Laparoscopic ureteroneocystostomy for distal ureteral injuries

Perioperative and functionnal outcomes of robot-assisted laparoscopic versus open ureterovesical reimplantation for benign lower ureteral pathologies: a single-center comparative study

PURPOSE

The robot-assisted laparoscopic (RALUVR) and open (OUVR) approaches have both been described for ureterovesical reimplantation to treat benign lower ureteral pathologies. Thus, we aimed to compare the perioperative and functional outcomes of RALUVR vs. OUVR.

METHODS

We performed a retrospective comparative study including all consecutive patients treated with RALUVR or OUVR for benign lower ureteral pathologies between January 2013 and December 2022 at our center. Logistic regression analyses were used to assess the predictors of complication ≥ Clavien-Dindo (CD) III within 90 days, prolonged length of stay (LOS), and 90-day overall success. The Kaplan-Meier method and Cox regression analyses were used to assess vesicoureteral reflux-free (VU-RFS) and stenosis-free (SFS) survivals.

RESULTS

Overall, 44 patients underwent RALUVR (n = 19; 43%) and OUVR (n = 25; 57%). In univariable logistic regression analyses, the use of RALUVR vs. OUVR was not significantly associated with postoperative complications ≥ CDIII (OR = 0.98; 95% CI=[0.17-5.09]; p = 0.98), and 90-day overall success (OR = 1.43; 95% CI=[0.24-11.28]; p = 0.7). Despite a shorter median LOS after RALUVR vs. OUVR (4 vs. 10 days, respectively; p < 0.001), multivariable logistic regression analysis showed no impact of the surgical approach on prolonged LOS (OR = 0.51, 95% CI=[0.03-13.86]; p = 0.65). No significant difference was observed in 2-year VU-RFS (72.9% vs. 100%, respectively; p = 0.2) and 2-year SFS between the RALUVR and OUVR groups (85.7% vs. 87.7%, respectively; p = 0.8). In Cox regression analysis, the use of RALUVR vs. OUVR was not significantly associated with VU-RFS (HR = 4.26; 95% CI=[0.38-47.84]; p = 0.24) or SFS (HR = 1.32; 95% CI=[0.22-8.01]; p = 0.76).

CONCLUSION

We observed that RALUVR provides similar perioperative and functional outcomes as compared to OUVR, except for potentially shorter LOS.

GI and GU fluoroscopy in common post-op oncologic surgeries: what you need to know about this leaky business!

Over the past several years, there has been a trend of decreasing screening or diagnostic fluoroscopic examinations ordered by clinical teams, particularly double contrast gastrointestinal studies. The underlying reason is due to increasing number of endoscopic procedures performed by Gastroenterology and Urology and usage of other imaging modalities, which are either more sensitive and/or offer the ability to obtain tissue for confirmation. Many fluoroscopic studies are now tailored toward patients who have undergone gastrointestinal or genitourinary oncologic surgeries, providing both functional and anatomic information, which are important tools for patient management. Some of these surgeries are very complex and an understanding of the postoperative anatomy and potential pitfalls is important to accurately evaluate for complications. The purpose of this article is to describe techniques and indications for common post-operative fluoroscopic procedures in gastrointestinal and genitourinary oncology while reviewing normal appearances. Complications, with emphasis on postoperative leaks, will be highlighted. Familiarity with the various types of gastrointestinal surgeries and urinary diversion techniques and knowledge of the expected postsurgical appearance is essential for achieving an accurate and prompt diagnosis of complications to allow for adequate treatment and management.

Laparoscopic ureteroneocystostomy for iatrogenic ureterovaginal fistula after modified radical hysterectomy: A case report

An unique laparoscopic ureteroneocystostomy technique was performed to treat an iatrogenic ureterovaginal fistula that was formed in a 69-year-old woman following open modified radical hysterectomy for endometrial cancer. Severe adhesions between the distal ureter and the surrounding tissues, including the iliac artery, were observed. Owing to difficulties in identifying the distal ureter, the proximal ureter was identified and dissected downward to free the ureter, thereby allowing anastomosis. This report shows that laparoscopic ureteroneocystostomy for ureterovaginal fistula repair may prove useful owing to its minimally invasive and broad approach.

Extravesical vs. intravesical ureteric reimplantation for primary vesicoureteral reflux: A systematic review and meta-analysis

PURPOSE

This study aims to compare the outcomes of extravesical (EVUR) and intravesical (IVUR) ureteric reimplantation for primary vesicoureteral reflux (VUR) via systematic review and meta-analysis.

METHODS

Literature review from Medline, Embase, and Cochrane since inception to March 2022 was performed. Meta-analysis was conducted on eligible randomized controlled trials (RCT) and observational cohort studies (OCS) comparing outcomes between EVUR and IVUR.

RESULTS

Twelve studies were included, comprising 577 patients (778 ureters) operated by EVUR and 395 patients (635 ureters) by IVUR. Pre-operative VUR grade, postoperative VUR persistence and hydronephrosis was not statistically significant. EVUR had shorter operative time [mean differences (MD) -22.91 min; 95% confidence interval (CI), -44.53 to -1.30, P = 0.04] and hospital stay (MD -2.09 days; 95% CI, -2.82 to -1.36, P < 0.00001) compared to IVUR. Bilateral EVUR had higher risk of postoperative acute urinary retention (ARU) (8.1%) compared to bilateral IVUR (1.7%) (OR = 4.40; 95% CI, 1.33-14.58, P = 0.02). No patient undergoing unilateral EVUR or IVUR experienced ARU.

CONCLUSION

Both EVUR and IVUR are equally effective in correcting primary VUR. Operative time and hospital stay are shorter after EVUR compared to IVUR. However, bilateral EVUR is associated with higher risk of postoperative ARU.

Management for Ureteral Stenosis: A Comparison of Robot-Assisted Laparoscopic Ureteroureterostomy and Conventional Laparoscopic Ureteroureterostomy

Background: To describe and analyze our experience of robotic-assisted laparoscopic ureteroureterostomy (RALU) and conventional LU for the repair of ureteral stenosis and compare the differences of safety and efficacy between RALU and LU. Materials and Methods: Patients who underwent RALU or LU for ureteral stenosis were retrospectively analyzed. Baseline characteristics, details of stenosis, surgery and some laboratory tests, and follow-up data were collected and analyzed. Results: Among 126 patients presented with ureteral stenosis, 65 patients underwent RALU and 61 patients underwent LU. All operations were completed successfully without conversion to open surgery. Both groups were comparable in baseline characteristics and details of stenosis. The mean operative time, suturing time, and hospitalization time of patients in RALU group were significantly less than those in LU group. The mean operative time of the RALU group was 126.34 minutes, whereas the mean operative time of the LU group was 176.57 minutes (P < .001). The average suturing time of RALU and LU was 26.88 and 70.43 minutes, respectively (P < .001). The mean hospitalization time of RALU and LU was 4.01 and 5.02, respectively (P < .001). RALU presented a lower degree of leukocytes rise than LU (P < .001). The mean follow-up time was 29.52 months. Conclusions: RALU and LU both are safe and feasible for ureteral stenosis with a low incidence of complications. Compared with LU, RALU may be a better choice with shorter operative time, suturing time, postoperative hospitalization time, and slighter inflammation. Further clinical studies of high quality are needed to confirm the priority of RALU.

Minimally invasive surgical treatment on delayed uretero-vaginal fistula

Objective

To evaluate the procedure of endoscopic surgery for ureterovaginal fistula (UVF) and its clinical efficacy.

Materials and methods

A retrospective analysis of 46 patients needing treatment for UVF with endourology technology was conducted (all patients had unilateral ureteric injury, 27 left and 19 right). Transurethral retrograde ureteric stenting or realignment retrograde/antegrade approach stenting was used to treat the fistula, and the relation between treatment and prognosis was analyzed.

Results

One case failed, the patient undergoing percutaneous nephrostomy instead. Success was achieved in 45 cases, and urinary leakage was stopped 48 h after surgery. Of the 45 patients operated on, 16 had their double-J stents removed after 3–6 months, and 29 needed replacement every 6–12 months. In a postoperative follow-up of 6–36 months, 10 patients had recurrent stenosis needing ureteroscopic endoureterotomy or reexpansion with a balloon. No other complications occurred.

Conclusions

Endoscopic surgery is an effective technology in the treatment of UVF, with the advantages of being effective, reliable, less invasive, and readily accepted by patients.

Laparoscopic surgery with urinary tract reconstruction and bowel endometriosis resection for deep infiltrating endometriosis

Deep infiltrating endometriosis (DIE) is the most severe form of endometriosis. It causes chronic pelvic pain, severe dysmenorrhea, deep dyspareunia, dyschezia, and dysuria, markedly impairing the quality of life of women of reproductive age. A number of randomized controlled trials on surgical and medical treatments to reduce the pain associated with endometriosis have been reported, but few have focused on this in DIE. DIE causes not only pain but also functional invasion to the urinary organs and bowel, such as hydronephrosis and bowel stenosis. In addition to DIE resection, surgical treatment involves adhesion separation as well as resection and reconstruction of the urinary organs and bowel; high-level skills are required. The severity of DIE should be evaluated preoperatively as accurately as possible. Using ENZIAN in conjunction with the AFS (The revised American Fertility Society classification of endometriosis) classification makes a more detailed assessment of DIE possible. The operative procedures used for laparoscopic resection of urinary DIE and reconstruction of the urinary organs are chosen based on the type of lesion (intrinsic/extrinsic) and length of stenosis. In addition to ureteroneocystostomy, the psoas bladder hitch and Boari bladder flap procedures are applied when necessary to extend the urinary tract. Bowel resection for bowel endometriosis is classified into classic segmental resection and conservative approaches (shaving/discoid). When these procedures are employed, it is advisable to work in consultation with urologists and gastroenterologists and to inform the patients of the associated risks and outcomes. Furthermore, postoperative medication is essential because it is difficult to conduct repeated surgeries.

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.

[Application of robotic-assisted versus conventional laparoscopy in ureteral reimplantation with psoas hitch]

OBJECTIVE

To compare the efficacy of robotic-assisted laparoscopic and conventional laparoscopic ureteral reimplantation with psoas hitch.

METHODS

We retrospectively analyzed the data of 10 patients undergoing robotic-assisted laparoscopic ureteral reimplantation with psoas hitch and 6 undergoing conventional laparoscopic ureteral reimplantation between June, 2013 and December, 2014 in the General Hospital of PLA. The indications, surgical techniques and outcomes of the two procedures were compared.

RESULTS

All the patients completed the laparoscopic procedures without conversion to open surgery. Robotic-assisted and conventional laparoscopic procedures were comparable in terms of the mean operation time (165.50=52.57 vs 152.50=73.60 min), mean volume of blood loss (81.00=69.35 vs 46.67=31.41 mL), mean duration of catheter retention (6.75=1.74 vs 7.50=2.43 days), and mean postoperative hospital stay (7.10=2.08 vs 8.67=3.14 days). The patients were followed up for a mean of 13.5 months, during which none of the patients experienced anastomotic leak, vesicoureteral reflux or hydronephrosis.

CONCLUSION

There are no significant differences in surgical indications, surgical techniques or postoperative effect between robotic-assisted and conventional laparoscopic procedures of ureteral reimplantation with psoas hitch, but robotic-assisted laparoscopy can reduced the complexity in operation and increase the surgical precision in patients with a history of pelvic surgery, pelvic adhesion or secondary reimplantation.

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.

Laparoscopic and robotic ureteral stenosis repair: a multi-institutional experience with a long-term follow-up

The treatment of ureteral strictures represents a challenge due to the variability of aetiology, site and extension of the stricture; it ranges from an end-to-end anastomosis or reimplantation into the bladder with a Boari flap or Psoas Hitch. Traditionally, these procedures have been done using an open access, but minimally invasive approaches have gained acceptance. The aim of this study is to evaluate the safety and feasibility and perioperative results of minimally invasive surgery for the treatment of ureteral stenosis with a long-term follow-up. Data of 62 laparoscopic (n = 36) and robotic (n = 26) treatments for ureteral stenosis in 9 Italian centers were reviewed. Patients were followed according to the referring center's protocol. Laparoscopic and robotic approaches were compared. All the procedures were completed successfully without open conversion. Average estimated blood loss in the two groups was 91.2 ± 71.9 cc for the laparoscopic and 47.2 ± 32.3 cc for the robotic, respectively (p = 0.004). Mean days of hospitalization were 5.9 ± 2.4 for the laparoscopic group and 7.6 ± 3.4 for the robotic group (p = 0.006). No differences were found in terms of operative time and post-operative complications. After a median follow-up of 27 months, the robotic group yielded 2 stenosis recurrence, instead the laparoscopic group shows no cases of recurrence (p = 0.091). Minimally invasive approach for ureteral stenosis is safe and feasible. Both robotic and pure laparoscopic approaches may offer good results in terms of perioperative outcomes, low incidence of complications and recurrence.

[Functional outcomes obtained after vesicoureteral reimplantation surgery in adults: A review]

OBJECTIVES

Vesico-ureteral reimplantations (VUR) for adults are complex procedures, often practicing for distal ureteral lesions. Our goal was to synthesis the main indications for VUR, different techniques and their functional outcomes.

MATERIAL AND METHODS

A literature review in English by Medline, Embase and Google scholar was performed using the following keywords: ureter; laparoscopy; robotics, reimplantation; surgery; obstruction; morbidity; complications; psoas hitch; Boari flap; ureteroneocystostomy.

RESULTS

In more than half of the cases, aetiology was a iatrogenic ureteral lesion. When the ureteral defect was less than 2 cm, direct or non-refluxing VUR was the technique of choice. If defect was superior than 2 cm the Boari flap or vesicopsoas hitch were preferred. Several surgical approaches were feasible: open, laparoscopic only, robot assisted laparoscopic. Estimated blood loss, pain and mean hospital stay seemed better with conventional or robotic coelioscopy. Nevertheless, complications, pre-/post-operative renal function and mean operative time seemed similar. The most frequent major complication was the anastomotic urine leakage.

CONCLUSIONS

The VUR techniques are well codified now even if it's a rare procedure. Functional outcomes are satisfied according to literature and morbidity is more and more decreasing but the level of evidence of the studies is low.

Robotic ureteral reconstruction distal to the ureteropelvic junction: a large single institution clinical series with short-term follow up

BACKGROUND AND PURPOSE

Use of the robotic platform for urinary reconstructive surgery is growing in popularity since its initial application with pyeloplasty for ureteropelvic junction (UPJ) repair. Although clinical series of adult robotic ureteral reconstruction appear in the literature, these reports tend to be limited in size and scope. We present the largest series to date of patients undergoing surgery for any obstruction distal to the UPJ along with outcomes and short-term follow up.

PATIENTS AND METHODS

A retrospective chart review was performed for patients undergoing robotic ureteral reconstructive procedures for any indication at our institution. Patients undergoing pyeloplasty, planned open procedures, and pediatric patients were excluded from the current analysis. Patient demographic data, etiology, procedure performed, and perioperative outcomes were reviewed. Postoperative follow up, imaging, and any re-interventions were also captured. The procedures performed included ureteroneocystostomy, psoas hitch, Boari flap, ureteroureterostomy, ureterolysis, ureterolithotomy, and nephropexy.

RESULTS

A total of 55 patients underwent robotic ureteral reconstructive procedures distal to the UPJ. Of these patients, 45 underwent intervention for a benign etiology and 10 for upper tract malignancy. All cases were successfully completed robotically with no open conversions and no intraoperative complications. Concurrent endoscopy was performed in 31 patients. The median operating room time was 221 minutes overall. Median blood loss was 50 ml with no intraoperative transfusions. The average hospital stay was 1.6 days, with 39 patients (71%) discharged on postoperative day 1. All surgical margins were negative for malignancy. The median follow up with imaging was 181 days. There were two serious complications (3.6%) and three failures (5.3%).

CONCLUSIONS

Robotic reconstruction of the ureter distal to the UPJ is feasible, safe, effective, and able to replicate techniques of open surgery with equivalent outcomes to large robotic pyeloplasty and smaller distal ureteral reconstruction series.

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.

Modified laparoscopic intravesical nonrefluxing ureteral reimplantation with psoas hitch using a submucosal tunneling

We aimed to study the safety and efficacy of the cystoscopy-assisted nonrefluxing ureteral reimplantation technique using submucosal tunneling during laparoscopic ureteroneocystostomy (UNC) with a psoas hitch in patients with distal ureter stricture after gynecologic surgery. We reviewed six female patients who underwent gynecological surgeries. All patients showed persistent postoperative distal ureter stricture or obstruction. These patients underwent laparoscopic nonrefluxing UNC with a psoas hitch using a submucosal tunneling technique combined with cystoscopy at our institute. They had corrective surgery at an average of 13.3 weeks after ureteral injury. The short-term success was confirmed either by voiding cystourethrography (VCU) or by diuretic isotope renal scan (MAG-3) conducted 3 months after the operation. None of the patients showed evidence of postoperative stricture at the reimplanted site and reflux on either MAG-3 renal scan or VCU. None of the patients showed major or minor complications during follow-up. It is safe and feasible to perform the laparoscopic nonrefluxing UNC with a psoas hitch using a submucosal tunneling technique combined with cystoscopy for ureteral stricture.

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.

Robot-assisted technique for boari flap ureteral reimplantation: is robot assistance beneficial?

BACKGROUND AND PURPOSE

Ureteral reconstructive surgery necessitates adequate exposure of the ureteral lesion and results in large abdominal incisions. Robot assistance allows the performance of complex ureteral reconstructive surgery through small incisions. The current series includes only cases of Boari flaps performed by robot assistance and attempts to describe in detail the technique, review the literature, as well as to expand the experience in the current literature.

PATIENTS AND METHODS

Eight patients underwent ureteral reimplantation by Boari flap technique. The indications for the performance of the procedure included ureteral stricture from iatrogenic injury in three patients, recurrent ureteral stricture after multiple endoscopic stone management procedures in one patient, ureteral stricture from previous malignant disease in the pelvis or abdomen in three patients, and ureteral stricture due to trauma in one patient. Five cases were located in the left side and three cases in the right side. A variety of parameters were recorded in a prospective database including the time for robot docking and total operative time as well as catheterization and drainage time. The follow-up of the patients included the performance of renal ultrasonography 4 weeks, 3, 6, and 12 months after the procedure.

RESULTS

Mean age of the patients was 50.8 (range 39-62) years and mean body mass index was 26.2 (range 23.22-29.29) kg/m(2). Operative time ranged 115 and 240 (mean 171.9) minutes. Mean blood loss was 161.3 (50-250) mL. Conversion to open surgery did not take place in the current series. No intraoperative complications were observed. Postoperative complications included one case of prolonged anastomotic leakage.

CONCLUSION

The robot-assisted approach is efficient in the performance of ureteral reimplantation with Boari flap. Low blood loss, short catheterization time, low complication rate, and excellent reconstructive outcome are associated with the approach. Robot assistance seems to be beneficial for ureteral reconstructive surgery.

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.

Ureteric injury: a challenging condition to diagnose and manage

Although ureteric injury is relatively uncommon, it is a serious event that can result in intra-abdominal sepsis, renal failure, and loss of the ipsilateral renal unit. Most injuries are iatrogenic and remain undiagnosed until the patient presents with symptoms postoperatively. In addition to compromising patient safety, missed ureteric injuries frequently result in litigation. Over the past 20 years, there has been a rapid uptake of laparoscopic and robotic techniques within urology and other surgical specialties. This trend, coupled with increased use of ureteroscopy, has increased the risk of injury to the ureter. The key to diagnosing and managing a ureteric injury is to have a low threshold for suspecting its presence. Diagnosis can be achieved using retrograde pyelography, ureteroscopy, CT, or intravenous urography. Initial management should involve ureteric stent placement or percutaneous nephrostomy drainage. In selected patients, surgical reconstruction might be the optimal approach. Decisions regarding surgical technique (open, laparoscopic, or robotic) are guided by the clinical situation and surgical expertise available.

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.

Management of benign ureteral strictures in the endoscopic era

BACKGROUND AND PURPOSE

During the past decade, endoscopic management has emerged as the first-line treatment of benign ureteral strictures. We reviewed our experience with the management of benign ureteral strictures to determine the success rate of endoscopic surgery in a contemporary series and assessed the viability of surgical reimplantation in the modern era.

PATIENTS AND METHODS

We identified 75 patients with a diagnosis of ureteral stricture between 2000 and 2005 via electronic medical records search and excluded those with completely obliterated, external compressive, malignant, or ureteroenteric strictures, ureteropelvic junction obstruction, and those with follow-up less than 2 months.

RESULTS

Thirty-four patients who were treated endoscopically (balloon dilation and/or holmium laser endoureterotomy) were identified. Mean stricture length in each patient was 1.6 +/- 1 cm (range 0.5-4 cm), and the mean number of procedures per patient was 1.7 +/- 0.8. Endoscopic success was achieved in 29 (85%), while 5 (15%) patients experienced endoscopic management failure and ultimately needed ureteral reimplantation. When comparing the endoscopically treated and reimplant groups, there was no significant difference in mean stricture length (1.38 +/- 1.13 vs 2 +/- 1.1 cm, P = 0.14), yet mean number of procedures performed (1.41 +/- 0.85 vs 3.6 +/- 1.5; P = 0.002) reached statistical significance. There were no clinical or radiographic signs of obstruction in 100% of patients who received endoscopic therapy only and 100% of patients who needed open surgical management at a mean follow-up of 25.2 +/- 19.3 and 7.7 +/- 3.2 months, respectively.

CONCLUSIONS

Endoscopic surgery is clearly a successful primary treatment modality in the management of benign ureteral strictures with minimal morbidity. In the modern era of endoscopic surgery, however, ureteral reimplantation remains a viable option in treating the small subset of patients with benign ureteral strictures for whom endoscopic management fails.

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.

Prevention and management of ureteral injuries occurring during laparoscopic radical prostatectomy: the Heilbronn experience and a review of the literature

OBJECTIVES

There is a small risk of ureteral injury during laparoscopic radical prostatectomy (LRP). It is important to recognise and repair such ureteral injuries immediately. Laparoscopic reconstructive surgery has proven to be feasible for the treatment of ureteral injury. We report our experience of ureteral injuries during LRP including the incidence, mechanism of injury, management, prevention and outcome.

MATERIALS AND METHODS

During a 9-year period, 2,164 LRP's were performed at our clinic. Three cases were complicated by lower ureteral injuries including two complete and one partial transection. The complete transections occurred during posterior dissection of the bladder neck and seminal vesicles, and the partial transection during an extended lymph node dissection. All were recognised and managed intraoperatively. We performed Lich-Gregoir (LG) extravesical ureteral reimplantation for complete transections, and primary repair for the partial ureteral transection.

RESULTS

Overall, the incidence of ureteral injuries was 0.13%. Laparoscopic reconstructive surgery was performed successfully in all cases without complication. This added 71, 46 and 59 min, respectively, to LRP operative time. The postoperative course was uneventful in all patients. Hospital stay was 8 days. After 30, 17 and 14 months of follow-up, intravenous urography (IVU) demonstrated good drainage.

CONCLUSION

Recognition and repair of ureteral injuries during LRP requires a high index of suspicion, and expertise in laparoscopic technique. Laparoscopic reimplantation or primary repair of these injuries during LRP is, in experienced hands, a safe, feasible and minimally invasive procedure with the benefits of laparoscopic surgery maintained for the patient.

Expanding the horizons: robot-assisted reconstructive surgery of the distal ureter

OBJECTIVES

To report our single-center experience with robotic ureteroneocystostomy for the treatment of distal ureteral obstruction.

METHODS

We performed robot-assisted laparoscopic ureteroneocystostomies between May 2005 and October 2007. We retrospectively collected information on patient demographics, and compared renal scans with furosemide washout and radiographic imaging before and after repair to determine radiographic success. Statistical analysis was performed using statistical software via paired Student's t test analysis.

RESULTS

Eight robot-assisted laparoscopic ureteroneocystostomies on seven patients were performed over a 30-month period. The etiology of the ureteric stricture was iatrogenic injury after hysterectomy in three patients, impacted stone in three, and infiltrative endometriosis in one. Mean stricture length was 2.2 cm. Right ureteroneocystostomy was performed in five patients and on the left in one, while one patient had bilateral disease. Mean operative time was 247 minutes (range 120-480), and average blood loss was 109 mL (range 50-200). Mean length of hospital stay was 2 days. All the procedures were completed successfully robotically without open conversion. Of the seven patients, one patient experienced recurrent symptoms. Subsequent imaging confirmed an anastomotic narrowing, which was treated by balloon dilation. There were no intraoperative or postoperative complications. Subsequent (99m)Tc-mercaptoacetyltriglycine scans showed no evidence of obstruction. After a mean follow-up of 18 months (range 5-31), relative renal function of the entire group of patients improved after ureteroneocystostomy, although this did not achieve statistical significance (p = 0.26).

CONCLUSIONS

Robotic ureteroneocystostomy is a safe and effective treatment option for the management of distal ureteric stricture disease.

Robot-assisted laparoscopic Boari flap ureteral reimplantation

Creation of a Boari flap is an option for ureteral reimplantation with high transection or stricture of the ureter. The benefits of laparoscopic surgery include decreased blood loss, quicker recovery time, and improved cosmesis. Robot-assisted surgery offers intraoperative advantages, including three-dimensional visualization with magnification and wristed movements with additional degrees of freedom. A 75-year-old woman with a persistent ureteral stricture opted for robot-assisted surgery for definitive management. To optimize the repair with least tension, creation of a Boari flap was chosen intraoperatively. Surgery and recovery were uncomplicated. Robot-assisted laparoscopic surgery can be safely used for Boari flap ureteral reimplantation.

Management of complications of prostate cancer treatment

Prostate cancer is the most commonly diagnosed noncutaneous cancer in men in the United States. Treatment of men with prostate cancer commonly involves surgical, radiation, or hormone therapy. Most men with prostate cancer live for many years after diagnosis and may never suffer morbidity or mortality attributable to prostate cancer. The short-term and long-term adverse consequences of therapy are, therefore, of great importance. Adverse effects of radical prostatectomy include immediate postoperative complications and long-term urinary and sexual complications. External beam or interstitial radiation therapy in men with localized prostate cancer may lead to urinary, gastrointestinal, and sexual complications. Improvements in surgical and radiation techniques have reduced the incidence of many of these complications. Hormone treatment typically consists of androgen deprivation therapy, and consequences of such therapy may include vasomotor flushing, anemia, and bone density loss. Numerous clinical trials have studied the role of bone antiresorptive therapy for prevention of bone density loss and fractures. Other long-term consequences of androgen deprivation therapy may include adverse body composition changes and increased risk of insulin resistance, diabetes, and cardiovascular disease. Ongoing and planned clinical trials will continue to address strategies to prevent treatment-related side effects and improve quality of life for men with prostate cancer.

Laparoscopic ureteroneocystostomy and psoas hitch for post-hysterectomy ureterovaginal fistula

PURPOSE

We assessed the results of laparoscopic ureteroneocystostomy with a psoas hitch for iatrogenic lower ureteral injuries leading to a ureterovaginal fistula.

MATERIALS AND METHODS

Between July 2003 and November 2007, 18 patients with iatrogenic lower ureteral injuries during hysterectomy leading to ureterovaginal fistula underwent laparoscopic ureteroneocystostomy with a psoas hitch. Of the patients 17 underwent abdominal or vaginal hysterectomy, while in 1 with a ruptured gravid uterus emergency hysterectomy was done for uncontrolled bleeding. Mean patient age was 35.5 years (range 23 to 45) and mean time to surgery since the injury was 2.2 months (range 1.5 to 3.5). Transperitoneal 3 or 4 port laparoscopic ureteroneocystostomy with a psoas hitch was performed.

RESULTS

Of the procedures 17 were completed successfully. Intraoperative cardiac arrhythmia occurred in 1 patient due to pneumoperitoneum and hypercarbia, requiring open conversion. Mean operative time was 2.5 hours (range 1.9 to 2.8) hours, mean blood loss was 90 ml (range 45 to 150) and total hospital stay was 5.3 days (range 2.9 to 8). The nephrostomy tube was blocked on the table in all patients and it was removed on day 7. At an average followup of 26.4 months (range 3 to 52) postoperative excretory urography did not reveal obstruction in any patient. One patient had vesicoureteral reflux on voiding cystogram.

CONCLUSIONS

Laparoscopic ureteroneocystostomy with a psoas hitch for ureterovaginal fistula secondary to hysterectomy is safe and effective, and associated with a low incidence of postoperative reflux and obstruction.

Iatrogenic ureteral lesions and repair: a review for gynecologists

Ureter injuries are a well-known complication of gynecologic surgery and a frequent cause of medicolegal problems. Because there are no randomized, controlled trials and the available studies are small series and case reports, the evidence on which to base treatment is weak. We therefore reviewed the complete English-language literature of ureter repair since 1990. In total, 608 ureter injuries were reported. Although it is widely believed that for laceration or section the prognosis is affected by a delay in diagnosis, we could not find evidence to substantiate this. An obstruction requires stenting only. For a laceration, stenting with suturing was more effective than stenting only (p = .006). A ureter anastomosis was successful in over 94% of cases either by laparotomy or laparoscopy. In conclusion, the literature data are scanty and heterogeneous and do not permit solid conclusions. Evidence, however, is emerging that a laceration should be treated by stenting and suturing. A ureter anastomosis over a stent could become a valid option especially when performed by laparoscopy.

Robot-Assisted Laparoscopic Distal Ureterectomy and Ureteral Reimplantation with Psoas Hitch

For midureteral and distal-ureteral tumors not amenable to endoscopic resection, distal ureterectomy with ureteral reimplantation is a treatment option. When ureteral length is insufficient for direct reimplantation, additional length can be gained with either a psoas hitch or a Boari flap. We describe our technique for robot-assisted laparoscopic distal ureterectomy and ureteral reimplantation with psoas hitch.

Laparoscopic ureteral reconstruction for benign stricture disease

OBJECTIVES

To describe our experience with laparoscopic ureteral reconstruction in the adult patient with benign ureteral stricture disease.

METHODS

We retrospectively compared laparoscopic (n = 12) and open (n = 34) ureteroureterostomy, ureteroneocystostomy, and Boari flap procedures conducted from January 1999 to November 2005 for benign stricture disease. The demographic, operative, complication, and outcome data were analyzed and compared.

RESULTS

The patient demographics and ureteral stricture etiology, location, and length were equivalent between the open and laparoscopic groups. The open surgical group had greater operative blood loss (258 versus 86 mL; P = 0.002) and a longer hospital stay (median 5 days versus 3 days; P <0.001) compared with the laparoscopic group. The overall complication rate in the open and laparoscopic groups was 15% and 8%, respectively (P = 0.225). Ureteral patency had been successfully reestablished in all 12 patients (100%) in the laparoscopic group at a mean follow-up of 23 months. In the open group, patency had been achieved in 30 patients (96%) at a mean follow-up of 43 months. No significant difference was found in patency success (P = 0.544) or the duration of follow-up (P = 0.098) between the two groups.

CONCLUSIONS

Laparoscopic ureteral reconstructive surgery is technically feasible and efficacious in treating benign ureteral stricture disease in adults.

[Reconstructive procedures in laparoscopic urology]

The introduction of laparoscopic pyeloplasty was the first step towards the development of suturing and knotting techniques. The final breakthrough came with the development of radical prostatectomy since the performance of the urethrovesical anastomosis required highly developed skills in reconstructive surgery. For most laparoscopic surgeons suturing and knot tying became quite familiar henceforth. As a consequence, the interest for other reconstructive procedures has increased tremendously since. Within a very short time pyeloplasty was developed to a surgical standard, and the results compare very favorably with open surgery. A very attractive method is the ureteral reimplantation according to the psoas hitch technique, which, however, does not completely duplicate the open surgical operation. Many patients can potentially be attracted by sacrocolpopexy to treat genital prolapse. The long-term success rate is 92% which is excellent for this indication. Urinary diversion following cystectomy is usually not performed completely intracorporeally, but laparoscopically assisted.