Lésions opératoires de l'uretère

Reconstruction after ureteral resection during HIPEC surgery: Re-implantation with uretero-neocystostomy seems safer than end-to-end anastomosis

INTRODUCTION

Resection of the pelvic ureter may be necessary in cytoreductive surgery for peritoneal carcinomatosis in combination with hyperthermic intraperitoneal chemotherapy (HIPEC). As the morbidity for cytoreductive surgery with HIPEC has decreased, expert teams have begun to perform increasingly complex surgical procedures associated with HIPEC, including pelvic reconstructions. After ureteral resection, two types of reconstruction are possible: uretero-ureteral end-to-end anastomosis and uretero-vesical re-implantation or uretero-neocystostomy (the so-called psoas hitch technique). By compiling the experience of three surgical teams that perform HIPEC surgeries, we have tried to compare the effectiveness of these two techniques.

METHODOLOGY

A retrospective comparative case-matched multicenter study was conducted for patients undergoing operation between 2005 and 2014. Patients included had undergone resection of the pelvic ureter during cytoreductive surgery with HIPEC for peritoneal carcinomatomosis; ureteral reconstruction was by either end-to-end anastomosis (EEA group) or re-implantation uretero-neocystostomy (RUC group). The primary endpoint was the occurrence of urinary fistula in postoperative follow-up.

RESULTS

There were 14 patients in the EEA group and 14 in the RUC group. The groups were comparable for age, extent of carcinomatosis (PCI index) and operative duration. Four urinary fistulas occurred in the EEA group (28.5%) versus zero fistulas in the RUC group (0%) (P=0.0308).

CONCLUSION

Re-implantation with uretero-neocystostomy during cytoreductive surgery with HIPEC is the preferred technique for reconstruction after ureteral resection in case of renal conservation.

[Aetiology and management of iatrogenic injury of the ureter: a review]

OBJECTIVE

Ureteric injuries (IU) are common complications occurring during abdomino-pelvic surgical procedures. Our aim was to review risk factors, treatment and methods of prevention of these iatrogenic UI.

MATERIAL AND METHODS

A literature review in English and French by Medline(®) was performed using the keywords: ureter; iatrogenic; injury; ureteroscopy; morbidity and endoscopy.

RESULTS

The analysis of the epidemiology of IU shows that the first two causes are gynecological and urological surgery. In 80% of cases, the pelvic ureter was concerned. Mechanisms of injury were essentially ligation, section and ischemia by altering the ureteral vasculature. The main risk factors found were pelvic inflammation (endometriosis, radiation…) and the occurrence of bleeding during surgery. In the presence of risk factors, placing a double J stent or a CT may be useful preoperatively. The choice of reparation technique depended on the location of the PU, the circumstances of the occurrence and experience of the surgical team.

CONCLUSION

Pelvic surgery is a provider of iatrogenic PU. Knowledge of the management of PU once occurred must be mastered before carrying out any risk surgery.