Laparoscopic Ureteroneocystostomy and Psoas Hitch for Post-Hysterectomy Ureterovaginal Fistula

Abstract

We assessed the results of laparoscopic ureteroneocystostomy with a psoas hitch for iatrogenic lower ureteral injuries leading to a ureterovaginal fistula. Between July 2003 and November 2007, 18 patients with iatrogenic lower ureteral injuries during hysterectomy leading to ureterovaginal fistula underwent laparoscopic ureteroneocystostomy with a psoas hitch. Of the patients 17 underwent abdominal or vaginal hysterectomy, while in 1 with a ruptured gravid uterus emergency hysterectomy was done for uncontrolled bleeding. Mean patient age was 35.5 years (range 23 to 45) and mean time to surgery since the injury was 2.2 months (range 1.5 to 3.5). Transperitoneal 3 or 4 port laparoscopic ureteroneocystostomy with a psoas hitch was performed. Of the procedures 17 were completed successfully. Intraoperative cardiac arrhythmia occurred in 1 patient due to pneumoperitoneum and hypercarbia, requiring open conversion. Mean operative time was 2.5 hours (range 1.9 to 2.8) hours, mean blood loss was 90 ml (range 45 to 150) and total hospital stay was 5.3 days (range 2.9 to 8). The nephrostomy tube was blocked on the table in all patients and it was removed on day 7. At an average followup of 26.4 months (range 3 to 52) postoperative excretory urography did not reveal obstruction in any patient. One patient had vesicoureteral reflux on voiding cystogram. Laparoscopic ureteroneocystostomy with a psoas hitch for ureterovaginal fistula secondary to hysterectomy is safe and effective, and associated with a low incidence of postoperative reflux and obstruction.