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V7 Endoscopic rendez-vous of ureteral iatrogenic detachment
V7
Endoscopic rendez-vous of ureteral iatrogenic detachment Eur Urol Suppl 2014;13;eV7
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Pastore A.L. 1 , Palleschi G.1 , Silvestri L. 1 , Maggioni C.1 , Fuschi A. 1 , Moschese D.1 , Al Salhi Y. 1 , Maneschi F.2 , Carbone A. 1 1 Sapienza
University of Rome, Faculty of Pharmacy and Medicine, Dept. of Medico Surgical Sciences and Biotechnologies, Urology Unit,
Icot, Latina, Italy, 2 Santa Maria Goretti Hospital, Dept. of Gynecology, Latina, Italy INTRODUCTION & OBJECTIVES: Injury to the ureter is the most common urologic complication of pelvic surgery with an incidence ranging from 1 to 10%. Gynaecologic procedures account for the vast majority of ureteral injuries. It is reported an incidence of ureteral injuries during laparoscopic hysterectomy which ranges from 0.4% to 2.5%. Although ureteral injuries are identified and managed at the time of injury, many lesions are not recognized intraoperatively, necessitating delayed repair. Traditionally these injuries have been repaired through a standard open surgery, and today by a laparoscopic or robotic approach. An integrated management between radiologist and urologist can successfully treat these lesions with a minimally invasive radio - endoscopic intervention, named ureteral rendez-vous. MATERIAL & METHODS: Two most representative cases selected from a case series of 18 treated patients with a complete iatrogenic ureteral monolateral detachment have been selected. First case: a 42 years old female with a complete detachment of the left ureter secondary to a laparoscopic hysterectomy. After diagnosis achieved 7 days after surgery by Computed Tomography, the patient underwent nephrostomy and positioning of a 0,035 inches j-shaped guidewire placed to reach the ureteral lesion. Under fluoroscopic monitoring, a rigid ureteroscopy through the distal stump of the ureteral lesion was then performed; the guidewire tail was caught with grasping forceps thus to realign the ureter by a double J 4.7 ch ureteral stent. Second case: a 30 years old female with a complete left ureteral detachment after hysterectomy due to post-partum complications. A nephrostomy with j-shaped 0,035 inches guidewire was placed through the proximal ureteral stump into the retroperitoneal space followed by the ureteroscopic retrival of the guidewire end with grasping forceps. In this case the retrograde double J stenting resulted unsuccessful and therefore the “JJ” stent was successfully passed through the trans-nephrostomic antegrade way. In both cases the nephrostomy was removed 15 days after the procedure, the “JJ” stent was left in the ureter for 3 months. The CT scan after stent removal showed the absence of leakage, hydronephrosis and/or stricture. RESULTS: The antegrade-retrograde endoscopic rendez vous is a minimally invasive technique which allows to restore ureteral integrity avoiding invasive procedures even if in some cases it represents a challenging maneuver. Our case series is represented by 18 procedures. In these patients the CT control at the moment of discharge and after 6 months confirmed the restored ureteral integrity without leakage in 66% (14/18) of cases while in 22% (4/18) of cases a ureteral stricture was diagnosed needing re-treatment. Iatrogenic damage of the ureter is a severe complication but unfortunately only 1/3 of these lesions are recognized during surgery. An early diagnosis and treatment are crucial to enhance the chances of a successful mini-invasive cure. However, as suggested by some authors, it is advisable to protect the ureters (by ureteral stenting) before performing surgical procedures with high risk of injury. CONCLUSIONS: A combined antegrade radiological and retrograde endourological technique can restore ureteral continuity with a JJ stenting. This maneuver reduces the need of invasive surgical repair and it should represent the first therapeutic attempt before invasive procedures in patients with iatrogenic ureteral lesions.
Endoscopic rendez-vous of ureteral iatrogenic detachment Eur Urol Suppl 2014;13;eV7
Print! Print!
Pastore A.L. 1 , Palleschi G.1 , Silvestri L. 1 , Maggioni C.1 , Fuschi A. 1 , Moschese D.1 , Al Salhi Y. 1 , Maneschi F.2 , Carbone A. 1 1 Sapienza
University of Rome, Faculty of Pharmacy and Medicine, Dept. of Medico Surgical Sciences and Biotechnologies, Urology Unit,
Icot, Latina, Italy, 2 Santa Maria Goretti Hospital, Dept. of Gynecology, Latina, Italy INTRODUCTION & OBJECTIVES: Injury to the ureter is the most common urologic complication of pelvic surgery with an incidence ranging from 1 to 10%. Gynaecologic procedures account for the vast majority of ureteral injuries. It is reported an incidence of ureteral injuries during laparoscopic hysterectomy which ranges from 0.4% to 2.5%. Although ureteral injuries are identified and managed at the time of injury, many lesions are not recognized intraoperatively, necessitating delayed repair. Traditionally these injuries have been repaired through a standard open surgery, and today by a laparoscopic or robotic approach. An integrated management between radiologist and urologist can successfully treat these lesions with a minimally invasive radio - endoscopic intervention, named ureteral rendez-vous. MATERIAL & METHODS: Two most representative cases selected from a case series of 18 treated patients with a complete iatrogenic ureteral monolateral detachment have been selected. First case: a 42 years old female with a complete detachment of the left ureter secondary to a laparoscopic hysterectomy. After diagnosis achieved 7 days after surgery by Computed Tomography, the patient underwent nephrostomy and positioning of a 0,035 inches j-shaped guidewire placed to reach the ureteral lesion. Under fluoroscopic monitoring, a rigid ureteroscopy through the distal stump of the ureteral lesion was then performed; the guidewire tail was caught with grasping forceps thus to realign the ureter by a double J 4.7 ch ureteral stent. Second case: a 30 years old female with a complete left ureteral detachment after hysterectomy due to post-partum complications. A nephrostomy with j-shaped 0,035 inches guidewire was placed through the proximal ureteral stump into the retroperitoneal space followed by the ureteroscopic retrival of the guidewire end with grasping forceps. In this case the retrograde double J stenting resulted unsuccessful and therefore the “JJ” stent was successfully passed through the trans-nephrostomic antegrade way. In both cases the nephrostomy was removed 15 days after the procedure, the “JJ” stent was left in the ureter for 3 months. The CT scan after stent removal showed the absence of leakage, hydronephrosis and/or stricture. RESULTS: The antegrade-retrograde endoscopic rendez vous is a minimally invasive technique which allows to restore ureteral integrity avoiding invasive procedures even if in some cases it represents a challenging maneuver. Our case series is represented by 18 procedures. In these patients the CT control at the moment of discharge and after 6 months confirmed the restored ureteral integrity without leakage in 66% (14/18) of cases while in 22% (4/18) of cases a ureteral stricture was diagnosed needing re-treatment. Iatrogenic damage of the ureter is a severe complication but unfortunately only 1/3 of these lesions are recognized during surgery. An early diagnosis and treatment are crucial to enhance the chances of a successful mini-invasive cure. However, as suggested by some authors, it is advisable to protect the ureters (by ureteral stenting) before performing surgical procedures with high risk of injury. CONCLUSIONS: A combined antegrade radiological and retrograde endourological technique can restore ureteral continuity with a JJ stenting. This maneuver reduces the need of invasive surgical repair and it should represent the first therapeutic attempt before invasive procedures in patients with iatrogenic ureteral lesions.