Ureteral compromise after laparoscopic burch colpopexy

Ureteral compromise after laparoscopic burch colpopexy

May 1999, Vo[. 6, No. 2 Thejourna[of the American Associationof Gynecologic Laparoscopists Ureteral Compromise after Laparoscopic Burch Colpopexy Ro...

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May 1999, Vo[. 6, No. 2

Thejourna[of the American Associationof Gynecologic Laparoscopists

Ureteral Compromise after Laparoscopic Burch Colpopexy Roger D. Ferland, M.D., and Peter Rosenblatt, M.D. Abstract Ureteral obstruction occurred in two patients after laparoscopic Burch cystourethropexy. Both women experienced right flank pain and right hydronephrosis. Cystoscopy revealed transmural passage of suture anterior and lateral to the ureteral orifice on the right side. One patient was managed by suprapubic cystoscopy to release the suture; the other was managed by preperitoneal laparoscopy to release suture at the bladder neck. In both patients efflux of urine was seen immediately from the ureteral orifice after suture release. Ultrasound confirmed prompt resolution of hydronephrosis. Cystoscopy with confirmation of patent ureters should be performed after every case of retropubic cystourethropexy. Retrograde rigid cystoscopy may not afford adequate access to remove transmural sutures. Placement of sutures at the bladder neck from medial to lateral may avoid entrapment of the intramural portion of ureter. (l Am Assoc Gynecol Laparosc 6(2):217-219, 1999)

Case Reports

Laparoscopic adaptation of retropubic cystourethropexy is an effective means of correcting rotational descent of the bladder neck and genuine stress urinary incontinenceJ ~*Although long-term (>5 yrs) results of this approach are not established, postoperative hospitalization is shorter2,5and short-term results are comparable with those for the abdominal procedure. 1~ Complications can occur with both laparoscopic and open approaches, however, and certain areas require special caution.

Patient No. 1 A 35-year-old gravida 3, para 3 woman had a urodynamic profile consistent with genuine stress urinary incontinence. She underwent laparoscopic retropubic colpopexy by three-port technique and transperitoneal entry to the space of Retzius. Sutures of CV0 Gore-Tex (W.L. Gore, Flagstaff, AZ) were placed bilaterally at the bladder neck and midurethra

From the Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island (Dr. Ferland); and Department of Obstetrics and Gynecology, Harvard University, Boston, Massachusetts, and Department of Urogynecology and Pelvic Reconstructive Surgery, Mount Auburn Hospital, Cambridge, Massachusetts (Dr. Rosenblatt). Address reprint requests to Roger D. Ferland, M.D., 310 Maple Avenue, Suite 102, Barrington, RI 02806; fax 401 245 4979. Accepted for publication November 9, 1998.

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Ureteral Compromise after Laparoscopic Burch Cotpopexy Ferland and Rosenblatt

level. Cystoscopy was not performed. Urinary output was adequate intraoperatively and in the recovery room. The woman was discharged on postoperative day 1 with no apparent problems. By 48 hours postoperatively she complained of right flank pain and ultrasound confirmed right-sided hydronephrosis. The patient underwent cystoscopy with a rigid 25F cystoscope using a 70-degree lens. Transmural passage of suture was noted anterior and lateral to the ureteral orifice. Attempts to release the suture with cystoscopic scissors failed due to extreme anterior displacement caused by the suture. General anesthesia was administered, and suprapubic cystoscopy allowed a proper approach to release the suture with resultant efflux of urine from the affected ureteral orifice. The patient was observed overnight and discharged with suprapubic urinary catheter drainage for 1 week and ureteral stenting for 6 weeks. Patient No. 2 A 57-year-old, gravida 3, para 3 patient had genuine urinary stress incontinence diagnosed by urodynamic study. She underwent a three-port preperitoneal laparoscopic colpopexy with suture placement at the bladder neck and midurethra bilaterally. Intraoperative cystoscopy was not done. On postoperative day 1 the woman complained of right flank pain, and hydronephrosis was confirmed by ultrasound. At repeat laparoscopy with simultaneous cystoscopy, the space of Retzius was entered through the previous incision and sutures were identified on the right. Cystoscopy revealed puckering of the right trigone with anterior and lateral displacement, but no suture material was identified. Traction on the bladder neck suture revealed intramural passage of the offending suture by cystoscopy. After laparoscopic release, urinary efflux was noted from the ureteral orifice. The patient was discharged after a 2-day postoperative stay and was maintained with a right ureteral stent for 6 weeks.

suture placement in the endopelvic fascia. This may cause counter-clockwise rotation of the trigone, exposing the intramural portion of ureter, which usually lies posteromedially, to injury during suture placement at the level of the UVJ. In retrospect, it appeared our sutures incorporated the outer surface of bladder muscularis as well as endopelvic fascia. The nature of the injury is thus more likely a kinking of the ureter rather than complete ligation with suture. In both patients, right-sided obstruction occurred despite good intraoperative exposure. Review of the literature uncovered two case reports of similar complications, each occurring on the right side. 6'7 In ;our cases, the surgeon was standing to the patient's left and using the right hand to pass suture lateral to medial. We propose it is more likely to entrap the right bladder wall and intramural ureter in this fashion, rather than starting medially at the bladder neck and passing the needle laterally (Figures 1 and 2). Contralateral placement of sutures by the same technique typically passes the needle medial to lateral, hence the absence of reported left-sided ureteral entrapment. Transmural passage of suture can easily be recognized using a 70-degree cystoscope, but the trigone will be drawn anteriorly and laterally by the suture. Consequently, we found it impossible to release the sutures with a rigid scope introduced through the urethra. Insertion of the scope through a suprapubic cystotomy provided excellent exposure of the suture, facilitating its release. Ureteral stenting was facilitated in 32 patients evaluated intraoperatively with such an approach during open procedures? Flexible cystoscopes may provide greater capabilities for suture release.

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Discussion

Our technique involves dissection of the space of Retzius and paravaginal space to identify the bladder neck and endopelvic fascia. By visualizing the Foley catheter bulb and hence urethrovesicle junction (UVJ), sites for suture placement at the midurethra and bladder neck are determined. Our technique also includes medial displacement of the bladder neck to assist

FIGURE 1. Medial displacement of the bladder neck with a blunt probe assists in suture placement.

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entrapment can occur despite excellent exposure, good operator experience, and confidence in a wellperformed case. Placement of colpopexy sutures from medial to lateral at the level of the UVJ may help to avoid entrapment of bladder or ureter. References

1. Ross J: Two techniques of laparoscopic Burch repair for stress incontinence: a prospective, randomized study. J Am Assoc Gynecol Laparosc 3(3):351-357, 1996 2. Kung RC, Lie K, Lee P, et al: The cost-effectiveness of laparoscopic versus abdominal Burch procedures in women with urinary stress incontinence. J Am Assoc Gynecol Laparosc 3(4):537-544, 1996

FIGURE 2. Starting medially at the bladder neck, the needle is passed laterally.

3. Lyons TL, Winer WK: Clinical outcomes with laparoscopic approaches and open Burch procedures for urinary stress incontinence. J Am Assoc Gynecol Laparosc 2(2):193-198, 1995

In the event of intramural passage of suture, cystoscopic release may be impossible. If such a complication is recognized intraoperatively or within 24 hours, laparoscopic exposure of sutures will not be impeded by tissue edema or organized clot. This made release possible without conversion to laparotomy in our second patient. Unsuspected bladder or ureteral injury was found after surgical repair of genital prolapse or incontinence in 4% of 224 patients during routine postoperative cystoscopy.9Among other bladder injuries, there were six ureteral ligations, four of which occurred after Burch cystourethropexy. The authors concluded that intraoperative cystoscopy should be considered to avoid delay in diagnosis and increased morbidity. Our experience validates this recommendation.

4. Ross JW: Multichanne] urodynamic evaluation of laparoscopic Burch colposuspension for genuine stress incontinence. Obstet Gynecolgl(l):55-59, 1998 5. Kohli N, Jacobs PA, Sze EH, et al: Open compared with laparoscopic approach to Butch colposuspension: A cost analysis. Obstet Gynecol 90(3):411-415, 1997 6. Aslan P, Woo H: Uretefic injury following laparoscopic colposuspension. Br J Obstet Gynaecol 104:266-268, 1997 7. Dietz HP, Wilson PD, Samalia, KP, et al: Ureteric injury following laparoscopic colposuspension [letter]. Br J Obstet Gynaecol 104(10): 1217, 1997

Conclusion

8. Timmons C, Addison WA: Suprapubic teloscopy: Extraperitoneal intraoperative technique to demonstrate ureteral patency. Obstet Gynecol 75:137-139, 1990

Routine intraoperative cystoscopy should be performed in every case of laparoscopic retropubic cystourethropexy to rule out bladder or ureteral injury. Retrograde rigid cystoscopy may not provide the proper angle of approach for suture release by drawing the bladder wall anterolaterally. Bladder or trigone

9. Harris RL, Cundiff GW, Theofrastous JP, et al: The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery. Am J Obstet Gynecol 177(6): 1367-1371, 1997

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