Management for Ureteral Injury during Laparoscopic or Robotic Hysterectomy: Minimally Invasive Strategies

Abstract

<h3>Study Objective</h3> To demonstrate minimally invasive techniques to repair ureteral injury or ureteral stenosis related to minimally invasive hysterectomy. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Gynecology and Obstetrics department of a general hospital. <h3>Patients or Participants</h3> 23 patients who suffered from ureteral injury during surgery or ureteral stenosis or ureterovaginal fistula after hysterectomy. <h3>Interventions</h3> Between January 2010 and December 2021, 7,154 patients underwent laparoscopic or robotic simple hysterectomy for benign pathology. 16 patients experienced intraoperative ureteral injury found during the procedure. (Group 1) All were repaired in the same operative session using laparoscopic or robotic ureteroneocystostomy using bladder mobilization. In cases with large defects, psoas hitch or boari flap are used to compensate. 7 patients had ureteral injuries undetected intraoperatively and discovered as stenosis or fistula 3 to 12 days postoperatively. (Group 2) All were repaired via laparoscopic or robotic ureteroneocystostomy with or without psoas hitch. <h3>Measurements and Main Results</h3> No patient required reoperation and no patient required laparotomy. Although Group 1 the patients required 3 days placement of an indwelling bladder catheter, the hospital stay of patients was the same as patients who did not experience injury. Operative duration for repair is difficult to evaluate as it is combined with the difficult hysterectomy procedure time. Estimations show intraoperative repair took 40-104 minutes. Group 2 patients required surgical duration ranging from 70- 120 minutes. Blood loss was minimal to 150mL. No patient suffered from stenosis of the anastomotic site. 7 patients suffered from mild vesicoureteral regurgitation which did not require surgical intervention. 7 patients suffered from pyelonephritis, but only one or two episodes. (Follow up period: 3 months to 10 years.) <h3>Conclusion</h3> Avoiding open surgery in cases where injury occurs is important for maintaining the minimally invasive goals of the original surgery. Even if technically demanding, knowledge of laparoscopic and robotic urinary tract reconstruction techniques makes it possible to avoid open surgery for repair.