The Phantom Urine: An Unexpected Finding during a Routine Cesarean Section

We present here an atypical finding during an elective repeat cesarean section. Despite urine flow through an indwelling bladder catheter, bladder remains distended during the whole procedure. Unexpected anatomical variations and malformations can make routine surgery challenging. Urinary tract anomalies should be suspected in cases of unexpected difficult bladder catheterization. 1. Introduction Maternal malformation can be diagnosed during pregnancy with ultrasound imaging. However, most of them remain undiagnosed or diagnosed unexpectedly during routine surgery. We present here a challenging repeat cesarean section with an unusual urinary finding. 2. Case Report A 36-year-old G3P2 patient with a history of two previous caesarean sections was admitted for an elective repeat cesarean section at 39 weeks of gestation. The routine preprocedure preparation was uneventful and an indwelling bladder catheter was placed without difficulty. Upon peritoneal entry, the bladder was noted to be significantly distended despite the fact that urine was confirmed in the urinary drainage bag. In an attempt to empty the bladder, a new 12？G Foley catheter was placed, followed by a rigid silicone catheter, but the bladder remained distended. In order to have a better view of the pelvic organs, fetal extraction and uterotomy closure were decided. Persistence of bladder distension might have resulted from a urinary tract injury at initial catheterization. To investigate this hypothesis, 400？mL of methylene blue was injected through the urinary catheter. The bladder volume did not change and no methylene blue was noted intraabdominally. After this negative test, most of the 400？mL of methylene blue flowed back into the urinary bag and the remaining blue-colored urine came in intermittent streams. A rectal digital examination did not reveal any injuries. Cystoscopy confirmed a distended bladder and two patent ureteral meatus. No trace of methylene blue was identified within the bladder. At the end of the cystoscopy procedure, a fold was noted on the posterior wall of the bladder neck (see Figure 1). This fold was initially thought to be iatrogenic. Insertion of the cystoscope inside this fold revealed a dilated peristaltic tubular structure containing methylene blue. This finding confirmed that the urinary catheter entered this ectopic ureter, and not the bladder. In order to avoid this fold and empty the bladder, a urinary catheter was placed under direct visualization. The postoperative course was uneventful and antibiotic prophylaxis was administered for 48 hours. Figure