Laparoscopic ureteroneocystostomy and psoas hitch for post-hysterectomy ureterovaginal fistula

Robot-assisted laparoscopic repair of injuries to bladder and ureter following gynecological surgery and obstetric injury: A single-center experience

Introduction:

The objective of the study is to evaluate the outcome of robot-assisted laparoscopic repair of injuries to urinary tract following gynecological surgery and obstetric injury.

Methods:

This retrospective analysis from prospectively collected data of repair of injuries to bladder and ureter using da Vinci Si robotic platform was carried out. Between April 2014 and May 2019, 27 patients were operated on in a single surgical unit; 25 had hysterectomy and 2 were obstetric cases. Fifteen patients underwent vesicovaginal fistula (VVF) repair, ten underwent ureteral reimplant, with concomitant psoas hitch, and two underwent Boari flap repair following gynecological surgery and obstetric injury.

Results:

Among 15 patients of VVF repair, 3 cases were previously attempted failed repair, 2 underwent concomitant ureteral reimplant, and 1 underwent concomitant ovarian cystectomy. The mean total operative time was 126 (75–206) min, and the mean hospital stay was 4.4 (3–6) days. Among 12 cases of ureteral injury, 5 were on the right side and 7 were on the left side; the mean total operative time was 150.16 (110–215) min, and the mean hospital stay was 4 (3–7) days. No case required conversion to open in this cohort. All cases were successfully cured without any recurrence of fistula or stricture during their mean follow-up period of 35.3 (9–66) months.

Conclusions:

Robot-assisted laparoscopic repair for injuries to bladder and ureter is effective and highly successful even in previously failed cases.

Laparoscopic ureteroneocystostomy for mid and lower ureteric strictures: Experience from a tertiary center

Purpose:

The purpose of this study is to evaluate our experience of laparoscopic ureteroneocystostomy for mid and lower ureteral stricture in a tertiary center in North India.

Materials and Methods:

A total of 20 laparoscopic ureteroneocystostomy were performed with or without bladder flap procedures in 20 patients (13 females and 7 males) with various etiologies such as ureteric stricture, ureterovaginal fistula, endometriosis, and distal ureteric tumor at our hospital in a time frame from August 2013 to January 2017. Eight cases each presented after laparoscopic/open hysterectomy and postureterorenoscopic stone removal while two cases each presented secondary to endometriosis and distal ureteric tumor. Simple laparoscopic ureteroneocystostomy in 4, psoas hitch in 9, and Boari flap was done in 7 cases.

Results:

The mean patient age was 44.2 years (range 19–65), mean surgical time was 184.25 min (115–250 min.), mean amount of bleeding was 153.25 mL (90–250 mL), and mean hospital stay was 3.05 days (2–7 days). Female-to-male ratio was 1.3:0.7. There was one conversion to open during laparoscopic Boari reimplant because of inadvertent injury to external iliac vein. The mean follow-up was 22.35 months (6–45). All the patients were asymptomatic with the resolution of hydronephrosis on ultrasound and without any significant obstruction on renal scan.

Conclusions:

Laparoscopic ureteroneocystostomy with or without bladder flap (Boari) provides good functional outcomes with excellent success rates and minimal morbidity comparable to open surgery in patients with ureteric stricture.

Prevention, Recognition, and Management of Urologic Injuries During Gynecologic Surgery

The urethra, bladder, and ureters are particularly susceptible to injury during gynecologic surgery. When preventive measures fail, prompt recognition and management of injury can avoid long-term sequelae such as fistula formation and loss of renal function. Intraoperative identification should be the primary goal when an injury occurs, although this is not always possible. Postoperative injury recognition requires a high level of suspicion and vigilance. In addition to history and physical examination, appropriate radiologic studies can be useful in localizing injury and planning management strategies. Some injuries may require Foley catheter drainage or ureteral stenting alone, whereas others will require operative intervention with ureteral resection and reanastomosis or reimplantation. Prompt restoration of urinary drainage or diversion will avoid further renal compromise.

Laparoscopic ureteroureterostomy with an intraoperative retrograde ureteroscopy-assisted technique for distal ureteral injury secondary to gynecological surgery: a retrospective comparison with laparoscopic ureteroneocystostomy

OBJECTIVES

The aim of this study was to compare the operative and postoperative outcomes of laparoscopic ureteroureterostomy (LAP-UU) using a retrograde ureteroscopy-assisted technique with laparoscopic ureteroneocystostomy (LAP-UNC) in treating ureteral injury after gynecological surgery.

MATERIALS AND METHODS

The study analyzed 60 ureteral injury repairs performed between May 2010 and February 2016 in patients who underwent either LAP-UU using the retrograde ureteroscopy-assisted technique (n = 26) or LAP-UNC (n = 34). Demographic parameters, operative variables and perioperative outcomes were retrospectively analyzed. The chi-squared test, Fisher's exact test and Student's t test were used for statistical analyses.

RESULTS

Demographic and clinical data revealed no significant differences between patients in each group in terms of age, body mass index, length of obstruction, incidence of postoperative urinary leakage, incidence of urinary tract infection during hospitalization, oral antibiotics, mean hospital stay, incidence of recurrent obstruction, rate of conversion to open surgery and mean operative time. The LAP-UU group had significantly less estimated blood loss (85 ± 40 vs 120 ± 35 ml, p = .0006) and a significantly lower incidence of vesicoureteral reflux (grade I) on cystography (0/26 vs 6/34, p = .031) during a mean follow-up of 36.5 months (range 7-71 months).

CONCLUSIONS

Compared with LAP-UNC, LAP-UU is also a technically feasible and safe option for repairing distal ureteral injury secondary to gynecological surgery. The intraoperative retrograde ureteroscopy-assisted technique during LAP-UU contributes to precise localization of the lesion, reduces intraoperative bleeding, enables sufficient dissection of the intramural ureter and preserves its natural antireflux mechanism.

Laparoscopic extravesical ureteral reimplantation (LEVUR): a systematic review

BACKGROUND

Laparoscopic ureteral reimplantation is a feasible method for treating ureteral pathology with good preliminary results in the literature. In this study, we review medium term results for laparoscopic ureteral reimplantation and discuss current developments of this procedure.

METHODS

Medline and Embase databases were searched using relevant key terms to identify reports of paediatric laparoscopic extravesical ureteral reimplantation (LEVUR). Literature reviews, case reports, series of <3 children and adult studies (age >20 years) were excluded.

RESULTS

Five studies were assessed, overall, 69 LEVUR were performed in children. Despite different surgical technique, in all case the technique was respected. Patient demographics, preoperative symptoms, radiological imaging, complications, and postoperative outcomes were analyzed. Median success rate was 96%. Complications were reported in five cases.

CONCLUSIONS

This study is limited by the data given in the individual series: varied criteria used for patient selection and outcome as well as inconsistent pre- and post-operative imaging data precluded a meta-analysis. But it demonstrates that the laparoscopic ureteral reimplantation is an effective procedure with good medium-term results. We believe that in well selected patients this procedure will become an established treatment option.

Urologic complications following obstetrics and gynecologicai surgery: Our experience in a tertiary care hospital

Introduction:

Urinary tract injuries are a known complication of obstetrical and gynecological surgeries because of their anatomical proximity. Delayed diagnosis and improper management leads to high morbidity and even mortality. This is our three year's experience of urological complications after obstetric and gynecological surgery, their treatment and follows up.

Materials and Methods:

We reviewed all cases of urological injuries managed in our department that were deemed to be of obstetric and gynecological origins.

Results:

Thirty seven women were treated in the department for urological complications secondary to obstetric and gynecological procedures from January 2012 to December 2014. The most common organ involved was urinary bladder, occurring in 54% patients followed by ureter in 35.13%. Vesicovaginal fistula (VVF) was the most common injury involving the bladder occurring in nineteen patients. Ureterovaginal fistula (UVF) occurred in nine patients and acute ureteric injury in three. Hysterectomy was the most common etiology occurring in 60% cases followed by obstetrical causes in 40% cases. All cases were successfully managed both with open surgery or laparoscopic surgery.

Conclusion:

Although obstetrical causes are still important in developing countries, gynecological procedures especially laparoscopic surgeries are on the rise. In these procedures the suspicion of urological injuries should be kept in mind and intra-operative detection and early repair should be attempted. Delayed diagnosis and improper treatment leads to severe complications.

Laparoscopic Extravesical Lich-Gregoir Ureteroneocystostomy with Psoas Hitch for the Management of Ureterovaginal Fistula in Post-Hysterectomy Patients

Introduction: Most commonly ureterovaginal fistula occurs due to surgical injury inflicted to the distal ureter and because of gynaecological procedures. Open surgical repair is a standard procedure and commonly involves ureteroneocystostomy. Methods: We retrospectively reviewed data of 9 patients, who underwent laparoscopic extravesical Lich-Gregoir ureteroneocystostomy using the psoas hitch procedure for ureterovaginal fistulas following hysterectomy during the period December 2012-August 2014. Transperitoneal laparoscopic ureteroneocystostomy was performed in all cases. Results: The mean operative time was 212 min (range 170-310) and estimated blood loss was 108 ml (range 70-150). Average hospital stay was 5.7 days. Follow-up time was from 6 to 26 months. Postoperative intravenous urography was done after 3 months, which showed patent anastomosis in 8 patients except for 1 patient who had nonvisualization of the ipsilateral renal moiety. Voiding cystogram done at 3 months showed no leakage in all patients. In the postoperative period, 1 patient had recurrent ipsilateral pyelonephritis 2 weeks after surgery, while another patient had febrile UTI. Apart from these no major complications were observed. Conclusion: Laparoscopic ureteroneocystostomy with psoas hitch can be performed safely with a success rate compared to that of open surgery but with less morbidity and quick convalescence.

Transumbilical laparoendoscopic single-site ureteral reimplantation

OBJECTIVE

To analyze the outcomes of umbilical laparoendoscopic single-site (LESS) ureteral reimplantation using a reusable single-port platform.

MATERIAL AND METHOD

The casuistic of LESS ureteral reimplantation in 5 patients is presented. The surgical technique using KeyPort system (reusable umbilical single-site platform) is described. Dissection, suctioning and suturing by minilaparoscopy through 3.5mm accessory port in the iliac fossa are performed. Operative and postoperative outcomes are presented. The median follow-up at time of analysis was 11 ± 14 months.

RESULTS

The median age of patients was a 49 ± 34 year; male-female ratio was 1:1.15. Left surgery was carried out in all cases. In 4 patients, the etiology was secondary to stenosis (3 iatrogenic and 1 pelvic endometriosis). In the remaining case, the procedure was performed after excision of a symptomatic adult ureterocele. In all cases, bladder catheter and double-J ureteral catheter were inserted for 7 ± 3 and 30 ± 15 days and then removed. No conversion to convectional laparoscopic or open surgery occurred. The surgery time was 145 ± 60 min, and intraoperative bleeding was 100 ± 75 cc. Neither transfusion nor high analgesia was necessary. No postoperative complications, minor or major, have been reported. Hospital stay was 2 ± 0.5 days. In any patient, restenosis or worsening of renal function occurred.

CONCLUSIONS

In experimented centers, transumbilical laparoendoscopic single-site ureteroneocystostomy is a safe alternative with comparable results to conventional laparoscopy and an excellent cosmetic result at low cost thanks to device reuse.

[Ureterovaginal fistulae]

Ureterovaginal fistulae are pathological communications between the ureter and the vagina; it commonly occur as a rare but serious sequela of unrecognized distal ureteral injuries during pelvic operations. Patients may present symptoms as leakage of urine from the vagina, flank pain and fever; in some cases it could be possible also the loss of renal function. The purpose of this study is to review the articles from 1991 to 2014 to evaluate the most correct diagnostic procedures and endourological and surgical techniques used in the management of ureterovaginal fistula. Nowadays computered tomography and retrograde pielography are the most commonly diagnostic modalities used to identify fistulous tract and to describe its anatomical position. The major of ureterovaginal fistulae can be successfully managed by conservative methods. Modern endourological treatment will result in resolution of a ureterovaginal fistula if retrograde or anterograde passage of a suitable internal stent is feasible. When stenting failed or in complicated cases, ureteral reimplantation is necessary. Ureteroneocystostomy, psoas hitch and Boari flap are three different possible surgical techniques used to realized an ureteral reimplantation. Both open and mini invasive (laparoscopy and robot assisted) surgical approach have proved successful.

Minimally invasive management of urological fistulas

PURPOSE OF REVIEW

Urological fistulas are an underestimated problem worldwide and have devastating consequences for patients. Many urological fistulas result from surgical complications and/or inadequate perinatal obstetric healthcare. Surgical correction is the standard treatment. This article reviews minimally invasive surgical approaches to manage urological fistulas with a particular emphasis on the robotic techniques of fistula correction.

RECENT FINDINGS

In recent years, many surgeons have explored a minimally invasive approach for the management of urological fistulas. Several studies have demonstrated the feasibility of laparoscopic surgery and the reproducibility of reconstructive surgery techniques. Introduction of the robotic platform has provided significant advantages given the improved dexterity and exceptional vision that it confers.

SUMMARY

Fistulas are a concern worldwide. Laparoscopic surgery correction has been developed through the efforts of several authors, and difficulties such as the increased learning curve have been overcome with innovations, including the robotic platform. Although minimally invasive surgery offers numerous advantages, the most successful approach remains the one with the surgeon is most familiar.

Laparoscopic repair of urogenital fistulae: A single centre experience

CONTEXT

Sparse literature exists on laparoscopic repair of urogenital fistulae (UGF).

AIMS

The purpose of the following study is to report our experience of laparoscopic UGF repair with emphasis on important steps for a successful laparoscopic repair.

SETTINGS AND DESIGN

Data of patients who underwent laparoscopic repair of UGF from 2003 to 2012 was retrospectively reviewed.

MATERIALS AND METHODS

Data was reviewed as to the aetiology, prior failed attempts, size, number and location of fistula, mean operative time, blood loss, post-operative storage/voiding symptoms and episodes of urinary tract infections (UTI).

RESULTS

Laparoscopic repair of 22 supratrigonal vesicovaginal fistulae (VVF) (five recurrent) and 31 ureterovaginal fistulae (UVF) was performed. VVF followed transabdominal hysterectomy (14), lower segment caesarean section (LSCS) (7) and oophrectomy (1). UVF followed laparoscopy assisted vaginal hysterectomy (18), transvaginal hysterectomy (2) and transabdominal hysterectomy (10) and LSCS (1). Mean VVF size was 14 mm. Mean operative time and blood loss for VVF and UVF were 140 min, 75 ml and 130 min, 60 ml respectively. In 20 VVF repairs tissue was interposed between non-overlapping suture lines. Vesico-psoas hitch was done in 29 patients of urterovaginal fistulae. All patients were continent following surgery. There were no urinary complaints in VVF patients and no UTI in UVF patients over a median follow-up of 3.2 years and 2.8 years respectively.

CONCLUSION

Laparoscopic repair of UGF gives easy, quick access to the pelvic cavity. Interposition of tissue during VVF repair and vesico-psoas hitch during UVF repair form important steps to ensure successful repair.

Laparoscopic ureteroneocystostomy for ureteral injuries after hysterectomy

This report suggests that laparoscopic ureteral reimplantation offers an alternative surgical approach to open surgery after distal ureteral injuries.

Objectives:

To examine the feasibility of early laparoscopic ureteroneocystostomy for ureteral obstruction due to hysterectomy injury.

Methods:

We retrospectively reviewed a 10-y experience from 2 institutions in patients who underwent early (<30 d) or late (>30 d) laparoscopic ureteroneocystostomy for ureteral injury after hysterectomy. Evaluation of the surgery included the cause of the stricture and intraoperative and postoperative outcomes.

Results:

A total of 9 patients with distal ureteral injury after hysterectomy were identified. All injuries were identified and treated as early as 21 d after hysterectomy. Seven of 9 patients underwent open hysterectomy, and the remaining patients had vaginal and laparoscopic radical hysterectomy. All ureteroneocystostomy cases were managed laparoscopically without conversion to open surgery and without any intraoperative complications. The Lich-Gregoir reimplantation technique was applied in all patients, and 2 patients required a psoas hitch. The mean operative time was 206.6 min (range, 120–280 min), the mean estimated blood loss was 122.2 cc (range, 25–350 cc), and the mean admission time was 3.3 d (range, 1–7 d). Cystography showed no urine leak when the ureteral stent was removed at 4 to 6 wk after the procedure. Ureteroneocystostomy patency was followed up with cystography at 6 mo and at least 10 y after ureteroneocystostomy.

Conclusion:

Early laparoscopic ureteral reimplantation may offer an alternative surgical approach to open surgery for the management of distal ureteral injuries, with favorable cosmetic results and recovery time from ureteral obstruction due to hysterectomy injury.

Laparoscopic ureteroneocystostomy: modification of current techniques

Purpose

To review the feasibility of laparoscopic ureteroneocystostomy with extracorporeal eversion of the ureteral end in various distal ureteral lesions.

Materials and Methods

We conducted a retrospective review of 5 laparoscopic procedures of ureteroneocystostomy with extracorporeal eversion of the ureteral end. Of these, 4 patients (range, 45 to 54 years) had distal ureter stricture or obstruction after gynecological surgeries for endometriosis or a large uterine myoma. One patient (male, 67 years) had low-grade distal ureter cancer. The laparoscopic procedure was combined with cystoscopic insertion of a ureteral stent and extracorporeal eversion of the ureter through the 10-mm port on the affected side.

Results

The laparoscopic ureteral reimplantations with and without a psoas hitch in patients with distal ureteral lesions was successful in all patients. The mean operation time was 137 minutes (range, 104 to 228 minutes). Two patients underwent additional psoas hitch. In all patients, short-term success was confirmed by voiding cystourethrography and intravenous pyelography conducted 3 months after the operation. The mean follow-up of the entire group was 12 months (range, 3 to 30 months). We noted no major or minor complications over the follow-up period.

Conclusions

The technique of laparoscopic ureteroneocystostomy for benign or malignant ureteral strictures continues to evolve. Surgeons should be versatile with various options and technical nuances when dealing with these cases. Simple modifications of laparoscopic ureteroneocystostomy with extracorporeal eversion of the ureteral end, nonreflux extravesical anastomosis, and simultaneous cystoscopy will be crucial to the ease of performance and a successful outcome.

Current trends in minimally invasive reconstructive urology

This paper is a systematic review of the current literature in minimally invasive reconstructive urological surgery. It focuses on the commonest reconstructive procedures in both the upper and lower urinary tracts including laparoscopic and robotic pyeloplasty for ureteropelvic junction obstruction, laparoscopic and robotic bladder diverticulectomy, laparoscopic and robotic partial cystectomy with urinary diversion, laparoscopic and robotic cystoplasty, repair of colovesical fistula, and, in urogynaecology, repair of vesicovaginal fistula. To evaluate the development, current status, feasibility, and safety of minimally invasive surgery (MIS) in reconstructive urology the literature on the topic was collated and reviewed.

Laparoscopic reconstruction of iatrogenic-induced lower ureteric strictures: Does timing of repair influence the outcome?

CONTEXT

Influence of timing of repair on outcome following laparoscopic reconstruction of lower ureteric strictures

AIMS

To assess the influence of timing of repair on outcome following laparoscopic reconstruction of lower ureteric strictures in our adult patient population.

SETTINGS AND DESIGN

Single surgeon operative experience in two institutes. Retrospective analysis.

MATERIALS AND METHODS

All patients were worked up in detail. All patients underwent cystoscopy and retrograde pyelography prior to laparoscopic approach. Patients were categorised into two groups: early repair (within seven days of inciting event) and delayed repair (after two weeks). Operative parameters and postoperative events were recorded. Postprocedure all patients were evaluated three monthly. Follow-up imaging was ordered at six months postoperatively. Improvement in renal function, resolution of hydronephrosis and unhindered drainage of contrast through the reconstructed unit on follow-up imaging was interpreted as a satisfactory outcome.

STATISTICAL ANALYSIS USED

Mean, standard deviation, equal variance t test, Mann Whitney Z test, Aspin-Welch unequal variance t test.

RESULTS

Thirty-six patients (37 units, 36 unilateral and 1 simultaneous bilateral) underwent laparoscopic ureteral reconstruction of lower ureteric stricture following iatrogenic injury - 21 early repair (Group I) and 15 delayed repair (Group II). All patients were hemodynamically stable at presentation. Early repair was more technically demanding with increased operation duration. There was no difference in blood loss, operative complications, postoperative parameters, or longterm outcome.

CONCLUSIONS

In hemodynamically stable patients, laparoscopic repair of iatrogenically induced lower ureteric strictures can be conveniently undertaken without undue delay from the inciting event. Compared to delayed repairs, the procedure is technically more demanding but morbidity incurred and outcome is at par.

[Sacral hitch vesical pexy: a new ancillary technique for ureteroneocystostomy]

BACKGROUND

To describe the Sacral Hitch, vesical pexys to sacral promontory, an alternative technique to the Psoas Hitch when this is impossible to perform. We report intraoperative complications, and long-term functional results.

METHODS

From 1989 to date we performed 66 ureteroneocystostomies (UNCS) (transbladder technique and Politano-Leadbetter antireflux plasty): 51 with ancillary "Psoas Hitch" (11 Casati-Boari); 15 with "Sacral Hitch" because of the intraoperative finding of deficiency or lack of psoas tendon. Note of technique. Ureter and bladder are dissected as usual. Sacral Hitch: left lateralization of sigmoid and exposition of sacral promontory; longitudinal incision and divarication of peritoneum; smooth dissection of fat tissue, displacement of medium sacral vessels and visualization of neurovascular bundles. Direct fixation of the dome/posterior aspect of bladder to anterior longitudinal ligament above promontory.

RESULTS

Among the patients who underwent the Psoas Hitch technique, 3 (5.4%) showed hypoesthesia, acute pain and impossible flexion of the thigh on hip with EMG positive for femoral (1) and genito-femoral (2) neuropathy. The re-operation in 2 cases solved the symptoms. One case resolved conservatively with corticoids, tricyclic antidepressants (Amitriptyline) and antiepileptics (gabapentin). Mean follow-up was 115 months (8-252); two stenosis of anastomosis. Sacral Hitch: (15 pts), mean follow-up: 47 months (range 4-110), no stenosis of anastomosis 0%; transfusion rate 0%.

DISCUSSION

The psoas tendon deficiency or its congenital absence (children or women) requires the direct fixation to the muscle, an inadequate and weak target and housing of important sensitive-motor nerves (Genito-femoral, femoral and latero-cutaneous). A "Psoas-Syndrome" could be present in 5.1% and a re-operation could be necessary. The sacral promontory represents an affixation target already successfully adopted in other surgery specialties (Gynaecology, Orthopaedic and General Surgery) and gives to UNCS a stiffness plate and an effective bladder cranialization. CONCLUSIONS. Sacral Hitch Vesical Pexys represents an ancillary procedure to UNCS and surgeons should keep it in mind in cases of difficult finding of the psoas muscle tendon.

Role of laparoscopy in reconstructive surgery

PURPOSE OF REVIEW

Despite increasing laparoscopic expertise in reconstructive surgery, open procedures still represent the gold standard. Robot-assisted techniques increasingly replace laparoscopy. However, laparoscopy is also developing: by improvement of ergonomics, new instruments, and techniques further reducing access trauma. We evaluated the actual role of laparoscopy focusing on main indications of urologic reconstructive surgery.

RECENT FINDINGS

We analysed the current literature (PubMed/Medline) concerning indications, perioperative results, complications, and long-term outcome of laparoscopy for pyeloplasty, ureteral reimplantation, stone surgery, management of vesico-vaginal fistula, sacrocolpopexy (including evidence level). For all indications, laparoscopy provides the advantages of less postoperative pain, blood loss, shorter convalescence, and minimal disfigurement. However, it requires expertise with endoscopic suturing. Most experience (N > 1000) exists with laparoscopic pyeloplasty and sacrocolpopexy which can be considered as valuable options (IIB). Concerning ureteral reimplantation and repair of vesico-vaginal fistula, only a limited number of cases were reported (N < 150) (III). Laparoscopic stone surgery may gain importance particularly in developing countries. Robot-assistance will definitively increase the application of laparoscopic techniques providing optimal ergonomics, whereas the role of single-port surgery will be limited.

SUMMARY

Laparoscopy will increasingly be used for reconstructive urologic surgery. This trend will be supported by the widespread use of the DaVinci device.

[Treatment of distal ureteral stricture by laparoscopic ureterovesical reimplantation]

INTRODUCTION

to analyse the results achieved to treat iliac or pelvic ureteric stricture using laparoscopic reimplantation of the ureter in a psoic bladder.

MATERIAL AND METHOD

in a four-year period, we performed laparoscopic ureteral reimplantation in a psoic bladder in 6 patients (right/left 1:1; male/female 1:2; mean age 59.2 years, range 47-87). In 4 cases the lesion was iatrogenic and in 2 cases idiopathic. Ureteral resection with bladder cuff and cystorraphy followed by ipsilateral lymph node dissection was performed in idiopathic cases or those with history of previous urothelial tumour (4 cases in total) before ureteral reimplantation. Bladder was extensively mobilized and fixed to minor psoas tendon before performing ureteroneocystostomy. Mixed intra and extravesical technique with submucosal tunnel (Politano) was used in a case and in the remaining 5 cases extravesical technique with submucosal tunnel (Goodwin) was used. Mean follow-up was 26 months (range 18-34).

RESULTS

there was no need to convert to open surgery. Time of surgery was 230 minutes in the case treated with Politano ureteroneocystostomy and 120 (range 75-150) in those treated purely extravesically. The mean hospital stay was 3.2 days (range 2-5). There were no intra or postoperative complications. Histologic assessment always revealed ureteral fibrosis and in 2 cases accompanying granulomatous inflammation and dysplasia. No patient suffered re-stricture or impairment in renal function during follow-up.

CONCLUSIONS

laparoscopic ureteral reimplantation is an effective and safe minimally invasive technique to treat benign distal stricture of the ureter. Simplicity of extravesical reimplantation has an advantage over its intravesical counterpart.

Laparoscopic ureteral reimplantation: prospective evaluation of medium-term results and current developments

OBJECTIVE

Laparoscopic ureteral reimplantation is a feasible method for treating ureteral pathology with good preliminary results in the literature. In this study, we review our medium-term results for laparoscopic ureteral reimplantation and discuss current developments of this procedure.

MATERIALS AND METHODS

Twenty-four laparoscopic ureteral reimplantations were performed between August 2003 and December 2008 for ureteral strictures or ureteral injuries. The mean age was 53.5 years (8 men, 16 women). Patient demographics, preoperative symptoms, radiological imaging, complications, and postoperative outcomes were analyzed. Ten patients underwent vesicopsoas-hitch, nine patients had a vesicopsoas-hitch combined with Boari-flap, and five had Lich-Gregoir extravesical ureteral reimplantations. Success was defined as relief of obstruction on postoperative imaging studies, as well as symptomatic relief.

RESULTS

Laparoscopic ureteral reimplantations were successfully performed in all patients. The mean operative time was 215 min (131-351). Mean estimated blood loss was 283 ml (50-550). One patient had an intraoperative bowel injury which was managed laparoscopically during the same procedure. There were two postoperative complications; two prolonged ileus and one deep venous thrombosis (DVT). Mean hospital stay was 8.7 days. Average time to return to normal activity was 2.6 weeks. Postoperative radiological imaging studies showed good drainage, without hydronephrosis, in 23 patients (success rate 95.8 %) at a median follow up interval of 35 months.

CONCLUSIONS

Laparoscopic ureteral reimplantation is an effective procedure with good medium-term results. We believe that this procedure will become an established treatment option.