract injuries are due to gynaecological surgery [4]. Previous studies have recommended proper ureteric identification before hysterectomy for women with increased risk of ureteric injuries [2, 3].
This report represents a case report of multiple fibroid uterus discovered to have a left uncomplicated ureterocele, to highlight the value of following hospital policies and/or protocols, and the value of a multidisciplinary team approach in the management of such cases. In addition, the report highlights the value of ureteric identification either pre-operatively using the intravenous pyelography or intraoperatively using the direct ureteric identification, and/or ureteric catheterization for women at risk of ureteric injuries, to avoid such problems during surgery. A 49-year-old woman presented to the Gynaecology outpatients’ clinic of Ahmadi hospital, Kuwait, with menorrhagia over the last year due to multiple fibroid uterus diagnosed by magnetic resonance imaging (MRI) (Figure 1).
The studied woman signed a written consent form for abdominal hysterectomy, and the pre-operative investigations done for the studied woman according to the hospital protocol including the following: complete blood picture, liver, and kidney function tests, prothrombin time, and pre-operative intravenous pyelography, showed cobra head sign (spring onion sign) of the left ureter. Cobra head sign refers to dilatation of the distal ureter, surrounded by thin lucent line, which can be seen in adult-type uncomplicated ureterocele (Figure 2).
The lucent “hood” of the cobra represents the combined thickness of the ureteral wall and prolapsed bladder mucosa outlined by contrast material within the bladder...


View full text...