Management of Urinary Tract Injuries in Minimally Invasive Gynecologic Surgery:

Three different laparoscopic techniques for the management of iatrogenic ureteral injury: A multi-institutional study with medium-term outcomes

BACKGROUND

Excellent success rates with short-term outcomes are noted for laparoscopic ureteral reconstruction (LUR) for iatrogenic ureteral injury. This multi-institutional study assessed the medium-term (>1 year) outcomes and compared three surgical techniques of LUR.

METHODS

Patients who underwent LUR at five tertiary hospitals between January 2007 and June 2016 were retrospectively analyzed. Patients with active abdominopelvic inflammatory disease, history of urothelial cancer, and tumor recurrence and those who received adjuvant chemotherapy or radiotherapy were excluded.

RESULTS

The success rates of LUR for 61 patients at 3 months postoperatively and at the last follow-up (at least 12 months postoperatively) were 100% and 95.1%, respectively. No significant difference was noted in the success rates of the three types of LUR. LUR was mainly performed in response to the demands of the primary surgeon responsible for the iatrogenic injury (33 of 45 cases, 73.3%). The vesicoureteral reflux (VUR) incidence was higher in the refluxing laparoscopic ureteroneocystostomy (LUN) group (40%) than in the anti-refluxing LUN group (15%, odds ratio: 1.5, p = 0.252). None of the patients in the LUN groups received treatment for VUR during the follow-up. The laparoscopic end-to-end ureteroureterostomy (LEEU) group had shorter operative time (p < 0.001) and lesser intraoperative blood loss (p < 0.001) than the LUN groups.

CONCLUSION

LUR is safe and feasible, with good medium-term outcomes. LEEU is a good surgical option in terms of the operative and subsequent outcomes. The anti-reflux technique in LUR reduces de-novo VUR development but is not necessary for preventing upper urinary tract infections in adults.

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

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