Ureteral injury in gynecologic surgery: a 5-year review in a community hospital

Robot-Assisted Vaginal Natural Orifice Transluminal Endoscopic Surgery (RvNOTES) With Total Hysterectomy for Management of Stage IV Endometriosis With/Without Complete Cul-de-Sac Obliteration: 23-Case Pilot Feasibility Study

STUDY OBJECTIVE

To show feasibility and short-term outcomes of robot-assisted vaginal NOTES (RvNOTES) for the treatment of stage IV endometriosis during total hysterectomy with/without complete cul-de-sac obliteration.

DESIGN

Retrospective case series.

SETTING

Single academic tertiary care hospital in Houston, Texas, USA.

PATIENTS

Twenty-three adult women with stage IV endometriosis.

INTERVENTIONS

RvNOTES with total hysterectomy for excision of severe endometriosis.

MEASUREMENTS AND MAIN RESULTS

Patients were assessed for various metrics including total operative time, robot dock time, robot console time, hysterectomy time, estimated blood loss, perioperative pain using the Visual Analogue Scale (VAS), and complications. The mean total operative time was 224.3 minutes. The study also found that patients with complete cul-de-sac obliteration had significantly longer operative times and higher estimated blood loss compared to those with partial or no obliteration. Postoperative VAS pain scores showed a significant reduction over a 6-week period. Complications included one case of complete ureteral transection, pelvic hematoma with infection, vaginal abscess, urinary tract infection, and pneumonia.

CONCLUSION

Our findings suggest that RvNOTES may be a feasible surgical approach in expert hands for treating stage IV endometriosis, even in cases with complete obliteration of the cul-de-sac.

Urological procedures performed by gynecologists: Activity profile in a gynecological surgery department, 10-year observation cohort

INTRODUCTION

The proximity of the urinary tract to the female genital tract explains its possible involvement in pelvic gynaecological cancer or deep endometriosis. Surgical treatment is aimed at improving overall survival and recurrence-free survival of patients, as well as restoring normal anatomy and functional integrity depending on the pathology. These operations are accompanied by significant post-operative complications. Thus, the urological procedures performed must be rigorously justified, and the different resection and reconstruction techniques adapted to the pathology and the level of infiltration.

OBJECTIVE

To describe the activity profile, over the last ten years, of a gynaecological surgery department in terms of urological procedures in the management of patients with deep endometriosis and pelvic carcinology.

STUDY DESIGN

This is a monocentric retrospective observational study, including all patients who underwent a urological procedure by a gynaecological surgeon only, as part of the management of pelvic gynaecological cancers or deep endometriosis, at the University Hospital Centre (CHU) of Strasbourg, between January 1st 2010 and April 31st 2021. The variables studied were early postoperative complications, the rate of surgical reintervention, operating time, length of hospital stay, the need for peri-operative drainage or transfusion, and post-operative functional disorders.

RESULTS

A total of 86 patients were included, 27 in the pelvic gynaecological cancer group and 59 in the deep endometriosis group. 61.6% of patients received uretero-vesical catheterization, 60.5% partial cystectomy, 10.5% psoic bladder ureteral reimplantation, and 3.5% trans-ileal Bricker skin ureterostomy. The mean operating time was 316 min in the pelvic gynaecological cancer group and 198.9 min in the deep endometriosis group. The average hospital stay was 11.5 days, 22.3 days for patients treated for pelvic cancer and 6.3 days for those treated for endometriosis. The rate of minor post-operative complications was 8.2% of cases, and major post-operative complications 17.4% of cases, the majority of which were in the gynecological cancer group. There were no cases of intra- or early post-operative death. Early postoperative urinary complications affected 14.0% of the total patients, mostly in the gynaecological cancer group with 33.3% of patients, but only 5.1% of patients in the deep endometriosis group. The total reoperation rate within 60 days postoperatively was 15.1%, 40.7% for patients treated for gynaecological cancer and 3.4% for those treated for deep pelvic endometriosis. The rate of reoperations for urinary complications was 11.6% of total patients, or 76.9% of total reoperations. 15 patients received labile blood products intra- or postoperatively, 11 in the pelvic gynaecological cancer group and 4 in the endometriosis group.

CONCLUSION

Our overall results appear comparable to those reported in the literature and are particularly satisfactory in terms of post-operative complications after partial cystectomy in the management of deep endometriosis compared to other gynaecological departments. This work encourages us to continue and improve the training of gynaecological surgeons in terms of multidisciplinary surgical procedures, including urological ones, to obtain a global vision of the pathology and to allow an optimal quality of care for the patients.

Intraoperative Fluorescent Ureter Visualization in Complex Laparoscopic or Robotic-Assisted Gynecologic Surgery

This study aimed to demonstrate the feasibility of ureteral navigation using intraoperative indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during complex laparoscopic or robot-assisted gynecologic surgery (LRAGS). Twenty-six patients at high risk of ureteral injury with complex pelvic pathology (CPP) due to pelvic organ prolapse (POP), multiple myomas, large intraligamentary or cervical myoma, severe pelvic adhesions, or cervical atresia underwent LRAGS. All patients underwent cystoscopic intraureteral ICG instillation before LRAGS and ureteral navigation under NIRF imaging intraoperatively. Both ureteral pathways were identified from the pelvic brim downwards through NIRF imaging in all patients, even though some were not visualized under the white light mode. The fluorescent ureters were visualized immediately after the beginning of surgery and typically lasted for >5 h during surgery. There were no cases of iatrogenic ureteral injury. The hemoglobin decrement was 1.47 ± 1.13 g/dL, and no transfusion was required. In our study, both ureters in all patients were identified with ICG-NIRF imaging during LRAGS, and these techniques made surgeries easier and safer. Despite the CPP, there was no ureteral injury or transfusion following surgery. Further prospective studies are needed to introduce intraoperative ureteral guidelines for ICG-NIRF imaging during LRAGS with CPP.

AN ULTRASOUND-BASED PREDICTION MODEL TO PREDICT URETEROLYSIS AT LAPAROSCOPIC ENDOMETRIOSIS SURGERY

STUDY OBJECTIVES

To develop a model, including clinical features and ultrasound findings, to predict the need for ureterolysis (i.e. dissection of the ureter) during laparoscopy for endometriosis.

DESIGN

A retrospective observational study of patients who had transvaginal ultrasound (TVS) according to the International Deep Endometriosis Analysis (IDEA) consensus and subsequent laparoscopy +/- excision of endometriosis between January 2017 and February 2021 was conducted.

SETTING

Sydney Medical School Nepean, University of Sydney, Nepean Hospital and Blue Mountains Hospital, New South Wales, Australia INTERVENTION: The demographic, clinical, TVS and intra-operative data were extracted through electronic clinical records.

MEASUREMENTS

Multi-categorical decision-tree and baseline models were built to choose the variables most correlated to the outcome under study. Receiver operating characteristic (ROC) analysis was performed on the binary classification. Based on our results, we selected the variables performing with significant statistical differences (p-value < .05).

MAIN RESULTS

During the study period, 177 consecutive patients were recruited and divided into two subgroups, ureterolysis (51.4%) and and non-ureterolysis (48.6%). Ureterolysis was noted in 87.5% of patients in which the left ovary was immobile (p-value< .001), and in 82.5% in which the right ovary was fixed (p-value<.001). For patients with right uterosacral ligament (USL) deep endometriosis (DE), ureterolysis was performed on 96.2% (p-value< .001), and 64.6% (p-value= .043) for left USL DE. Among patients with bowel DE, the proportion of patients undergoing ureterolysis was 95.5% (p-value < .001). The prognostic variables utilized in the final model to predict ureterolysis included dyschezia, absence of ovarian mobility, presence of right or left USL DE and presence of bowel DE on TVS. According to the developed model, the baseline risk for performing ureterolysis is 20% in our sample. The overall model performance demonstrated an area under the ROC curve 0.82.

CONCLUSION

Our study demonstrates that it is possible to predict the need for ureterolysis with clinical and sonographic data. Furthermore, patients presenting with the combination of the variables of our model (dyschezia, ovarian immobility, USL and bowel DE lesions) have a high risk of ureterolysis. On the other hand, patients without these features have a low risk (approximately 20%) of needing ureterolysis.

The Use of near Infra-Red Radiation Imaging after Injection of Indocyanine Green (NIR-ICG) during Laparoscopic Treatment of Benign Gynecologic Conditions: Towards Minimalized Surgery. A Systematic Review of Literature

Background and Objectives: To assess the use of near infrared radiation imaging after injection of indocyanine green (NIR–ICG) during laparoscopic treatment of benign gynecologic conditions. Materials and Methods: A systematic review of the literature was performed searching 7 electronic databases from their inception to March 2022 for all studies which assessed the use of NIR–ICG during laparoscopic treatment of benign gynecological conditions. Results: 16 studies (1 randomized within subject clinical trial and 15 observational studies) with 416 women were included. Thirteen studies assessed patients with endometriosis, and 3 studies assessed non-endometriosis patients. In endometriosis patients, NIR–ICG use appeared to be a safe tool for improving the visualization of endometriotic lesions and ureters, the surgical decision-making process with the assessment of ureteral perfusion after conservative surgery and the intraoperative assessment of bowel perfusion during recto-sigmoid endometriosis nodule surgery. In non-endometriosis patients, NIR–ICG use appeared to be a safe tool for evaluating vascular perfusion of the vaginal cuff during total laparoscopic hysterectomy (TLH) and robotic-assisted total laparoscopic hysterectomy (RATLH), and intraoperative assessment of ovarian perfusion in adnexal torsion. Conclusions: NIR–ICG appeared to be a useful tool for enhancing laparoscopic treatment of some benign gynecologic conditions and for moving from minimally invasive surgery to minimalized surgery. In particular, it might improve treatment of endometriosis (with particular regard to deep infiltrating endometriosis), benign diseases requiring TLH and RATLH and adnexal torsion. However, although preliminary findings appear promising, further investigation with well-designed larger studies is needed.

Prophylactic ureteral catheterization in the intraoperative diagnosis of iatrogenic ureteral injury

BACKGROUND

Iatrogenic ureteral injury (IUI) is a rare but feared complication in pelvic surgery. Prophylactic ureteral catheterization (PUC) is inconsistently used to reduce this risk, however no strong evidence exists for this practice. The objective is to investigate whether prophylactic ureteral catheterization can enhance intraoperative detection of IUI and reduce associated patient morbidity.

METHODS

The database of our tertiary referral hospital was retrospectively queried for ureter repairs due to iatrogenic injuries. The search yielded 845 unique patient files. After application of exclusion criteria and manual review of files, 155 individual cases remained. Statistical analysis was performed on the following parameters: timing of ureteral injury discovery, duration until catheter removal and postoperative complications.

RESULTS

Prophylactic ureteral catheterization was able to significantly enhance intraoperative diagnosis of IUI (OR = 5.09; 95%CI = 2.26-11.48). The number needed to treat is 2.6 patients. Furthermore, when the IUI was diagnosed during surgery, a significant reduction in postoperative complications was observed (RR = 0.64; 95%CI = 0.42-0.98).

CONCLUSION

Although the beneficial effects of PUC on IUI incidence remain controversial, when a ureteral injury occurs during pelvic surgery, the presence of prophylactic ureteral catheters can significantly reduce both diagnostic delay and postoperative morbidity. By promoting an immediate repair, ureteral catheterization reduces need for further diagnostics and secondary interventions.

Use of a Novel Fluorescent Catheter to Locate the Ureters during Total Laparoscopic Hysterectomy

Ureteral injury can occur during total laparoscopic hysterectomy. This report documents our experience in using the near-infrared ray catheter (NIRC), a newly developed fluorescent ureteral catheter made of material that contains a fluorescent dye to improve visualization of the ureters. We have used the device in 3 patients between 40 and 50 years of age (mean, 46.3 ± 4.5 years) undergoing total laparoscopic hysterectomy and bilateral salpingectomy for uterine myomas. The time of catheter insertion ranged from 4 minutes and 9 seconds to 10 minutes and 57 seconds. A number of intraoperative procedures were performed near the ureters, namely, identification and ligation of the uterine arteries, dissection of the cardinal ligament, incision of the vaginal canal, and suturing of the vaginal stump. The abovementioned fluorescent ureteral catheter appears green on a monitor when illuminated by near-infrared light, and this facilitated real-time confirmation of the ureter positions, increasing surgical safety. The patients were followed up for 6 months postoperatively, and no urinary tract infection or injury was found. Prophylactic use of the fluorescent ureteral catheter may improve visualization of the ureters in patients considered to be at high risk of ureteral injury, such as those expected to exhibit ureteral deviation due to severe adhesions or an enlarged uterus and when the surgeon has little experience in laparoscopic surgery.

Preservation of the mesureter to reduce urinary complications: analysis of data from the observational Leipzig School MMR study

OBJECTIVE

To evaluate the feasibility and effect of mesureteral preservation on urinary complications in the context of total mesometrial resection (TMMR), a surgical treatment for cervical cancer.

DESIGN

Retrospective cohort study with historic control.

SETTING

Single tertiary academic centre.

POPULATION

Women older than 18 with primary cervical cancer staged FIGO IB1-IIB enrolled in the prospective Leipzig School MMR study and underwent total mesometrial resection (TMMR) without adjuvant radiation.

METHOD

We retrospectively analysed 100 consecutive TMMR procedures which were performed for cancer of the uterine cervix and in which the mesureter was preserved (intervention group, 01/2014-06/2017). We compared this group with the previous 100 consecutive TMMRs, which were performed before the introduction of mesureteral preservation (control group, 09/2010-01/2014).

MAIN OUTCOME MEASURES

The occurrence of urological and specifically ureteral complications.

RESULTS

Mesureteral preservation was feasible and was associated with a significant decrease in ureteral complications (11% without mesureteral preservation versus 3% with mesureteral preservation, P = 0.049). Furthermore, we found a significant decrease in the number of postoperative percutaneous nephrostomies and re-operations (7% versus none, P = 0.014). There was also a trend towards a decrease in other urinary complications such as postoperative bladder atony and uretero-vaginal fistulas.

CONCLUSION

The mesureter constitutes a convenient dissection plane enabling the preservation of lateral ureteral blood supply during TMMR. In our study, maintenance of mesureteral integrity was associated with a significant reduction in ureteral complications. Mesureteral preservation might also be useful in other types of pelvic surgeries that carry a high risk of ureteral damage.

TWEETABLE ABSTRACT

Surgical preservation of the mesureter in cervical cancer patients was associated with a reduction in urinary complications.

Does Early Ureteroneocystostomy After Iatrogenic Ureteral Injury Jeopardize Outcome?

OBJECTIVE

To compare the outcomes of patients who underwent early repair (≤7 days) of iatrogenic ureteral injury with ureteroneocystostomy and compare them to those repaired in a delayed fashion (>7 days).

METHODS

A retrospective review of billing data between 2012 and 2018 identified patients who underwent ureteroneocystostomy for a benign ureteral disease. Inclusion criteria included all ureteral injuries related to a laparoscopic, robotic, or open surgical injury. Patients with ureteral injury related to radiation, stones, or reconstructive surgery were excluded. Patients undergoing reconstruction during the initial injury or within ≤7 days were designated as having undergone early repair, while the remaining were considered delayed repair. Demographics, as well as inpatient and postdischarge data were acquired, and statistical analysis was performed comparing the 2 groups.

RESULTS

Sixty-seven patients met inclusion criteria. Early repair was performed on 12 patients, while 55 underwent delayed repair. No significant difference in age, gender, Charlson Comorbidity Score, laterality, stricture location, or history of pelvic/abdominal radiation was noted. Inpatient complications were significantly higher in the immediate group (58 vs 18%, P =.004). Thirty- and 90-day complications were similar. Two patients in the delayed group and none in the immediate group demonstrated stricture recurrence (P =.710). A higher rate of Boari flap ureteral reconstruction was performed in the delayed cohort (P =.001).

CONCLUSION

In this cohort, there was no detectable difference in outcomes when comparing early and delayed ureteroneocystostomy for iatrogenic ureteral injuries.

Case selection for urological input in planned laparoscopic rectovaginal endometriosis surgery

BACKGROUND

Surgery for deep endometriosis often requires input from urological surgeons. This study aims to determine pre-operative and intra-operative factors that influence the need for urological input in laparoscopic resection of rectovaginal endometriosis and to assess the usefulness of a scoring system to predict this.

METHODS

We conducted a retrospective cohort study of 230 patients undergoing laparoscopic excision of deep endometriosis, at a tertiary referral centre for endometriosis in London UK, 2011 to 2015. Data from pre-operative assessment, surgery and post-operative follow up were analysed and patients were categorised according to their pre-operative and intra-operative risk factors. The primary outcome measure was the requirement of intra-operative input by urological surgeons.

RESULTS

The median age was 35 years. In addition to the excision of endometriosis, 19.6% patients (45 patients) underwent hysterectomy, 14.8% (34 patients) required JJ stent placement, 6.1% (14 patients) had bowel resections and 2.6% (6 patients) required an ileostomy. 93.9% (216 patients) were considered normal-risk pre-operatively, of whom 89.4% (193/216) did not require any intra-operative urological input. 10.6% of this normal-risk group (23/216) required JJ stents, of whom 69.6% (16/23) also required a hysterectomy or bowel resection. Post operative complications occurred in 0.9% (2/216) of normal-risk patients, with none having required intra-operative urological reconstruction.Six percent (14 patients) were deemed to be increased-risk pre-operatively, of whom 78.6% (11/14) required JJ stent insertion. Thirty-six percent of increased-risk patients (5/14) had pre-operative renal dysfunction demonstrated on MAG3/DMSA and 80.0% of these (4/5) required intra-operative ureteric reconstruction.

CONCLUSIONS

Patients considered normal-risk pre-operatively, planned for excision, without hysterectomy or bowel resection, can be safely managed without specific urology input. Patients with risk-features are highly likely to require urological input, particularly for JJ stent insertion. Patients with pre-operative renal dysfunction, demonstrated on MAG3/DMSA, have a high chance of requiring intra-operative ureteric reconstruction and are best managed with pre-planned reconstructive urologist input.

Prognostic imaging of iatrogenic and traumatic ureteral injury by near-infrared fluorescence

Background

Iatrogenic or traumatic ureteral injuries are life-threatening but difficult to diagnose early. Ureteral visualization is essential for both the prevention and diagnosis of iatrogenic or traumatic ureter injuries. In the present study, we evaluated the feasibility of near-infrared (NIR) with ZW800-1C as a diagnostic tool of iatrogenic or traumatic ureteral injury in addition to ureter visualization, compared to methylene blue.

Methods

With mice model, we compared the image quality of ZW800-1C with methylene blue for ureter visualization. We also made ureter perforation, obstruction, crushing injury, and transection model with mice and evaluated the feasibility of ZW800-1C for diagnostic tool for ureteral injuries.

Results

We could confirm the ureter in the ZW800-1C images in maximally 30 minutes after injection, and the ureter was visible until NIR imaging concluded at 180 minutes after injection. However, methylene blue failed to provide clear ureter imaging during the same period. ZW800-1C imaging successfully visualized ureters subjected to obstruction, transection, perforation, and crush injuries, although urinary leakage was not visible by eye.

Conclusions

Our results indicate ZW800-1C is better suited for ureter visualization than methylene blue and that ZW800-1C has considerable potential for the early diagnosis of various ureteral injuries.

Currently available and experimental dyes for intraoperative near-infrared fluorescence imaging of the ureters: a systematic review

Background

Iatrogenic ureteral injury (IUI) following abdominal surgery has a relatively low incidence, but is associated with high risks of morbidity and mortality. Conventional assessment of IUI includes visual inspection and palpation. This is especially challenging during laparoscopic procedures and has translated into an increased risk of IUI. The use of near-infrared fluorescent (NIRF) imaging is currently being considered as a novel method to identify the ureters intraoperatively. The aim of this review is to describe the currently available and experimental dyes for ureter visualization and to evaluate their feasibility of using them and their effectiveness.

Methods

This article adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard for systematic reviews. A systematic literature search was performed in the PubMed database. All included articles were screened for eligibility by two authors. Three clinical trial databases were consulted to identify ongoing or completed unpublished trials. Risk of bias was assessed for all articles.

Results

The search yielded 20 articles on ureter visualization. Two clinically available dyes, indocyanine green (ICG) and methylene blue (MB), and eight experimental dyes were described and assessed for their feasibility to identify the ureter. Two ongoing clinical trials on CW800-BK and one trial on ZW800-1 for ureter visualization were identified.

Conclusions

Currently available dyes, ICG and MB, are safe, but suboptimal for ureter visualization based on the route of administration and optical properties, respectively. Currently, MB has potential to be routinely used for ureter visualization in most patients, but (cRGD-)ZW800-1 holds potential for this role in the future, owing to its exclusive renal clearance and the near absence of background. To assess the benefit of NIRF imaging for reducing the incidence of IUI, larger patient cohorts need to be examined.

Electronic supplementary material

The online version of this article (10.1007/s10151-019-01973-4) contains supplementary material, which is available to authorized users.

Successful treatment of ureteral stricture after total hysterectomy: An antegrade ureteroscopic approach facilitates the insertion of a guidewire for endoscopic dilation

Introduction

Iatrogenic ureteral injury is sometimes seen in daily clinical practice, and gynecological surgery carries the highest risk of ureteral injury among iatrogenic surgical ureteral injury.

Case presentation

A 61‐year‐old woman was referred to our department for right ureteral stricture and hydronephrosis after total hysterectomy. We initially attempted ureteral stenting, but hydronephrosis redeveloped 1 month after ureteral stent removal. We performed ureteroscopy via an antegrade approach and successfully incised and dilated the ureter.

Conclusion

We encountered a case of severe ureteral stenosis after total hysterectomy that was successfully treated endoscopically using ureteroscopy via an antegrade approach.

Our Experience with Iatrogenic Ureteric Injuries among Women Presenting to University College Hospital, Ibadan: A Call to Action on Trigger Factors

Background

Ureteric injuries leading to ureterovaginal fistula (UVF) is less common than vesicovaginal fistula, as a cause of urinary incontinence. Recently, there is a surge in the number of UVF cases presenting to University College Hospital (UCH) following a caesarean delivery. The urogynaecology unit at UCH is at the forefront of providing surgical repair for women with all forms of genitourinary fistulas. We describe our experience with managing UVF arising from ureteric injury.

Methods

A retrospective data collection of UVF cases managed from January 2012–December 2017 at UCH is presented. Information on sociodemographic and obstetric characteristics, presenting complaints, antecedent surgery, treatment received, findings at surgery, and postoperative complications were obtained with a structured proforma.

Results

Eighteen cases of UVFs due to iatrogenic ureteric injury were managed. Majority (N=11; 61.1%) of the women suffered the injury following the emergency caesarean section (EMCS). Abdominal hysterectomy operation accounted for four (22.2%) cases, and one case each (5.6%) was due to vaginal hysterectomy and destructive operations. Prolonged obstructed labour (POL) (81.8%) was the most common indication for the EMCS, while 18.2% had surgery on account of lower uterine segment fibroid. Most of the ureteric injuries were on the left side. Postoperative complications documented were haemorrhage, urinary tract infection, wound infection, and injury to the neighbouring structure.

Conclusion

Caesarean section being one of the most performed surgical operations in Nigeria was surprisingly found to be the most common cause of ureteric injury ahead of hysterectomy. It is a pointer that the surgeons might not have properly learnt the art of the caesarean delivery well. We recommend adequate surgical training of medical officers/surgeons that are involved.

Real-Time Visualization of Ureters Using Indocyanine Green During Laparoscopic Surgeries: Can We Make Surgery Safer?

Background. Intraoperative ureteral injury is rare, but a grave complication during laparoscopic surgery. Several methods for intraoperative localization of ureters are described with their own pitfalls. Intraoperative localization using near-infrared (NIR) fluorescence with indocyanine green (ICG) is an easier and assured method during laparoscopic pelvic surgeries. Method. From September 2017 to December 2017, patients undergoing laparoscopic pelvic surgeries were administered cystoscopic-guided intraureteral ICG immediately preoperatively with tip of a 6-Fr ureteral catheter. The fluorescence of ureters was visualized in the NIR mode of the camera system, localizing the ureters precisely and in real time. Results. This technique was used to visualize ureters in 30 surgeries. Median age of the patients was 46.7 years with median body mass index of 23.2 kg/m2. Mean duration between administration of dye and insertion of trocar was 10 minutes. Mean duration for insertion of cystoscopically guided intraureteral ICG was 7 minutes. Ureteral fluorescence was visualized in all cases with some variation in intensity of the brightness perceived depending on surrounding fat. Duration of the lengthiest surgery was 240 minutes, and fluorescence was appreciated till the end. There were no intraoperative or postoperative complications attributed to ICG administration. In 10 patients (33%), there was difficulty in identifying the ureters on conventional white light mode, in which ICG localization was extremely helpful. Conclusion. ICG-stained ureteral visualization under NIR light is a safe and feasible method that provides real-time ureteral demarcation. This easily replicable, sensitive, and specific method of ureteral visualization can make complex laparoscopic pelvic surgeries safer.

PEGylated BF2-Azadipyrromethene (NIR-AZA) fluorophores, for intraoperative imaging

Clinical imaging utilising near-infrared fluorescence is growing as an intraoperative aid for the decision-making processes during complex surgical procedures. Existing uses include perfusion assessment and lymph node identification with many new applications currently being proposed and developed. While imaging hardware and software have significantly progressed in recent times, suitable NIR-fluorophores remain a limiting factor. In this report, we describe the design, synthesis, photophysical characterization and in vivo imaging assessment of new PEGylated NIR-fluorophores based on the BF₂-azadipyrromethene fluorophore class. The synthetic route includes PEGylation as the final step, thereby allowing routine access to derivatives substituted with different molecular weights of PEG. Absorption and emission wavelength maxima in PBS lie at 690 and 720 nm respectively with quantum yields over 12%. They show excellent photostability and no light induced singlet oxygen production. A time-course of NIR-fluorescence imaging, post i.v. administration, in BALB/c mice showed a rapid and preferential accumulation in the renal excretion pathway within 20 min, indicative of potential clinical usage for intraoperative identification of vial structures along this pathway. Assessment with clinical imaging equipment showed the NIR-AZA fluorophores to be wavelength compatible and brighter than currently used methylene blue (MB), and that they have the ability to be imaged simultaneously with indocyanine green (ICG) offering a potential for dual colour clinical imaging.

Evaluation of a novel dye for near-infrared fluorescence delineation of the ureters during laparoscopy

BACKGROUND

Iatrogenic ureteric injury remains a risk in laparoscopic pelvic procedures. Near-infrared fluorescence (NIRF) imaging is a promising new technique for enhanced intraoperative visualization of anatomical structures that could improve the safety of laparoscopic surgery. A new dye, IRDye® 800-BK, has been developed for intraoperative visualization of the ureters using NIRF. The present study was a first evaluation of the performance of IRDye® 800-BK for ureteric imaging during NIRF laparoscopy.

METHODS

This study consisted of three parts: real-time in vivo NIRF imaging using IRDye® 800-BK in pigs during laparoscopic surgery, ex vivo NIRF imaging of freshly explanted pig ureters and ex vivo NIRF imaging of explanted human ureters.

RESULTS

In all animals, both left and right ureters were visualized throughout the laparoscopic procedure for 120 min, with the best results at a dose of 0·15 mg dye per kg bodyweight. NIRF imaging was successful in all human and porcine ureters studied, with a range of dye concentrations.

CONCLUSION

NIRF imaging of the ureters using IRDye® 800-BK was used successfully both in vivo in a porcine model, and ex vivo in porcine and human ureters.

Minimally Invasive management of delayed recognition iatrogenic ureteric injury

INTRODUCTION

Iatrogenic ureteric injuries are a rare but serious complication of abdomino-pelvic surgery which can be associated with significant morbidity. 65-80% of ureteric trauma is only identified in the postoperative period. Current guidelines recommend stent insertion or urinary diversion via percutaneous nephrostomy. Good quality evidence on success and outcomes remains scant and the optimum treatment pathway unknown.

METHODS

A retrospective review of all delayed presentation ureteric injuries treated in our unit between 2005 and 2013 was performed. Clinical, treatment and outcome data were collected in a custom proforma.

RESULTS

19 patients with 21 injured ureters met inclusion criteria. 16/19 (84.2%) injuries were sustained during gynaecological procedures with 10 (52.6%) of these during total abdominal hysterectomy. Suspected mechanisms from diagnostic studies was defined as partial transection in 9/21 (42.9%), complete transection in 3/21 (14.3%) and perforation in 1/21 (4.8%).Median time from injury to presentation was 16 days (IQR 7-25). 11/21 (52.4%) had successful stenting with a median time to stent placement of 25 days (IQR 18.5-42). Those with failed stenting had a median time to attempted stenting of 65 days (IQR 10-91.3). Those with successful stenting 3/11 (27.3%) had resolution requiring no further intervention. 6/11 (54.5%) required open reconstruction, with the remaining two patients unfit for reconstruction and managed with long term stents. With successful stenting median time to definitive surgery was 413 days (IQR 156-476).

CONCLUSION

Success rates for stenting are similar to those reported in the literature (55% vs. 44-59%), but resolution rates are significantly lower (15% vs. 44-80%). Data for an endourological approach as a possible long-term solution is limited by heterogeneity, and a further well conducted multicentre prospective study is required.

Fluorescence Ureteral Visualization in Human Laparoscopic Colorectal Surgery Using Methylene Blue

BACKGROUND

Ureteral injury during laparoscopic surgery is rare, but when it occurs, it can be a serious problem. Near-infrared fluorescence (NIRF) with methylene blue (MB) administration is a promising technique for easier and potentially earlier intraoperative visualization of the ureter. Aim of this prospective study was to assess the feasibility of NIRF imaging of the ureter during laparoscopic colorectal surgery, using MB.

METHODS

Patients undergoing laparoscopic colorectal surgery were included and received intravenous injection of MB preoperatively. The ureter was visualized using a laparoscope, which offered both conventional and fluorescence imaging. Intraoperative recognition of the ureter was registered. The precision of ureter distinction with MB imaging was compared to the conventional laparoscopic view.

RESULTS

Ten patients were included. All procedures were initially performed using a laparoscopic approach. Dose per injection ranged between 0.125 mg/kg and 1.0 mg/kg bodyweight. There were no adverse effects attributable to MB administration. The ureter was successfully detected in five patients, with highest contrast between ureter and surrounding tissue at an administered dose of 0.75-1.0 mg/kg. The fluorescent signal was only picked up after the ureter was already visible in the conventional white light mode.

CONCLUSION

Ureteral fluorescence imaging using MB proved to be safe and feasible. However, the present technique does not provide practical advantage over conventional laparoscopic imaging for identification of the ureter during laparoscopic colorectal surgery. Future research is necessary to explore more extensive dose finding, alternative fluorescent dyes, or improvement of the imaging system to make this application clinically beneficial.

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.

Laparoscopic Fluorescent Visualization of the Ureter With Intravenous IRDye800CW

OBJECTIVES

Ureter injury is a serious complication of laparoscopic surgery. Current strategies to identify the ureters, such as placement of a ureteral stent, carry additional risks for patients. We hypothesize that the systemically injected near-infrared (NIR) dye IRDye800CW-CA can be used to visualize ureters intraoperatively.

METHODS

Adult female mixed-breed pigs weighing 24 to 41 kg (n = 2 per dose) were given a 30, 60, or 120 μg/kg systemic injection of IRDye800CW-CA. Using the Food and Drug Administration-cleared Pinpoint laparoscopic NIR system, images of the ureter and bladder were captured every 10 minutes for 60 minutes after injection. To determine the biodistribution of the dye, tissues were collected for ex vivo analysis with the Pearl Impulse system. ImageJ software was used to quantify fluorescence signal and signal-to-background ratio (SBR) for the intraoperative images.

RESULTS

The ureter was identified in all pigs at each dose, with peak intensity reached by 30 minutes and remaining elevated throughout the duration of imaging (60 minutes). The 60 μg/kg dose was determined to be optimal for differentiating ureters according to absolute fluorescence (>60 counts/pixel) and SBR (3.1). Urine fluorescence was inversely related to plasma fluorescence (R(2) = -0.82). Ex vivo imaging of kidney, ureter, bladder, and abdominal wall tissues revealed low fluorescence.

CONCLUSION

Systemic administration of IRDye800CW-CA shows promise in providing ureteral identification with high specificity during laparoscopic surgery. The low dose required, rapid time to visualization, and absence of invasive ureteral instrumentation inherent to this technique may reduce complications related to pelvic surgery.

Modified laparoscopic intravesical nonrefluxing ureteral reimplantation with psoas hitch using a submucosal tunneling

We aimed to study the safety and efficacy of the cystoscopy-assisted nonrefluxing ureteral reimplantation technique using submucosal tunneling during laparoscopic ureteroneocystostomy (UNC) with a psoas hitch in patients with distal ureter stricture after gynecologic surgery. We reviewed six female patients who underwent gynecological surgeries. All patients showed persistent postoperative distal ureter stricture or obstruction. These patients underwent laparoscopic nonrefluxing UNC with a psoas hitch using a submucosal tunneling technique combined with cystoscopy at our institute. They had corrective surgery at an average of 13.3 weeks after ureteral injury. The short-term success was confirmed either by voiding cystourethrography (VCU) or by diuretic isotope renal scan (MAG-3) conducted 3 months after the operation. None of the patients showed evidence of postoperative stricture at the reimplanted site and reflux on either MAG-3 renal scan or VCU. None of the patients showed major or minor complications during follow-up. It is safe and feasible to perform the laparoscopic nonrefluxing UNC with a psoas hitch using a submucosal tunneling technique combined with cystoscopy for ureteral stricture.

Anatomic relationships of psoas muscle: clinical applications to psoas hitch ureteral reimplantation

OBJECTIVE

The objective of the study was to examine the anatomic relationship of the genitofemoral and femoral nerves to the psoas major muscle.

STUDY DESIGN

Dissections were performed in 17 unembalmed female cadavers. Point A was used as the approximate location for placement of psoas hitch sutures and as the reference point from which all measurements were taken. Measurements included the width of the psoas major muscle, psoas minor tendon, genitofemoral nerve branches, and femoral nerve. The relative location of the genitofemoral and femoral nerves to point A and the presence or absence of a psoas minor tendon were documented.

RESULTS

The psoas minor tendon was absent on at least 1 side in 11 specimens (64.7%). The median width of the psoas minor tendon was 7 mm (range, 3-11.5 mm). The median width and depth of the psoas major muscle was 21.5 mm (range, 10-35 mm) and 20.0 mm (range, 11.5-32 mm), respectively. The median width of the genitofemoral nerve was 2 mm (range, 1-4.5 mm) and that of the femoral nerve was 6.3 mm (range, 5-10.5 mm). Overall, 54 genitofemoral nerve branches were identified in 17 cadavers, 30 medial (55.5%), 22 lateral (40.7%), and 2 directly overlying point A (3.7%).

CONCLUSION

The exact location for the placement of the psoas hitch sutures will vary, depending on the location of the ureteral injury and the anatomy of the psoas muscle and surrounding structures. A thorough understanding of this regional anatomy should optimize the placement of psoas hitch sutures during ureteral reimplantation procedures and help avoid nerve and vessel injury.

Laparoscopic ureteroneocystostomy: modification of current techniques

Purpose

To review the feasibility of laparoscopic ureteroneocystostomy with extracorporeal eversion of the ureteral end in various distal ureteral lesions.

Materials and Methods

We conducted a retrospective review of 5 laparoscopic procedures of ureteroneocystostomy with extracorporeal eversion of the ureteral end. Of these, 4 patients (range, 45 to 54 years) had distal ureter stricture or obstruction after gynecological surgeries for endometriosis or a large uterine myoma. One patient (male, 67 years) had low-grade distal ureter cancer. The laparoscopic procedure was combined with cystoscopic insertion of a ureteral stent and extracorporeal eversion of the ureter through the 10-mm port on the affected side.

Results

The laparoscopic ureteral reimplantations with and without a psoas hitch in patients with distal ureteral lesions was successful in all patients. The mean operation time was 137 minutes (range, 104 to 228 minutes). Two patients underwent additional psoas hitch. In all patients, short-term success was confirmed by voiding cystourethrography and intravenous pyelography conducted 3 months after the operation. The mean follow-up of the entire group was 12 months (range, 3 to 30 months). We noted no major or minor complications over the follow-up period.

Conclusions

The technique of laparoscopic ureteroneocystostomy for benign or malignant ureteral strictures continues to evolve. Surgeons should be versatile with various options and technical nuances when dealing with these cases. Simple modifications of laparoscopic ureteroneocystostomy with extracorporeal eversion of the ureteral end, nonreflux extravesical anastomosis, and simultaneous cystoscopy will be crucial to the ease of performance and a successful outcome.