Laparoscopic ureteral repair in gynaecological surgery

Approach to ureteral endometriosis: A single-center experience and meta-analysis of the literature

AIM

To report single-center outcomes of laparoscopic management of patients with ureteral endometriosis and perform a meta-analysis in order to select the best approach for these patients.

METHODS

The cross-sectional study was conducted during a 6-year period (2015-2021) in the referral endometriosis center on 353 patients with ureteral endometriosis. For the meta-analysis, 10 articles, including 505 patients, were found to be eligible. In our meta-analysis, as well as our study, all endometriosis-related pain symptoms and complications of surgery were evaluated, analyzed, and reported.

RESULTS

Of the 326 patients whose ureteral involvement was confirmed in pathology, hydronephrosis and intrinsic ureteral lesions were detected in only 10.76% and 3.1% of the patients. Mean operating time and hospitalization were 3.25 ± 1.83 h and 86 ± 2.58 days, respectively. The most common site of concomitant involvement with endometriosis was uterosacral ligament (92.9%) and rectosigmoid (70.53%). Type II and III of Cliven-Dindo complications were seen in 5.66% and 1.13% of patients, respectively. During a follow-up period, no evidence of bladder or ureteral re-involvement was observed. Similar to our meta-analysis, all endometriosis-related pain decreased significantly following operation (p ≤ 0.001). In our meta-analysis, the rate of ureteral endometriosis recurrence, stenosis/stricture, bladder atonia, urinary tract infection, hematuria, and fistula formation after surgery were: 2.0% (I² : 50.42%), 15.0% (I² : 0.00%), 14.0% (I² : 8.76%), 6.0% (I² : 0.00%), 7.0% (I² : 79.28%), and 2.0% (I² : 0.0%), respectively.

CONCLUSION

The laparoscopic resection of the UE could be suggested as a feasible and safe method associated with favorable functional outcomes.

Management strategies and outcome of ureterovaginal fistulae: A systematic review and meta-analysis

BACKGROUND

Genitourinary fistula is a distressful condition involving mental, social, marital, and financial repercussions.

OBJECTIVE

The objective of this study is to systematically evaluate etiology, clinical presentation, diagnosis, the timing of repair, and perform a meta-analysis evaluating the success rate of various treatment modalities with respect to time taken to seek treatment.

SEARCH STRATEGY

We performed a critical review of PubMed/Medline, Embase, and the Cochrane Library in April 2020 according to the PRISMA statement. Seventeen studies were included in the final analysis and all were retrospective in design.

SELECTION CRITERIA

Each article was rated by the evidence-based medicine levels of evidence scale and the Methodological Index for Nonrandomized Studies scale for assessment of bias among nonrandomized studies.

MAIN RESULTS

Of the 799 fistulae reported in 17 studies, endoscopic management was done in 35.6% (12 studies), whereas surgical management was preferred in 85.6% fistulae (15 studies). The pooled success of endoscopic stenting was 32% (95% confidence interval [CI]: 7-64) and 100% (95% CI: 98-100) in operated patients. Patients who underwent stenting within 2 weeks (20%), 2-6 weeks (21%), and >6 weeks (40%) had pooled success rates of 95% (95% CI: 87-100), 46% (95% CI: 0-100), and 20% (95% CI: 1-49), respectively. Patients who underwent surgical management <6 weeks (15.9%) and >6 weeks (22%) of diagnosis had pooled success rates of 100% (95% CI: 99-100) and 100% (95% CI: 99-100), respectively.

CONCLUSIONS

Stent placement as early as <6 weeks (preferably < 2 weeks) had better outcomes as compared to >6 weeks. Proceeding to surgery regardless of timing in cases of stent failure seems to be a feasible option.

Judgment and Prevention of Urinary Tract Injury in Gynecological Surgery Based on Data Mining

In this paper, a data mining-enabled model is developed to analyze the case-related data of 39 patients with urinary tract injury who underwent laparoscopic surgery in a certain hospital from 2012 to 2017. Statistics on the history and characteristics of the case data summarized and analyzed the causes of urinary tract injury and the urinary system. The relationship between the occurrence of injury and the type of surgery and the treatment and preventive measures taken for urinary tract injury during and after surgery are summarized. The statistical method with SPSS16.0 statistical software was used to analyze the data of this study, and the X ² test was used to compare the rates. The differences of P ≤ 0.05 and P ≤ 0.01 were statistically significant. Laparoscopic surgery in gynecology is a minimally invasive technique, but it is still accompanied by the possibility of complications. During the experimental setup and implementation, we have observed that among 8742 cases of laparoscopic surgery complicated by urinary tract injury, there were 39 cases with a rate of 0.45%. In the past five years, the incidence of urinary tract injury in gynecological surgery in our country has increased year by year, and the number of cases of urinary tract injury has also increased year by year. Through analysis, it is found that the cause of the injury is related to the level of surgery, pelvic adhesion, and energy equipment. Based on the above problems, according to the clinical data of patients with urinary tract injury complicated by gynecological surgery in the hospital, the relevant factors of gynecological surgery complicated by urinary tract injury are analyzed to improve the awareness of urinary tract protection and prevention of injury during the operation and preventive measures are actively taken to avoid medical treatment.

Preoperative ureteral stenting in women with deep posterior endometriosis and ureteral involvement: Is it useful?

OBJECTIVE

Systematic placement of a ureteral stent before surgery for posterior deep infiltrating endometriosis (DIE) was previously recommended, but it could increase perioperative complications. We evaluate the role of preoperative ureteral stent in women requiring surgery for ureteral involvement (UI) with large posterior DIE nodules and/or grade I-II hydronephrosis.

METHODS

Women undergoing minimally invasive surgery for DIE with UI having posterior nodules >3 cm and/or grade I-II hydronephrosis from 2014 to 2019 were retrospectively included. We progressively changed our strategy from a systematic pre-operative stent insertion (S-PS, up to 2016) to a non-systematic one (NS-PS, from 2016).

RESULTS

Eighty-eight women in the S-PS group and 96 in the NS-PS were included. Low urinary tract infections (UTI) were higher in the S-PS group (13.6% vs 2.1%, P = 0.003). Hospital stay was longer in women with S-PS (9.8 ± 5.3 days vs 6.7 ± 2.5 days, P < 0.001). Logistic regression analysis confirmed a significant association between NS-PS and low UTI (adjusted OR 0.20, 95% CI 0.05-0.81, P = 0.024).

CONCLUSION

Systematic placement of a ureteral stent before surgery in women requiring surgery does not reduce overall perioperative complication rate, but it is associated with a longer duration of hospitalization and a higher low UTI rate.

Surgical management of endometriosis-associated pain

Endometriosis and pelvic pain are associated. However, only half of the subtle and typical, and not all cystic and deep lesions are painful. The mechanism of the pain is explained by cyclical trauma and repair, an inflammatory reaction, activation of nociceptors up to 2.7 cm distance, painful adhesions and neural infiltration. The relationship between the severity of lesions and pain is variable. Diagnosis of the many causes requires laparoscopy and expertise. Imaging cannot exclude endometriosis. Surgical removal is the treatment of choice. Medical therapy without a diagnosis risks missing pathology and chronification of pain if not 100% effective. Indications and techniques of surgery are described as expert opinion since randomised controlled trials were not performed for ethical reasons, since not suited for multimorbidity while a control group is poorly accepted. Subtle endometriosis needs destruction since some cause pain or progress to more severe disease. Typical lesions need excision or vaporisation since depth can be misjudged by inspection. Painful cystic ovarian endometriosis needs adhesiolysis and either destruction of the lining or excision of the cyst wall, taking care to avoid ovarian damage. Cysts larger than 6cm need a 2 step technique or an ovariectomy. Excision of deep endometriosis is difficult and complication prone surgery involving bladder, ureter, and bowel surgery varying from excision and suturing, disc excision with a circular stapler and resection anastomosis. Completeness of excision, prevention of postoperative adhesions and recurrences of endometriosis, and the indication to explore large somatic nerves will be discussed.

Pathogenesis Based Diagnosis and Treatment of Endometriosis

Understanding the pathophysiology of endometriosis is changing our diagnosis and treatment. Endometriosis lesions are clones of specific cells, with variable characteristics as aromatase activity and progesterone resistance. Therefore the GE theory postulates GE incidents to start endometriosis, which thus is different from implanted endometrium. The subsequent growth in the specific environment of the peritoneal cavity is associated with angiogenesis, inflammation, immunologic changes and bleeding in the lesions causing fibrosis. Fibrosis will stop the growth and lesions look burnt out. The pain caused by endometriosis lesions is variable: some lesions are not painful while other lesions cause neuroinflammation at distance up to 28 mm. Diagnosis of endometriosis is made by laparoscopy, following an experience guided clinical decision, based on history, symptoms, clinical exam and imaging. Biochemical markers are not useful. For deep endometriosis, imaging is important before surgery, notwithstanding rather poor predictive values when confidence limits, the prevalence of the disease and the absence of stratification of lesions by size, localization and depth of infiltration, are considered. Surgery of endometriosis is based on recognition and excision. Since the surrounding fibrosis belongs to the body with limited infiltration by endometriosis, a rim of fibrosis can be left without safety margins. For deep endometriosis, this results in a conservative excision eventually with discoid excision or short bowel resections. For cystic ovarian endometriosis superficial destruction, if complete, should be sufficient. Understanding pathophysiology is important for the discussion of early intervention during adolescence. Considering neuroinflammation at distance, the indication to explore large somatic nerves should be reconsidered. Also, medical therapy of endometriosis has to be reconsidered since the variability of lesions results in a variable response, some lesions not requiring estrogens for growth and some being progesterone resistant. If the onset of endometriosis is driven by oxidative stress from retrograde menstruation and the peritoneal microbiome, medical therapy could prevent new lesions and becomes indicated after surgery.

Use of Indocyanine Green for Intraoperative Perfusion Assessment in Women with Ureteral Endometriosis: A Preliminary Study

STUDY OBJECTIVE

To evaluate the feasibility, safety, and potential usefulness of near-infrared imaging (NIR) with indocyanine green (ICG) to assess ureteral perfusion after conservative surgery (ureterolysis or nodule removal) for ureteral endometriosis. Any changes to the surgical plan regarding intraoperative ureteral stent placement after NIR-ICG evaluation and early postoperative outcomes were recorded.

DESIGN

Prospective case series study.

SETTING

Tertiary level referral center for endometriosis and minimally invasive gynecology.

PATIENTS

Consecutive symptomatic women scheduled for laparoscopic conservative ureteral surgery for ureteral endometriosis.

INTERVENTIONS

After ureterolysis or nodule removal, residual perfusion of the ureters with regular caliber and peristalsis was evaluated through NIR-ICG imaging. Ureteral perfusion grade was defined as absent, irregular, or regular. Time required for NIR-ICG assessment, interoperator agreement regarding ureteral perfusion grade, any changes to the surgical plan after NIR-ICG evaluation, perioperative complications, and clinical-radiologic outcomes at early follow-up were recorded.

MEASUREMENTS AND MAIN RESULTS

A total of 31 ureters were examined with NIR-ICG imaging after conservative ureteral procedures. ICG assessment required 5.4 + 2.3 minutes. No complications related to fluorescence imaging were observed. Local ischemia supporting ureteral stent placement was suspected in 5 ureters (16.1%) at white light. Of these, 2 (40.0%) presented regular fluorescence; thus, ureteral stent placement was avoided. In the remaining 3 (60.0%), NIR-ICG confirmed irregular or absent fluorescence, requiring ureteral stent placement. Interoperator agreement regarding NIR-ICG evaluation was high. At a 3-month follow-up, all procedures were clinically and radiologically successful.

CONCLUSION

NIR-ICG imaging after conservative surgery for ureteral endometriosis seems to be a feasible, safe, and useful tool to assess ureteral perfusion and guide surgical decision, together with other visual cues at white light. However, this approach needs to be validated by further larger and controlled studies.

Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility

BACKGROUND

The ureter is the second most common site affected by urinary tract endometriosis, after the bladder. Optimal strategies in the diagnosis and treatment of ureteral endometriosis (UE) are not yet well defined.

OBJECTIVE AND RATIONALE

The aim of this study was to systematically review evidence regarding the epidemiology, pathophysiology, diagnosis, medical and surgical treatment, impact on fertility and risk of malignant transformation of UE.

SEARCH METHODS

A systematic literature review, by searching the MEDLINE and PUBMED database until April 2018, was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and was registered in the PROSPERO registry (www.crd.york.ac.uk/PROSPERO CRD42017060065). A total of 67 articles were selected to be included in this review.

OUTCOMES

The involvement of the ureter by endometriosis is often asymptomatic or leads to non-specific symptoms. When the diagnosis is delayed, UE may lead to persistent hydronephrosis and eventually loss of renal function. Ultrasonography is the first-line technique for the assessment of UE; alternatively, magnetic resonance imaging provides an evaluation of ureteral type involvement. The surgical treatment of UE aims to relieve ureteral obstruction and avoid disease recurrence. It includes conservative ureterolysis or radical approaches, such as ureterectomy with end-to-end anastomosis or ureteroneocystostomy performed in relation to the type of ureteral involvement. Fertility and pregnancy outcomes are in line with those observed after surgical treatment of deep infiltrating endometriosis (DIE). Current evidence does not support the potential risk of malignant transformation of UE.

WIDER IMPLICATIONS

In this article, we review available evidence on ureteral endometriosis, providing a useful tool to guide physicians in the management of this disease. Diagnosis and management of UE remain a challenge. In relation to the degree of ureteral involvement and the association with other DIE implants, the surgical approach should be planned and carried out in an interdisciplinary collaboration between gynecologist and urologist.

Contemporary management of ureteral strictures

Ureteral stricture disease is a luminal narrowing of the ureter leading to functional obstruction of the kidney. Treatment of strictures is mandatory to preserve and protect renal function. In recent times, the surgical management of ureteral strictures has evolved from open repair to include laparoscopic, robotic and interventional techniques. Prompt diagnosis and early first line intervention to limit obstructive complications remains the cornerstone of successful treatment. In this article, we discuss minimally invasive, endo-urological and open approaches to the repair of ureteral strictures. Open surgical repair and endoscopic techniques have traditionally been employed with varying degrees of success. The advent of laparoscopic and robotic approaches has reduced morbidity, improved cosmesis and shortened recovery time, with results that are beginning to mirror and in some cases surpass more traditional approaches.

Level of evidence: Not applicable for this multicentre audit.

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.

Renal Pelvis Injury in Case of Blunt Trauma Abdomen

Isolated renal pelvis/upper ureteric injuries are uncommon in a case of blunt abdominal trauma. These injuries are associated with fractures of transverse process of the adjoining vertebrae. We report a case of such a case in a 35 year old male involved in road traffic accident. He underwent exploration and repair of the right UPJ/Upper ureteric injury. This case presented with injury to the transverse processes on the left side, which is unusual.

Laparoscopic dissection of the intramural ureter to repair a complete transection of the distal ureter: Initial experience with a new minimally invasive technique that preserves the anatomy of the urinary tract

We report 2 patients with ureteral injury after a simple total laparoscopic hysterectomy for uterine myoma with a complete resection of the distal ureter. One patient had unilateral injury and the other 2 patients had bilateral injury. The surgical laparoscopic repair procedure was carried out 3 to 5 days after the injury. Surgery involved intramural dissection of the distal ureteral stump to expose at least 1 cm of the ureter, percutaneous ureteral stent placement, elimination of tension between the proximal ureter and the dissected distal stump, end-to-end anastomosis, and reinsertion of the distal ureter into the bladder muscle layer, which was previously dissected for the anastomosis.

Feasibility and outcomes of ureteroureterostomy and extravesical ureteroneocystostomy as part of radical surgery for infiltrating gynecologic disease

OBJECTIVE

Abdominopelvic infiltrative disease may require aggressive surgical procedures. This study reports on our experience with distal ureterectomy, ureteroureterostomy, and extravesical ureteroneocystostomy as part of radical surgery for infiltrating gynecologic disease.

PATIENTS AND METHODS

Twenty-one women required surgery to the distal ureter at the Queensland Centre for Gynecological Cancer, Australia, from January 2006 to September 2012. Details of the patient's history, operation record, inpatient notes, and follow-up data were obtained through chart review.

RESULTS

Patients' median age was 57.8 ± 14.7 years (range, 30-80 years). Seventeen patients had gynecologic cancer. Mean operating time was 3.9 ± 0.9 hours (range, 2.5-5.5 hours). Restoration of continuity was achieved through extravesical ureteroneocystostomy and ureteroureterostomy in 18 and 3 patients, respectively. Boari flap was used in 3 patients, and psoas hitch was the technique chosen in 11 patients. Urinary tract infection was the most common clinical adverse event. Albeit clinically irrelevant, 38% of the patients showed structural renal tract changes postoperatively.

CONCLUSIONS

To achieve maximal surgical radicalness, resection of the distal ureter with subsequent ureteroureterostomy or extravesical ureteroneocystostomy is feasible and safe. Radical surgery to the urinary tract should be considered as a legitimate part of a gynecologic oncologist's surgical armamentarium to increase a patient's probability of survival and its positive effect on kidney function.

Ureteral Stricture after Laparoscopic Tubal Ligation due to Suturing of the Serosa

Strictures secondary to traumas of the ureter are some of the complications of urogynecologic surgery. We present a 43-year-old female who had a history of laparoscopic tubal ligation a year ago and was admitted to our department with recurrent flank and inguinal pain. It was soon understood that a suture has pulled the ureter from the lateral serosa of the upper part to the lateral serosa of the lower part causing dilatation of the proximal and midureter because of the previous surgery while there was no damage on the ureteral lumen. Consequently successful reconstruction was performed with open ureteroureterostomy.

Deep endometriosis: definition, diagnosis, and treatment

Deep endometriosis, defined as adenomyosis externa, mostly presents as a single nodule, larger than 1 cm in diameter, in the vesicouterine fold or close to the lower 20 cm of the bowel. When diagnosed, most nodules are no longer progressive. In >95% of cases, deep endometriosis is associated with very severe pain (in >95%) and is probably a cofactor in infertility. Its prevalence is estimated to be 1% -2%. Deep endometriosis is suspected clinically and can be confirmed by ultrasonography or magnetic resonance imaging. Contrast enema is useful to evaluate the degree of sigmoid occlusion. Surgery requires expertise to identify smaller nodules in the bowel wall, and difficulty increases with the size of the nodules. Excision is feasible in over 90% of cases often requiring suture of the bowel muscularis or full-thickness defects. Segmental bowel resections are rarely needed except for sigmoid nodules. Deep endometriosis often involves the ureter causing hydronephrosis in some 5% of cases. The latter is associated with 18% ureteral lesions. Deep endometriosis surgery is associated with late complications such as late bowel and ureteral perforations, and recto-vaginal and uretero-vaginal fistulas. Although rare, these complications require expertise in follow-up and laparoscopic management. Pain relief after surgery is excellent and some 50% of women will conceive spontaneously, despite often severe adhesions after surgery. Recurrence of deep endometriosis is rare. In conclusion, defined as adenomyosis externa, deep endometriosis is a rarely a progressive and recurrent disease. The treatment of choice is surgical excision, while bowel resection should be avoided, except for the sigmoid.