PD3-10 FISTULATION INTO THE PUBIC SYMPHYSIS FOLLOWING RADIOTHERAPY FOR PROSTATE CANCER - AN IMPORTANT AND SURGICALLY CORRECTABLE COMPLICATION

Abstract

INTRODUCTION AND OBJECTIVES: Previous publications have reported on the role of ureteral reconstructive techniques for repair of ureteral defects from extirpative surgery for urologic malignancies or external trauma. Our institution has managed a large volume of ureteral obstruction and injuries from other sources such as iatrogenic injury during pelvic surgery and retroperitoneal fibrosis. We sought to review this experience, report on outcomes, and develop an algorithm for treatment. METHODS: We reviewed the charts of 139 patients that underwent ureteral reconstruction or endoscopic treatment of ureteral injury in an eleven-year period at a single institution by three surgeons (TTH, PJM, BJF). Data including mechanism of injury, type of repair, location of injury, length of stricture, comorbid factors, length of follow up, success rate, complications, and need for secondary procedures was obtained. Success rate was defined based on ureteral patency and stabilization or improvement of renal function. RESULTS: 115 patients met inclusion criteria, of which 18 were bilateral systems, for a total of 133 renal units. 24 patients were excluded due to primary repair for UPJ obstruction, active malignancy, or external traumatic injuries. Mechanism of injury included iatrogenic injury during pelvic surgery (50%), radiation-induced or idiopathic retroperitoneal fibrosis (26%), endoscopic stone surgery (4%), and other (20%). Location of the injury was proximal (22%), mid (36%), and distal ureter (42%). The average length of stricture was 5 cm. The type of repair included ureterolysis +/omentoplasty (n 1⁄4 17), ureteroureterostomy (n 1⁄4 5), ureteral reimplant +/psoas hitch (n 1⁄4 58), Boari Flap (n 1⁄4 2), TUU (n 1⁄4 3), ileal ureter (n 1⁄4 39). Our primary success rate was 93%, with 7% of patients undergoing a subsequent procedure. Of the 9 failures, 3 underwent successful secondary procedure for a total success rate of 95%. There were 11 major complications defined as a Clavien grade 3 or greater including bowel obstruction, enterocutaneous fistula, anastomotic dehiscence, boari flap necrosis, and one death within 90 days. Median length of follow up was 121 days. CONCLUSIONS: Ureteral reconstruction for benign stricture disease is highly successful. Most strictures can be resolved utilizing simple techniques such as ureteral reimplantation +/psoas hitch. Longer strictures, particularly those involving the proximal or mid ureter, often require complex techniques such as ileal-ureteral substitution.