An unusual cause of voiding dysfunction following colposuspension

Case report In April 1997 a 43-year-old woman presented to the department of urogynaecology complaining of symptoms suggestive of stress incontinence. She was multiparous, having had two children delivered by caesarean section, a spontaneous vaginal delivery at term and a mid-trimester miscarriage at 20 weeks gestation. Having contracted tuberculosis as a child she complained of mild asthma but had no other relevant medical or gynaecological history. Videocystourethography was performed and confirmed severe genuine stress incontinence with a normal pressure-flow study and no urinary residual. She was initially managed conservatively with pelvic floor exercises, but as there as no improvement in her symptoms she underwent a colposuspension in July 1997. A standard open Burch colposuspension was performed under general anaesthesia with the insertion of a suprapubic catheter. The procedure was uncomplicated and there were no postoperative voiding problems. The catheter was left on free drainage for 48 hours following which it was clamped and released in keeping with the departmental protocol. She was discharged on the fifth postoperative day when she had urinary residuals less than 100 ml and when seen in clinic at 6 weeks was, subjectively, cured. As is standard practice in our unit following continence surgery she was invited for repeat urodynamic studies 6 months later, although she failed to attend. No further follow-up was arranged. In September 2000 she was admitted through casualty with 3-week history of abdominal pain and distension, vomiting, pyrexia and weight loss in addition to urinary and faecal incontinence. On clinical examination she had a grossly distended abdomen with a mass arising from the pelvis. Investigations on admission revealed the following: haemoglobin 10.1 g/dl, white cell count 32.5 10/l, sodium 128 mmol/l, potassium 5.0 mmol/l and creatinine 766 mmol/ l. A urethral catheter was inserted and 2,500 ml drained from the bladder over 1 hour. A diagnosis of acute renal failure secondary to sepsis was made and she was admitted under the care of the general surgeons. Subsequent blood cultures confirmed a Klebsiella septicaemia while urine cultures showed a heavy mixed growth. She responded well to intravenous gentamicin and Tazocin (Wyeth, Berkshire, UK) and her renal function continued to improve with free drainage and intravenous fluids. CT scan of the abdomen and pelvis at this time was unremarkable, except for some small volume para-aortic lymphadenopathy. A urogynaecological opinion was sought. Despite improving renal function she remained unwell. Pelvic examination revealed a large tumour adherent to the anterior vaginal wall and the pubic symphysis. Transvaginal ultrasound showed a 2.8 cm paraurethral mass while colour flow Doppler was suggestive of neo-vascularisation. The uterus, cervix and ovaries appeared normal. In light of the ultrasound findings a MRI scan of the pelvis was requested. This showed a 3 cm heterogeneous soft tissue mass arising within the line of the urethra and effacing the anterior vaginal wall (Figure 1). There was associated left inguinal lymphadenopathy although no evidence of intra-pelvic disease. The appearances were suggestive of a primary urethral carcinoma. In view of the imaging findings an examination under anaesthesia was arranged jointly with the urological team. Cystourethoscopy was performed and multiple urethral biopsies taken which revealed a poorly differentiated primary urethral adenocarcinoma. Biopsy of a right groin node confirmed metastatic disease. Subsequent intravenous pyleogram (IVP) revealed an obstructed left kidney and a left nephrostomy tube and ureteric stent were inserted prior to a transurethral resection of the primary tumour. Histological examination confirmed the biopsy findings while a repeat CT scan of the abdomen revealed disseminated lymph node metastases. Chest X-ray was normal. Following diagnosis she underwent a six-cycle course of cisplatin and doxorubicin adjuvant chemotherapy, which resulted in a decrease in tumour volume, although her treatment was complicated by recurrent malignant pleural effusions. In February 2001, during the course of chemotherapy, she was admitted under the care of the cardiology team with an anterior myocardial infarction and underwent angioplasty and insertion of a stent to the left anterior descending coronary artery. Unfortunately, despite making a good initial recovery she continued to deteriorate clinically and was admitted for palliative care and symptom control in June 2001. She died of metastatic disease later that month.