Management of Ureteroscopic Ureteral Injuries

Ureteroscopy-Assisted Laparoscopic Segmental Resection of Ureteral Stricture with a Modified Flank Position: Clinical Experience

PURPOSE

To share the surgical technique that possesses the advantage of a perioperative ureteroscope without position change, which allows for a laparoscopic segmental resection of the ureteral stricture to be performed more precisely.

PATIENTS AND METHODS

Between 2006 January and 2015 December, 10 patients with a ureteral stricture received a laparoscopic segmental resection and ureteroureterostomy in our clinical institute. The etiology included stone, endometriosis, crossing vessel, and idiopathic benign ureteral polyp. With the advance of bilateral lower extremities extended and abducted, 1 assistant used a ureteroscope as a direct guide to the precise location of the stricture affected ureter. Thus, the surgeon was able to perform a more specific resection without an unnecessary excision, which may have compromised the blood supply or increased the tension at anastomosis.

RESULTS

Five patients received the traditional transperitoneal laparoscopic approach, whereas the other 5 patients received a ureteroscopy-assisted laparoscopic segmental resection and ureteroureterostomy. The operating time appears to be no different between the two groups (124 minutes versus 142 minutes, P = .351), and, thus, no additional time is consumed for the ureteroscope procedure. After at least 1 year of follow-up, only 1 patient in the traditional laparoscopic group suffered from recurrence. One patient had a right ureteral stricture due to stone impaction, where with the advantage of a ureteroscope guide without change position, the operator was able to make a limited excision at the affected location. No complications related to the decubitus and bilateral leg in the extended position were noted.

CONCLUSIONS

Ureteroscopy-assisted laparoscopic segmental resection of the ureter without a change in position is a feasible and safe procedure when dealing with a refractory ureter stricture. Although it is convenient, the surgeon should be aware of possible pressure sores at the dependent part.

Optimal management of distal ureteric strictures following renal transplantation: a systematic review

Our objective was to define optimal management of distal ureteric strictures following renal transplantation. A systematic review on PubMed identified 34 articles (385 patients). Primary endpoints were success rates and complications of specific primary and secondary treatments (following failure of primary treatment). Among primary treatments (n = 303), the open approach had 85.4% success (95% CI 72.5-93.1) and the endourological approach had 64.3% success (95% CI 58.3-69.9). Among secondary treatments (n = 82), the open approach had 93.1% success (95% CI 77.0-99.2) and the endourological approach had 75.5% success (95% CI 62.3-85.2). The most common primary open treatment was ureteric reimplantation (n = 33, 81.8% success, 95% CI 65.2-91.8). The most common primary endourological treatment was dilation (n = 133, 58.6% success, 95% CI 50.1-66.7). Fourteen complications, including death (4 weeks post-op) and graft loss (12 days post-op), followed endourological treatment. One complication followed open treatment. This is the first systematic review to examine the success rates and complications of specific treatments for distal ureteric strictures following renal transplantation. Our review indicates that open management has higher success rates and fewer complications than endourological management as a primary and secondary treatment for post-transplant distal ureteric strictures. We also outline a post-transplant ureteric stricture evaluation and treatment algorithm.

Handling and prevention of complications in stone basketing

OBJECTIVE

To review the incidence, risk factors, and treatment options of intraoperative and postoperative complications of stone basketing in urology with emphasis on certain principles that must be upheld to prevent those complications.

METHODS

A literature search was performed using the MEDLINE database on stone basketing between 1970 and 2005.

RESULTS

Iatrogenic trauma due to retrieval of a stone is well known but the exact incidence is difficult to ascertain. Rarely, stone basketing can cause major trauma to the ureter, such as avulsion or intussusception, requiring open or laparoscopic intervention for ureteral continuity restoration. Mucosal abrasion, ureteral perforation, and stricture formation have also been described as complications of stone basketing. Occasionally, the engaged or broken basket can provoke anxiety even for experienced urologists. Factors that increase the risk of complications, strategies for repair, and techniques for prevention are discussed extensively.

CONCLUSION

Infrequent, surgical misadventures during stone basketing can occur and must be treated appropriately. Careful attention to instrument selection and surgical techniques and awareness of risk factors and type and site of potential injury are essential to reduce these complications.

Ureteroscopic management of ureteral and ureteroenteral strictures

The ureteroscopic approach to ureteral strictures has diminished morbidity because of smaller-caliber equipment, improved optics, Ho:YAG laser, and a better understanding of the risk factors for ureteral strictures. Direct visualization by means of retrograde ureteroscopy provides a safe and effective approach to treat ureteral strictures without the need for an open incision or percutaneous nephrostomy access. All patients with a ureteral stricture require an extensive evaluation and planning before treatment. Generally, patients with ureteral strictures and a history of carcinoma should undergo biopsy of the area of stricture. With recurrent cancer, patients may present with pain, nausea, vomiting, pyelonephritis, or loss of the ipsilateral renal unit. Malignant strictures tend to not respond well to balloon dilation alone. Open or laparoscopic resection and reconstruction may be indicated if there is a chance for cure. In patients who are not good surgical candidates or in those who have advanced disease, the urologist is left with the option of an indwelling stent or nephrostomy tube.

Update On Minimally Invasive Management of Ureteral Strictures

PURPOSE

To review the role of minimally invasive management in ureteral stricture disease.

MATERIALS AND METHODS

A literature search was performed on the MEDLINE database through 2002 concerning endoscopic treatment of patients with ureteral strictures.

RESULTS

Many endourologic methods are available for ureteral strictures. Ureteral dilation may be accomplished in most cases, with various rates of success depending on stricture etiology, location, and length. Endoureterotomy also leads to long-term patency in properly selected cases and appears to be superior to dilation alone.

CONCLUSIONS

Significant advances in technique and technology have improved our ability to treat ureteral strictures without the need for open surgery in most patients.

Acute ureteral elongation in two animal models using a balloon expander

BACKGROUND AND OBJECTIVE

Repair of ureteral injuries and strictures often necessitates a major reconstructive procedure such as a psoas hitch, Boari flap, renal mobilization, ileal interposition, or autotransplantation. Tissue expanders have been used to elongate nerves and arteries. We examined the effects of acute ureteral elongation in two animal models.

MATERIALS AND METHODS

In eight female rabbits, we exposed the left ureter through a midline incision and placed a Ruiz-Cohen balloon beneath the undermined portion. The expander was then inflated until the ureter was tightly stretched across it. After deflation, the expanded segment was measured in situ and compared with its original length. Follow-up urography was performed, and the tissue was harvested and examined by a pathologist. The same procedure was performed in five pigs; however, in these animals, a segment of ureter was excised, and a ureteroureterostomy was performed, after the acute expansion.

RESULTS

We were able to achieve acute elongation of the expanded ureteral segment. The mean elongation was 31.3% in the rabbits and 32.0% in the pigs. An intravenous urogram (IVU) 6 weeks after the elongation showed a functioning kidney and a patent ureter. Histologic examination of the ureter within 24 hours after the expansion revealed that all segments were viable, the luminal epithelium was intact, and the muscular layers appeared normal. At 6 weeks, the expanded segment showed mild inflammatory changes, but the overall morphology, size, and cytology findings were similar to those of a normal control.

CONCLUSIONS

Acute ureteral elongation using a tissue expander is a new method of increasing ureteral length. It may be useful to cover defects that would need major operations with greater morbidity.

Use of endoscopy in the management of postoperative ureterovaginal fistula

The aim of the study was to evaluate endourological techniques in the management of iatrogenic ureterovaginal fistula. Seventeen patients referred to us after gynecologic surgery were diagnosed as having iatrogenic ureterovaginal fistula. First, retrograde double-J stenting was tried. If this failed, percutaneous nephrostomy using an antegrade double-J stent was performed. If this also failed, open surgical repair was performed. The retrograde double-J stent bypassed the fistula in 2 patients (11.8%). Percutaneous nephrostomy was performed in the remaining 15. The antegrade double-J stent bypassed the fistula in another 2 of these patients (11.8%). Open surgical repair was performed in the remaining 13 patients (67.5%) (direct ureteroneocystostomy) with nipple valve in 11 patients and Boari flap with psoas hitch in 2 patients). Of all patients, 2 had ureteral stricture, one after antegrade double-J stenting and the other after open repair. It was concluded that early intervention is recommended in the treatment of iatrogenic uretrovaginal fistula, causing minimal morbidity and discomfort, and being less expensive.

Fluoroscopically guided incision of ureteral strictures in pigs with the cautery-wire balloon catheter: a phase 1 study

We investigated a catheter that can longitudinally incise ureteral strictures under fluoroscopic guidance without the need for ureteroscopy and its attendant risks. The catheter consists of a low-pressure balloon and an overlying cautery wire; the balloon allows precise localization of the stricture, seen as a waist in the balloon, and the overlying cautery wire can be fluoroscopically oriented at the stricture. One to two centimeter ureteral strictures were created in 6 swine. Two to four weeks later strictures were incised in a retrograde or antegrade fashion with the cautery-wire balloon catheter, and double J stents placed for a duration of three weeks. In 5 of 6 renal units strictures improved anatomically with resolution of hydronephrosis at 3 to 4 months' follow-up. Urodynamic absence of obstruction was verified by Whitaker testing. In one animal, the tip of the catheter dislodged in the ureter with subsequent loss of the renal unit. The engineering error that lead to this complication has since been rectified. With correction of the aforementioned problem, this Phase 1 study has demonstrated the feasibility, safety and preliminary efficacy of the cautery-wire balloon catheter for endourologic management of ureteral strictures.

Ureteral stents and flexible ureterorenoscopy

Numerous methods of dilating the intramural ureter for ureteroscopy are effective when used by experts, but none is ideal. In the authors' experience, a ureteral stent left indwelling for 1 or, better, 2 weeks usually is the safest, most reliable, and least traumatic method.

Traumatic disruption of the ureteropelvic junction managed by ileal interposition

The use of ileal interposition in the management of a patient with delayed diagnosis of traumatic disruption of the ureteropelvic junction is presented. The unusual presentation of this problem, potential options in reconstructing the ureter and successful outcome are discussed.