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Laparoscopic Repair of Ureteral Injuries
May 2001, Vol. 8, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
Laparoscopic Repair of Ureteral Injuries Paul K. Tulikangas, M.D., Inderbir S. Gill, M.D., and Tommaso Falcone, M.D.
Abstract Study Objective. To assess the outcome of laparoscopic repair of pelvic ureter injuries. Design. Retrospective case series (Canadian Task Force classification II-2). Setting. Large urban tertiary care medical center. Patients. Four women who had pelvic ureter injuries and laparoscopic repair during laparoscopic gynecologic procedures. Intervention. Laparoscopic ureteroureterostomy. Measurements and Main Results. All injuries were identified immediately and repaired laparoscopically. No patient required repeat surgery. On assessment by physical examination, serum creatinine, and intravenous urogram, no patient had evidence of renal insufficiency. One woman had a narrowing at the site of ureteroureterostomy 6 weeks after repair; it was resolved on urogram 8 months after the injury. Conclusion. Laparoscopic ureteroureterostomy is feasible in some cases of ureteral injury. Experience with laparoscopic suturing is necessary to perform this procedure. (J Am Assoc Gynecol Laparosc 8(2):259–262, 2001)
Injury to the ureter occurs in 0.1% to 1.5% of pelvic surgeries.1,2 The frequency of serious urinary complications appears to be increasing as a result of greater numbers of complex endoscopic procedures being performed.2–4 A laparoscopic approach to repair of these injuries offers many possible benefits to the patient, including lower rates of wound infection and incisional hernias. Four laparoscopic injuries of the pelvic ureter were repaired laparoscopically.
carmine was injected to confirm the injury. Cut ends of transected ureters were spatulated to increase ureteral circumference at the site of anastomosis (Figure 1). In each case cystoscopy was performed and patency of the contralateral ureter was confirmed. A 7F double-J ureteral stent (Microvasive, Boston Scientific Corp., Natick, MA) was placed in retrograde fashion across the injured area and into the renal pelvis. When necessary, a single interrupted suture was placed to align the ends of transected ureters and facilitate passage of the ureteral stent (Figure 2). Additional interrupted sutures of chromic gut or polyglycolic acid were placed and full-thickness knots were tied intracorporeally. Intravenous indigo carmine was injected to confirm absence of an anastomotic leak. In no cases were additional cannula sites necessary to perform ureteroureterostomy.
Materials and Methods Laparoscopic injuries of the pelvic ureter occurred in four women (Table 1). (One was reported with only short-term follow-up.5) All injuries occurred 3 to 4 cm from the ureterosvesical junction and were identified intraoperatively. In three cases intravenous indigo
From the Departments of Gynecology and Obstetrics (Drs. Tulikangas and Falcone) and Urology (Dr. Gill), Cleveland Clinic Foundation, Cleveland, Ohio. Address reprint requests to Paul K. Tulikangas, M.D., Department of Obstetrics and Gynecology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195; fax 216 444 8551. Presented at the 29th annual meeting of the American Association of Gynecologic Laparoscopists, Orlando, Florida, November 14–19, 2000. Accepted for publication January 6, 2001.
259
Laparoscopic Repair of Ureteral Injuries Tulikangas et al
TABLE 1. Patient Variables Age (yrs) 56 29 50 39
Surgery
Endometriosis
No. of Stitches
Drain
Hospital stay (days)
Bilateral salpingo-oophorectomy Excision ovarian remnant Sacral colpopexy Excision endometriosis
No Stage IV No Stage IV
4 4 5 1
Yes No No No
3 1 3 6
FIGURE 1. Cut ends of the ureter are spatulated.
FIGURE 2. After alignment suture is placed, a retrograde stent is passed.
Patients were discharged when they were afebrile, ambulating, and tolerating oral analgesia. They were given prophylactic antibiotics while the ureteral stent was in place. Stents were removed cystoscopically 4 to 6 weeks postoperatively in the outpatient clinic. Follow-up consisted of intravenous pyelograms, serum creatinine, and physical examination.
Results Follow-up ranged from 6 to 33 months (mean 13 mo; Table 2). No patient required repeat surgery and none showed evidence of renal insufficiency. In one woman the entire pelvic ureter was dissected free from surrounding tissue. There was some
260
May 2001, Vol. 8, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
TABLE 2. Postoperative Course
Urogram None Normal Narrowing at repair site Normal
Creatinine (mg/dl)
Physical Examination (mo)
Longest Follow-up
0.8 0.7 0.8 0.7
Normal Normal Normal Normal
33 6 8a 6
aThis woman had a normal urogram at 8 months.
stent across the transected area into the kidney. The remainder of procedure is completed with the J stent in place. We have found no difference between chromic and polygycolic acid sutures, and believe that “atraumatic handling of suture and meticulous, watertight, fine suture technique without tension are more important than whether the anastomosis is running or interrupted or what type or size of absorbable suture is used.”11 If the anastomosis does not appear watertight, a closed drain should be placed a few centimeters from it. Postoperative asymptomatic ureteral obstruction was reported.12 Although this could have occurred in any of our patients, we think that it is unlikely, as each patient had normal renal function postoperatively. We plan to evaluate these women annually by renal ultrasound to detect hydronephrosis or hydroureter. Some surgeons advocate preoperative ureteral stents when they anticipate the need for extensive pelvic sidewall dissection. Ureteral stenting is associated with complications.13 We advocate identification and dissection of the ureter when it is anticipated that it will be at risk for injury. Laparoscopic surgeons must be familiar with the anatomy of the ureter and changes that can occur with pelvic disease. If ureteral injury occurs, prompt recognition and treatment will save the patient from undue morbidity.14 Laparoscopic repair is feasible in some instances.
concern about perfusion to the site of the ureteroureterostomy. An omental flap was brought over the repair and sutured in place on the pelvic sidewall. Another woman had a narrowing at the site of ureteroureterostomy 6 weeks postoperatively; it was resolved on repeat urogram 8 months after the repair. Discussion Laparoscopic ureteroureterostomy is reported four times in the English literature.5–8 We believe this is the first series documenting long-term follow-up of these repairs. Traditionally, traumatic injury to the distal ureter was approached by laparotomy with various anastomosis and reimplantation techniques. The primary concern with direct anastomosis is that the blood supply to the ureter could be compromised with resultant stricture formation. Even in two cases of severe endometriosis where the entire pelvic ureter was dissected free from its blood supply on the pelvic sidewall, no stricture was noted on follow-up pyelogram. The pelvic ureter likely maintains its viability through the rich plexus of vessels in the lamina propria. After one injury, an omental flap was used to protect and enhance the collateral blood supply to the ureter.9 This option could be considered if a surgeon is concerned about the blood supply to the ureter. It is critical that the ureter not be under tension for ureteroureterostomy. If the surgeon believes that ureteral length is not adequate for direct anastomosis, reimplantation should be considered. A psoas hitch or Borari flap can be used if the proximal end of the ureter does not reach the bladder without tension.10 During laparoscopic ureteroureterostomy, we think that it is helpful to place an initial alignment stitch to approximate cut ends of the ureter. This greatly facilitates retrograde passage of a guidewire and J
References 1. Thompson JD: Operative injuries to the ureter: Prevention, recognition and management. In Te Linde’s Operative Gynecology, 8th ed. Edited by JA Rock, JD Thompson. Philadelphia, Lippincott–Raven, 1997, p 1135
261
Laparoscopic Repair of Ureteral Injuries Tulikangas et al
2. Saidi MH, Sadler RK, Vancaillie TG, et al: Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol 87:272–276, 1996
9. Turner-Warwick R: The use of pedical grafts in the repair of urinary tract fistulae. Br J Urol 44:644–656, 1972
3. Harkki-Siren P, Kurki T: A nationwide analysis of laparoscopic complications. Obstet Gynecol 89(1):108–112, 1997
10. Blandy JP, Badenoch DF, Fowler CG, et al: Early repair of iatrogenic injury to the ureter or bladder after gynecological surgery. J Urol 146:761–765, 1991
4. Assimos DG, Patterson LC, Taylor CL: Changing incidence and etiology of iatrogenic ureteral injuries. J Urol 152:2240–2246, 1994
11. Pearse HD, Barry JM, Fuchs EF: Intraoperative consultation for the ureter. Urol Clin North Am 12(3):423–437, 1985
5. Tulikangas PK, Goldberg JM, Gill IS: Laparoscopic repair of ureteral transection. J Am Assoc Gynecol Laparosc 7(3):415–416, 2000
12. St Martin EC, Trichel EB, Cambell JH, et al: Ureteral injuries in gynecologic surgery. J Urol 70(1):51–57, 1953
6. Nezhat C, Nezhat F: Laparoscopic repair of ureter resected during operative laparoscopy. Obstet Gynecol 80:543–544, 1992
13. Wood EC, Maher P, Pelosi MA: Routine use of ureteric catheters at laparoscopic hysterectomy may cause unnecessary complications. J Am Assoc Gynecol Laparosc 3(3):393–397, 1995
7. Nezhat C, Nezhat F, Green B: Laparoscopic treatment of obstructed ureter due to endometriosis by resection and ureteroureterostomy: A case report. J Urol 148:865–868, 1992
14. Grainger DA, Soderstrom RM, Schiff SF, et al: Ureteral injuries at laparoscopy: Insights into diagnosis, management, and prevention. Obstet Gynecol 75:839–843, 1990
8. Gomel V, James C: Intraoperative management of ureteral injury during operative laparoscopy. Fertil Steril 55:416–419, 1991
262
The Journal of the American Association of Gynecologic Laparoscopists
Laparoscopic Repair of Ureteral Injuries Paul K. Tulikangas, M.D., Inderbir S. Gill, M.D., and Tommaso Falcone, M.D.
Abstract Study Objective. To assess the outcome of laparoscopic repair of pelvic ureter injuries. Design. Retrospective case series (Canadian Task Force classification II-2). Setting. Large urban tertiary care medical center. Patients. Four women who had pelvic ureter injuries and laparoscopic repair during laparoscopic gynecologic procedures. Intervention. Laparoscopic ureteroureterostomy. Measurements and Main Results. All injuries were identified immediately and repaired laparoscopically. No patient required repeat surgery. On assessment by physical examination, serum creatinine, and intravenous urogram, no patient had evidence of renal insufficiency. One woman had a narrowing at the site of ureteroureterostomy 6 weeks after repair; it was resolved on urogram 8 months after the injury. Conclusion. Laparoscopic ureteroureterostomy is feasible in some cases of ureteral injury. Experience with laparoscopic suturing is necessary to perform this procedure. (J Am Assoc Gynecol Laparosc 8(2):259–262, 2001)
Injury to the ureter occurs in 0.1% to 1.5% of pelvic surgeries.1,2 The frequency of serious urinary complications appears to be increasing as a result of greater numbers of complex endoscopic procedures being performed.2–4 A laparoscopic approach to repair of these injuries offers many possible benefits to the patient, including lower rates of wound infection and incisional hernias. Four laparoscopic injuries of the pelvic ureter were repaired laparoscopically.
carmine was injected to confirm the injury. Cut ends of transected ureters were spatulated to increase ureteral circumference at the site of anastomosis (Figure 1). In each case cystoscopy was performed and patency of the contralateral ureter was confirmed. A 7F double-J ureteral stent (Microvasive, Boston Scientific Corp., Natick, MA) was placed in retrograde fashion across the injured area and into the renal pelvis. When necessary, a single interrupted suture was placed to align the ends of transected ureters and facilitate passage of the ureteral stent (Figure 2). Additional interrupted sutures of chromic gut or polyglycolic acid were placed and full-thickness knots were tied intracorporeally. Intravenous indigo carmine was injected to confirm absence of an anastomotic leak. In no cases were additional cannula sites necessary to perform ureteroureterostomy.
Materials and Methods Laparoscopic injuries of the pelvic ureter occurred in four women (Table 1). (One was reported with only short-term follow-up.5) All injuries occurred 3 to 4 cm from the ureterosvesical junction and were identified intraoperatively. In three cases intravenous indigo
From the Departments of Gynecology and Obstetrics (Drs. Tulikangas and Falcone) and Urology (Dr. Gill), Cleveland Clinic Foundation, Cleveland, Ohio. Address reprint requests to Paul K. Tulikangas, M.D., Department of Obstetrics and Gynecology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195; fax 216 444 8551. Presented at the 29th annual meeting of the American Association of Gynecologic Laparoscopists, Orlando, Florida, November 14–19, 2000. Accepted for publication January 6, 2001.
259
Laparoscopic Repair of Ureteral Injuries Tulikangas et al
TABLE 1. Patient Variables Age (yrs) 56 29 50 39
Surgery
Endometriosis
No. of Stitches
Drain
Hospital stay (days)
Bilateral salpingo-oophorectomy Excision ovarian remnant Sacral colpopexy Excision endometriosis
No Stage IV No Stage IV
4 4 5 1
Yes No No No
3 1 3 6
FIGURE 1. Cut ends of the ureter are spatulated.
FIGURE 2. After alignment suture is placed, a retrograde stent is passed.
Patients were discharged when they were afebrile, ambulating, and tolerating oral analgesia. They were given prophylactic antibiotics while the ureteral stent was in place. Stents were removed cystoscopically 4 to 6 weeks postoperatively in the outpatient clinic. Follow-up consisted of intravenous pyelograms, serum creatinine, and physical examination.
Results Follow-up ranged from 6 to 33 months (mean 13 mo; Table 2). No patient required repeat surgery and none showed evidence of renal insufficiency. In one woman the entire pelvic ureter was dissected free from surrounding tissue. There was some
260
May 2001, Vol. 8, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
TABLE 2. Postoperative Course
Urogram None Normal Narrowing at repair site Normal
Creatinine (mg/dl)
Physical Examination (mo)
Longest Follow-up
0.8 0.7 0.8 0.7
Normal Normal Normal Normal
33 6 8a 6
aThis woman had a normal urogram at 8 months.
stent across the transected area into the kidney. The remainder of procedure is completed with the J stent in place. We have found no difference between chromic and polygycolic acid sutures, and believe that “atraumatic handling of suture and meticulous, watertight, fine suture technique without tension are more important than whether the anastomosis is running or interrupted or what type or size of absorbable suture is used.”11 If the anastomosis does not appear watertight, a closed drain should be placed a few centimeters from it. Postoperative asymptomatic ureteral obstruction was reported.12 Although this could have occurred in any of our patients, we think that it is unlikely, as each patient had normal renal function postoperatively. We plan to evaluate these women annually by renal ultrasound to detect hydronephrosis or hydroureter. Some surgeons advocate preoperative ureteral stents when they anticipate the need for extensive pelvic sidewall dissection. Ureteral stenting is associated with complications.13 We advocate identification and dissection of the ureter when it is anticipated that it will be at risk for injury. Laparoscopic surgeons must be familiar with the anatomy of the ureter and changes that can occur with pelvic disease. If ureteral injury occurs, prompt recognition and treatment will save the patient from undue morbidity.14 Laparoscopic repair is feasible in some instances.
concern about perfusion to the site of the ureteroureterostomy. An omental flap was brought over the repair and sutured in place on the pelvic sidewall. Another woman had a narrowing at the site of ureteroureterostomy 6 weeks postoperatively; it was resolved on repeat urogram 8 months after the repair. Discussion Laparoscopic ureteroureterostomy is reported four times in the English literature.5–8 We believe this is the first series documenting long-term follow-up of these repairs. Traditionally, traumatic injury to the distal ureter was approached by laparotomy with various anastomosis and reimplantation techniques. The primary concern with direct anastomosis is that the blood supply to the ureter could be compromised with resultant stricture formation. Even in two cases of severe endometriosis where the entire pelvic ureter was dissected free from its blood supply on the pelvic sidewall, no stricture was noted on follow-up pyelogram. The pelvic ureter likely maintains its viability through the rich plexus of vessels in the lamina propria. After one injury, an omental flap was used to protect and enhance the collateral blood supply to the ureter.9 This option could be considered if a surgeon is concerned about the blood supply to the ureter. It is critical that the ureter not be under tension for ureteroureterostomy. If the surgeon believes that ureteral length is not adequate for direct anastomosis, reimplantation should be considered. A psoas hitch or Borari flap can be used if the proximal end of the ureter does not reach the bladder without tension.10 During laparoscopic ureteroureterostomy, we think that it is helpful to place an initial alignment stitch to approximate cut ends of the ureter. This greatly facilitates retrograde passage of a guidewire and J
References 1. Thompson JD: Operative injuries to the ureter: Prevention, recognition and management. In Te Linde’s Operative Gynecology, 8th ed. Edited by JA Rock, JD Thompson. Philadelphia, Lippincott–Raven, 1997, p 1135
261
Laparoscopic Repair of Ureteral Injuries Tulikangas et al
2. Saidi MH, Sadler RK, Vancaillie TG, et al: Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol 87:272–276, 1996
9. Turner-Warwick R: The use of pedical grafts in the repair of urinary tract fistulae. Br J Urol 44:644–656, 1972
3. Harkki-Siren P, Kurki T: A nationwide analysis of laparoscopic complications. Obstet Gynecol 89(1):108–112, 1997
10. Blandy JP, Badenoch DF, Fowler CG, et al: Early repair of iatrogenic injury to the ureter or bladder after gynecological surgery. J Urol 146:761–765, 1991
4. Assimos DG, Patterson LC, Taylor CL: Changing incidence and etiology of iatrogenic ureteral injuries. J Urol 152:2240–2246, 1994
11. Pearse HD, Barry JM, Fuchs EF: Intraoperative consultation for the ureter. Urol Clin North Am 12(3):423–437, 1985
5. Tulikangas PK, Goldberg JM, Gill IS: Laparoscopic repair of ureteral transection. J Am Assoc Gynecol Laparosc 7(3):415–416, 2000
12. St Martin EC, Trichel EB, Cambell JH, et al: Ureteral injuries in gynecologic surgery. J Urol 70(1):51–57, 1953
6. Nezhat C, Nezhat F: Laparoscopic repair of ureter resected during operative laparoscopy. Obstet Gynecol 80:543–544, 1992
13. Wood EC, Maher P, Pelosi MA: Routine use of ureteric catheters at laparoscopic hysterectomy may cause unnecessary complications. J Am Assoc Gynecol Laparosc 3(3):393–397, 1995
7. Nezhat C, Nezhat F, Green B: Laparoscopic treatment of obstructed ureter due to endometriosis by resection and ureteroureterostomy: A case report. J Urol 148:865–868, 1992
14. Grainger DA, Soderstrom RM, Schiff SF, et al: Ureteral injuries at laparoscopy: Insights into diagnosis, management, and prevention. Obstet Gynecol 75:839–843, 1990
8. Gomel V, James C: Intraoperative management of ureteral injury during operative laparoscopy. Fertil Steril 55:416–419, 1991
262