Ureteroileoneocystostomy: the use of an ileal segment for ureteral substitution in gynecologic oncology

Feasibility and outcomes of ureteroureterostomy and extravesical ureteroneocystostomy as part of radical surgery for infiltrating gynecologic disease

OBJECTIVE

Abdominopelvic infiltrative disease may require aggressive surgical procedures. This study reports on our experience with distal ureterectomy, ureteroureterostomy, and extravesical ureteroneocystostomy as part of radical surgery for infiltrating gynecologic disease.

PATIENTS AND METHODS

Twenty-one women required surgery to the distal ureter at the Queensland Centre for Gynecological Cancer, Australia, from January 2006 to September 2012. Details of the patient's history, operation record, inpatient notes, and follow-up data were obtained through chart review.

RESULTS

Patients' median age was 57.8 ± 14.7 years (range, 30-80 years). Seventeen patients had gynecologic cancer. Mean operating time was 3.9 ± 0.9 hours (range, 2.5-5.5 hours). Restoration of continuity was achieved through extravesical ureteroneocystostomy and ureteroureterostomy in 18 and 3 patients, respectively. Boari flap was used in 3 patients, and psoas hitch was the technique chosen in 11 patients. Urinary tract infection was the most common clinical adverse event. Albeit clinically irrelevant, 38% of the patients showed structural renal tract changes postoperatively.

CONCLUSIONS

To achieve maximal surgical radicalness, resection of the distal ureter with subsequent ureteroureterostomy or extravesical ureteroneocystostomy is feasible and safe. Radical surgery to the urinary tract should be considered as a legitimate part of a gynecologic oncologist's surgical armamentarium to increase a patient's probability of survival and its positive effect on kidney function.

Ureteral surgery performed by a university gynecologic oncology service

OBJECTIVE

The purpose of this study is to describe the incidence and types of ureteral surgical procedures that are necessitated during the course of surgical treatment of a population of patients who are cared for by a gynecologic oncology training program.

STUDY DESIGN

From 1997 through 2004, the University of South Florida Division of Gynecologic Oncology database was accessed to extract the specifics of ureteral surgery that had been done during the course of the fellowship training program.

RESULTS

Forty-six of 4844 major operations included ureteral surgery. Thirty of 46 procedures were repair of injury; all were recognized intraoperatively. The method of repair was simple closure (1 procedure), ureteroureterostomy (7 procedures), or direct ureteroneocystostomy (22 procedures). Two of the 7 ureteroureterostomies strictured. Ureteral resection was done for gynecologic malignancy in 15 of 16 patients. All 16 patients underwent reconstruction with direct ureteroneocystostomy. Seven of 16 patients underwent concomitant rectosigmoid colectomy. One of 16 patients who underwent en-bloc partial cystectomy had a postoperative vesicovaginal fistula. All 36 ureteroneocystostomies with short-term follow-up had radiologically normal upper urinary tracts. Eighteen patients had subsequent follow-up evaluations; all of them had radiologically normal upper urinary tracts at 5 to 42 months (mean, 19 months).

CONCLUSION

When significant injury to the pelvic ureter occurs during radical pelvic surgery, ureteroneocystostomy may be the repair of choice. After resection of a portion of the pelvic ureter for gynecologic malignancy, the urinary tract was reconstructed successfully with direct ureteroneocystostomy. In those patients who underwent ureteral resection for malignancy, the extent of the disease process necessitated concomitant rectosigmoid colectomy 47% of the time.

Ureteric reconstruction

Although the ureter is functionally simply a tube to transport urine, ureteric surgery requires detailed anatomical knowledge and advanced surgical skills, because the ureter has a delicate blood supply. Therefore, the urological surgeon must have distinct strategies available to bridge ureteric defects of various sites and lengths. Furthermore, handling during and after surgery should be individualized to the patient's pre- and intraoperative situation. In this review, the indications for reconstruction of a specific ureteric defect, the required techniques and postoperative recommendations are discussed.