Laparoscopic Ureteroneocystostomy for Iatrogenic Ureteral Insult—Early and Delayed Repairs

Abstract

Introduction: Ureteral rehabilitation after iatrogenic ureteral insult poses dual challenges—satisfactory restoration of ureteral continuity and limiting the procedural morbidity. In cases refractory to endourologic approach, the laparoscopic approach may be attempted in view of its favorable morbidity profile. The procedural performance may be considerably affected by the time interval between the primary insult and the restorative procedure.1 We present a video demonstration of this approach in different scenarios. Methods: All patients are evaluated in detail. Imaging included ultrasonography, magnetic resonance urogram or computed tomography urogram, cystoscopy, and retrograde urogram. Patients refractory to endourologic approach with a salvageable renal unit were planned for laparoscopic approach. All procedures were attempted through transperitoneal access utilizing four ports. After familiarizing with the pelvic anatomy, the lower ureteral course was identified. Dissection was continued till the pathological segment. Periureteral adventitia was meticulously preserved during ureteral handling, and thermal energy was utilized selectively. Ureter was dismembered proximal to the pathological segment. The ureter edge was refreshened and spatulated to ensure wide anastomosis. The vesical unit was then mobilized to ensure tension-free approximation. Additional psoas hitch was employed when tension was apprehended during ureterovesical approximation and Boari flap in long-segment defects. Ureteroneocystostomy was conducted with 3-0 polyglactin. Ureteral stent was inserted intracorporeal. Postoperative course was recorded. Ureteral stents were removed at 6 weeks postprocedure. Subsequent follow-ups were scheduled 3 monthly. Imaging was repeated at 6 months postprocedure. Resolution of hydronephrosis and a satisfactory drainage pattern were appraised as a successful outcome. Results and Discussion: Forty-five laparoscopic ureteroneocystostomies were performed between June 2006 and December 2011. Mean±SD age was 37.4±3.5 years. Two were men and 43 women. Etiologies included gynecological surgeries (41 cases), colorectal surgeries (2 cases), and urological surgeries (2 cases). Injuries involved right side in 35 cases, left side in 8 cases, and bilateral in 1 case. All procedures were completed successfully by a laparoscopic approach. Twenty-four patients underwent laparoscopic ureteroneocystomy with psoas hitch, and 19 patients underwent laparoscopic ureteroneocystomy and 2 patients laparoscopic Boari flap. Twenty-five procedures were undertaken within 7 days of the primary event, and 20 procedures were performed after 2 weeks of the primary event. The mean±SD operation duration was 155±10.2 minutes. The mean±SD blood loss was 120±22.5 mL. The operation duration in early and delayed repairs differed significantly (187.05±12.8 minutes, vs. 113.27±17.7 minutes, p = 0.00). No remarkable intraoperative complications were encountered. The mean±SD hospital stay was 3.5±1.2 days. Forty-three patients completed 6-month follow-up and revealed satisfactory outcome. No patients required any additional intervention. Laparoscopic ureteroneocystostomy after iatrogenic ureteral insult is feasible in different scenarios and offers durable outcome with limited morbidity. Diligent handling of the ureter and anastomosis without tension are key aspects of this exercise. The operator should be sufficiently versed with laparoscopic anatomy and intracorporeal suturing exercises. No competing financial interests exist. Runtime of video: 7 mins 35 secs