Endoscopic Rendezvous Procedure for Ureteral Iatrogenic Detachment: Report of a Case Series with Long-Term Outcomes

The Rendezvous Technique: A Minimally Invasive Non-Surgical Approach for the Management of Iatrogenic Ureteral Injuries

Background/Objectives: The aim of our study is to evaluate the feasibility and efficacy of the rendezvous technique for the treatment of iatrogenic ureteral injuries. Methods: From 2014 to 2019, 29 patients treated with the rendezvous technique for mono- or bilateral iatrogenic ureteral injuries were enrolled in this retrospective study. All the leaks were previously assessed by CT-urography and antegrade pyelography. Ureteral continuity was restored by performing the rendezvous technique, combining antegrade trans-nephrostomic access and a retrograde trans-cystostomic approach. A double J stent was antegradely inserted, and a nephrostomy tube was kept in place at the end of the procedure. A post-procedure CT-urography and a 30-day nephrostogram follow-up were performed. In the absence of a contrast leak, the nephrostomy tube was removed. Patient follow-up was set with CT-urography at 3, 6, and 12 months and stent substitution every 4 months. The CT-urography was performed to confirm the restored integrity of the ureter before stent removal. Results: The rendezvous technique was successful in all cases with the resolution of the ureteral leak. No major complications were observed. In all the patients, the nephrostomy tube was removed after 30 days. After performing CT-urography, the stent was removed permanently after 12 months. Only three cases showed local post-treatment stenosis treated with surgical ureteral reimplantation. Conclusions: The rendezvous technique is a safe and effective minimally invasive procedure that can be used to restore the continuity of the ureter, avoiding open surgery and providing valuable support for the management of complications after gynecological surgery.

Long-term Outcomes of Minimally Invasive Rendezvous Procedures to Treat Complex Ureteric Strictures and Injuries

Background

Complex ureteric strictures and injuries occurring during major abdominal and pelvic operations may cause significant morbidity and distress to patients. A rendezvous procedure is an endoscopic technique used in case of such injuries.

Objective

To evaluate perioperative and long-term outcomes of rendezvous procedures to treat complex ureteric strictures and injuries.

Design setting and participants

We retrospectively reviewed patients undergoing a rendezvous procedure for ureteric discontinuity including strictures and injuries, treated between 2003 and 2017 at our Institution and completing at least 12 mo of follow-up. We divided patients into two groups: early postsurgical obstruction, leakage, or detachment (group A) and late strictures (oncological/postsurgical; group B).

Outcome measurements and statistical analysis

If appropriate, we performed a retrograde study ± rigid ureteroscopy to assess the stricture 3 mo after the rendezvous procedure, followed by a MAG3 renogram at 6 wk, 6 mo, and 12 mo, and annually thereafter for 5 yr.

Results and limitations

Forty-three patients underwent a rendezvous procedure, 17 in group A (median age 50 yr, range 30-78) and 26 in group B (median age 60 yr, range: 28-83). Ureteric strictures and ureteric discontinuities were stented successfully in 15 out of 17 patients in group A (88.2%) and 22 out of 26 patients (84.6%) in group B. For both groups, the median follow-up was 6 yr. In group A, of 17 patients, 11 (64.7%) were stent free with no further interventions, two (11.7%) had a subsequent Memokath stent insertion (38%), and two (11.7%) required reconstruction. Of 26 patients in group B, eight (30.7%) required no further interventions and were stent free, ten (38.4%) were maintained with long-term stenting, and one was managed with a Memokath stent (3.8%). Of the 26 patients, only three (11.5%) required major reconstruction, while four patients with malignancy (15%) died during follow-up.

Conclusions

With a combined antegrade and retrograde approach, the majority of complex ureteric strictures/injuries can be bridged and stented with an overall immediate technical success rate of above 80%, avoiding major surgery in unfavourable circumstances and allowing time for stabilisation and recovery of the patient. Additionally, in case of technical success, further interventions may be unnecessary in up to 64% of patients with acute injury and about 31% of patients with late stricture.

Patient summary

The majority of complex ureteric strictures and injuries can be resolved using a rendezvous approach, avoiding major surgery in unfavourable circumstances. Moreover, this approach can help avoid further interventions in 64% of such patients.

Is endourological intervention a suitable treatment option in the management of iatrogenic thermal ureteral injury? A contemporary case series

BACKGROUND

Iatrogenic ureteral injury (IUI) is relatively rare, however, can cause sepsis, kidney failure, and death. Most cases of IUI are not recognized until the patient presents with symptoms following pelvic surgery or radiotherapy. Recently, minimally invasive approaches have been used more frequently in the treatment of IUI. This study evaluates urological intervention success rates and long-term clinical outcomes according to the type of IUI following hysterectomy.

METHODS

Twenty-seven patients who underwent surgery due to IUI in our clinic following hysterectomy were evaluated between January 2011 and April 2018. Patients were classified according to the time of diagnosis of IUI. The IUI cases diagnosed within the first 24 h following hysterectomy were designated as "immediate" IUI, while that diagnosed late period was considered 'delayed' IUI. The type of IUI was categorized as "cold transection" if it was due to surgical dissection or ligation without any thermal energy, and "thermal injury" if it was related to any energy-based surgical device. Patient information, laboratory and perioperative data, imaging studies, and complications were assessed retrospectively.

RESULTS

All cases of delayed diagnosis IUI were secondary to laparoscopic hysterectomy (P = 0.041). Patients with thermal injury to the ureter were mostly diagnosed late (delayed) (P = 0.029). While 31% of the patients who underwent endourological intervention were diagnosed immediately, 69% of them were diagnosed as delayed. These rates were roughly reversed for open reconstructive surgery: 73% and 27% (P = 0.041), respectively. We detected eight ureteral complications in our patient cohort following the urological intervention. In all these failed cases, the cause of IUI was a thermal injury (P = 0.046) and the patients had received endourological treatment (P = 0.005). No complications were detected in patients who undergo open urological reconstructive surgery. While one of the patients who developed urological complications had an immediate diagnosis, seven were in the delayed group (P = 0.016).

CONCLUSION

Endourological intervention is performed more frequently in delayed diagnosed IUI following hysterectomy, however, the treatment success rate is low if thermal damage has developed in the ureter. Surgical reconstruction is should be preferred in these thermal injury cases to avoid further ureter-related complications.

OUP accepted manuscript

We present the endoscopic management of two cases of complete ureteric occlusion at vesico-ureteral junction (VUJ) level following iatrogenic injury. Case 1 is a 60-year-old man who developed bilateral ureteric injury at the level of the VUJ following robot-assisted radical prostatectomy (RARP) for Gleason 3 + 4 = 7 T2bN0 prostate cancer. Case 2 is an 81-year-old man with history of recurrent G2pTa transitional cell carcinoma of the bladder originally diagnosed in 2005 and history of radical radiotherapy for prostate cancer. At his most recent transurethral resection of bladder tumour, the left ureteric orifice was not visualized. We describe step-by-step our technique in restoring continuity of the ureter with minimally invasive endoscopic approach, resulting in excellent long-term upper tract drainage for our patients. To our knowledge, combined utilization of a Collins knife to incise the area around the ureteric orifice to unearth them is not reported. We aim to report our technique and its outcomes.

Terminal augmented ureteroplasty with bladder onlay flap technique for recurrent distal ureteral stricture after ureteroneocystostomy: an initial case series

Background

Bladder flap has been shown to be a feasible treatment for distal ureteral stenosis; this technique has been improved such that it can be used to address complex urinary tract obstructions. The purpose of the present study was to describe a surgical technique of ureteroplasty with a bladder onlay flap, which consists of a nontransecting and terminal augmented anastomosis, for repairing recurrent distal strictures of the ureter.

Methods

We retrospectively reviewed 6 patients who underwent this procedure between May 2018 and November 2019. These patients were diagnosed with distal ureteral stenosis and had previously undergone ureteroneocystostomy (one with a Boari flap) but suffered recurrence of flank pain. Patient characteristics, perioperative data and follow-up outcomes were gathered. The success of the operation was judged by symptomatic relief (subjective success) and improved radiographic imaging and renal function (objective success).

Results

Preoperative computed tomography urography (CTU) showed hydronephrosis in all patients: severe hydronephrosis was observed in 83.3% of patients (5/6), and moderate hydronephrosis was observed in 16.7% (1/6). The mean stricture length was 2 cm. The mean operating time, estimated blood loss and postoperative hospital stays of the six patients were 193.3 min (160–270 min), 41.5 mL (10–58 mL) and 8.2 days (6–11 days), respectively. No serious complications (Clavien-Dindo grade ≥3) occurred during or after the operations. The mean follow-up time was 24.5 months (range, 14 to 29). The objective success rate was 83.3% (5/6), and the subjective success rate was 100%.

Conclusions

Our technique of ureteroplasty with a bladder onlay flap by nontransecting and terminal augmented anastomosis is feasible and improves the recovery rate after the repair of recurrent distal ureteral stenosis. Patients who have had previous unsuccessful surgeries might benefit from this approach.

Acute management of complete bilateral ureteral transections aligned via stent through antegrade and retrograde approach

To manage bilateral complete distal ureteral transections (CDUT) via stent placement achieved through a combination of antegrade and retrograde approaches. An antegrade wire was advanced through the nephrostomy tube. Flexible ureteroscopy was utilized via retrograde approach to identify the guidewire in the pelvis. The guidewire was grasped and withdrawn out the urethra, and bilateral stents were placed over guidewire. Patient continues to remain asymptomatic one year later, with symmetrical renal function and no evidence of obstruction. We demonstrate that a CDUT can be successfully realigned with a combined endourological approach, thereby avoiding open/laparoscopic ureteral repair.

Hospital Ownership, Geographic Region, Patient Age, Comorbidities and Insurance Status Appear to Influence Patient Selection Robotic-Assisted Ureteral Reimplantation for Benign Disease: A Population-Based Analysis

BACKGROUND

Robotic-assisted ureteral reimplantation (RAUR) is a relatively new minimally-invasive surgery. As such, research is lacking, and the largest adult cohort studies include fewer than 30 patients. Our aim was to be the first population-based study to report on national utilization trends, factors associated with patient selection, inpatient outcomes, and the relative cost of RAUR for adults with benign ureteral disease (BUD).

MATERIALS AND METHODS

The National Inpatient Sample (2010-2015) was queried to identify all elective, non-transplant related, open and robotic-assisted reimplants for adult BUD. Survey-weighted logistic regression using Akaike Information Criterion identified patient-/hospital-level factors associated with robotic surgery. Survey-weighted regression models examined the association of robotic surgery with outcomes and charges.

RESULTS

A weighted-total of 9,088 cases were included: 1,688 (18.6%) robotic-assisted and 7,400 (81.4%) open. There were significantly increased odds of RAUR across consecutive years (OR 3.0, p < 0.001) and among patients operated on at private for-profit hospitals (OR 2.1; p = 0.01), but significantly decreased odds among older patients (OR 0.98, p < 0.001), those with Medicaid (OR 0.5, p = 0.02), those with 2+ comorbidities (OR 0.6, p = 0.009) and those operated on in Western (OR 0.5; p = 0.005) states. RAUR was significantly associated with a reduced length-of-stay (IRR: 0.60; p <0.001), decreased odds of blood transfusion (OR: 0.40; p <0.001) and a lower mean ratio of total hospital charges (Ratio: 0.71; p = 0.006).

CONCLUSIONS

This is the first population-based study to report on the utilization and clinical benefits of RAUR for adult BUD. Open reimplantation remains the most common surgical technique utilized, despite the potential benefits of RAUR. Future research is needed to explore the mechanisms behind patient-/hospital-level factors and surgical selection. Work to investigate potential barriers in access to robotic surgery can help us provide equitable care across patient populations.

The diagnostic utility of retroperitoneoscopic tissue biopsy for unresectable retroperitoneal lesions excluding urogenital cancers

Background

Retroperitoneal tumors are an uncommon disease known to consist of a diverse group of benign and malignant neoplasms. Treatment of unresectable retroperitoneal lesions requires pathological diagnosis. Here, we report the utility and safety of retroperitoneoscopic biopsy for unresectable retroperitoneal lesions excluding urogenital cancers.

Methods

We analyzed 47 patients consisting of 23 (49%) and 24 (51%) cases that underwent retroperitoneoscopic tissue biopsy and open biopsy, respectively. The clinicopathological features, including postoperative complications, were compared between the two groups.

Results

Tumor pathology was diagnosed successfully with a single operation in all patients. Malignant pathology (68%) was more common than benign pathology (32%). The most common pathology was malignant lymphoma, which accounted for about 50% of all cases. There was no significant difference with respect to the age, sex, tumor size, presence of tumor-related symptom, histopathology, operative time, and complications. Three (13%) of 23 patients in the retroperitoneoscopic biopsy group received percutaneous needle biopsy before laparoscopic excisional biopsy because the evaluation of needle cores failed to confirm subclasses of diagnosed pathologies. One patient was converted to open surgery just after the initiation of operation due to severe adhesion of adjacent structures. We had two cases with iatrogenic urinoma due to ureteral injury after retroperitoneoscopic biopsy.

Conclusions

We conclude that retroperitoneoscopic biopsy is a safe and useful tool for benign and malignant retroperitoneal lesions, in comparison to open biopsy. It is critical to carefully examine the preoperative imaging for the location of tumors, especially those close to the renal pelvis and ureter.

Combined antegrade and retrograde access to difficult ureters: revisiting the rendezvous technique

INTRODUCTION

Complex ureteric strictures present a significant challenge to the endourologist and uro-radiologist. Multiple separate interventions to try to cross the stricture are often attempted. We describe our experience managing a heterogenous patient group using the 'rendezvous' procedure.

METHODS AND MATERIALS

16 patients and 18 ureters (one bilateral procedure, and two separate procedures in one patient) underwent rendezvous procedures. Seven patients had coexisting ureteric calculi treated. Each case was followed up for between 3 months and 5 years.

RESULTS

In 16/18 ureters there was technical success at time of surgery; successfully crossing the stricture, allowing ureteroscopic access to the ureter, dilating and/or stenting the ureter. 2/18 were unsuccessful; one secondary to advanced malignancy resulting in a uretero-vaginal fistula and the second a failure to remove a retained, displaced ureteric stent. Of the 18 ureteric procedures; 7/18 were stent free at 3 months, improving to 8/18 stent free at 6 months. 4/18 remained nephrostomy dependent (failure of drainage despite stent or failure to stent) at 3 months, increasing to 6/18 being nephrostomy dependent at 6 months. 1/16 remained dialysis dependent with a nephrostomy tube. For those procedures involving ureteric calculi, 6/7 were stone free and 1/5 had a persistent stone fragment requiring further intervention.

CONCLUSIONS

A combined approach may decrease the number of separate interventions required, with the aim of removing the need for a long-term nephrostomy, as well as providing opportunity to treat ureteric calculi in the context of stricture disease. Our experience has been that where the rendezvous has been required to treat strictures caused by malignant extrinsic compression, stenting has not been successful; this information is key to informed consent in a group of patients who may have a limited life expectancy.

Adult iatrogenic ureteral injury and stricture-incidence and treatment strategies

Iatrogenic ureteral injuries and strictures are relatively common complication of pelvic surgery and radiation treatment. Left untreated they are associated with severe short- and long-term complications such as urinoma, septic state, renal failure, and loss of a renal unit. Treatment depends on timing of diagnosis, as well as extent of injury, and ranges from simple endoscopic management to complex surgical reconstruction under usage of pedicled grafts. While recent advances in ureteral tissue engineering are promising the topic is still underreported. Historically a domain of open surgery, laparoscopic and robotic-assisted approaches have proven their feasibility in small case series, and are increasingly being utilized as means of reconstructive surgery. This review aims to give an outline of incidence and treatment of ureteral injuries and strictures in light of the latest advances.

Endometriosis: clinical features, MR imaging findings and pathologic correlation

Objective

We illustrate the magnetic resonance imaging (MRI) features of endometriosis.

Background

Endometriosis is a chronic gynaecological condition affecting women of reproductive age and may cause pelvic pain and infertility. It is characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus and includes three different manifestations: ovarian endometriomas, peritoneal implants, deep pelvic endometriosis. The primary locations are in the pelvis; extrapelvic endometriosis may rarely occur. Diagnosis requires a combination of clinical history, invasive and non-invasive techniques. The definitive diagnosis is based on laparoscopy with histological confirmation. Diagnostic imaging is necessary for treatment planning. MRI is as a second-line technique after ultrasound. The MRI appearance of endometriotic lesions is variable and depends on the quantity and age of haemorrhage, the amount of endometrial cells, stroma, smooth muscle proliferation and fibrosis. The purpose of surgery is to achieve complete resection of all endometriotic lesions in the same operation.

Conclusion

Owing to the possibility to perform a complete assessment of all pelvic compartments at one time, MRI represents the best imaging technique for preoperative staging of endometriosis, in order to choose the more appropriate surgical approach and to plan a multidisciplinary team work.

Teaching Points

• Endometriosis includes ovarian endometriomas, peritoneal implants and deep pelvic endometriosis.

• MRI is a second-line imaging technique after US.

• Deep pelvic endometriosis is associated with chronic pelvic pain and infertility.

• Endometriosis is characterized by considerable diagnostic delay.

• MRI is the best imaging technique for preoperative staging of endometriosis.

Image-guided ureteral reconstruction using rendezvous technique for complex ureteric transection after gunshot injuries

Management of complex ureteric transection poses a significant clinical challenge, particularly after gunshot injuries due to marked distortion of anatomy and associated tissue loss. We report two cases of total ureteric transection due to gunshot injury successfully repaired using fluoroscopy-guided rendezvous procedure and double J stent placement. This minimally invasive approach may offer a safe and effective technique to repair complete ureteral transection and obviate the need for complex surgical procedures.

Management of iatrogenic ureteral injury and techniques for ureteral reconstruction

PURPOSE OF REVIEW

Ureteral reconstruction is still a sophisticated approach. Because of an increase in endoscopic procedures for kidney and ureteral stone treatment, radiation therapy and pelvic surgery, ureteral strictures are more frequently observed. Short proximal and distal strictures can be reconstructed by using the renal pelvis or urinary bladder. New techniques are needed for reconstruction of long strictures as well as those located in the middle ureter.

RECENT FINDINGS

This article summarizes very recent studies from 2014, investigating new techniques and their functional outcome of procedures for ureteral reconstruction. In an open reconstruction, some new techniques to reconstruct full-length ureter defects using bladder flaps or by intestinal onlay techniques were described. In addition, laparoscopic and robotic reconstruction methods as well as single site procedures demonstrated feasibility. Visualizing the ureter using near-infrared fluorescence techniques for prevention of ureteral injuries is also a new aspect. Future targets focus on the development of artificial transplants by tissue engineering for ureteral reconstruction.

SUMMARY

Novel open and minimally invasive techniques for reconstruction of full-length and middle ureter strictures demonstrated feasibility in the past year. Although reasonable outcomes were reported, current results are significantly compromised by short-term follow-up. To date, artificial transplants remain experimental.

Simultaneous percutaneous nephrolithotomy and early endoscopic ureteric realignment for iatrogenic ureteropelvic junction avulsion during ureteroscopy

We present a case report of successful management of ureteropelvice junction avulsion during ureteroscopy successfully managed with simultaneous percutaneous nephrolithotomy and early endoscopic ureteral realignment.