Ureteral Fistula Research Articles

Sigmoid colon ureteral fistula presenting with urosepsis

This 72-year-old white male presented in the emergency room with symptoms of urosepsis. He had been sick for about ten days, reporting in-creasing malaise, temperature elevation, left flank pain, and “foul-smelling” urine. He had three prior episodes of left lower quadrant pain associated with diarrhea; which his physician had diagnosed as di-verticulitis and treated with antibiotics and dietary restrictions.At admission, vital signs of the cachec-tic patient were recorded as BP 160/78, pulse rate 92, respiration 22, and temperature of 38.4 Celsius. Physical exam demonstrated the lungs clear to aus-cultation and percussion; tenderness to percussion in the left back, and rebound tenderness in the left lower abdominal quadrant. Laboratory data were: RBC 3.8, Hb 9.4, HCT 36, WBC 24,000, BUN 28, Creatinine 2.6; K 4.2, and Na & Cl within normal limits. Urinanalysis and cytology demonstrated a murky appearance, specific gravity of 1.024, cellu-lar debris, WBC 120/hpf, RBC 80/hpf, gram negative bacteria, and vegetable fibers. An admission chest radiograph was negative.A three-phase contrast-enhanced CT (with intravenous contrast medium reduced to 60 mL, because of elevated creatinine) was performed with both coronal and sagittal reconstructions. An axial slice showed a hugely dilated left ureter with an air fluid level (Figure-1). A coronal reconstruction ( the area of interest enlarged to156%) demonstrates gas in the fistula to the thickwalled segment of the sig-moid colon as well as at the level of the UPJ (Fig-ure-2). Diverticula are shown in the third portion of the sigmoid colon. An aneurysm of the infra-renal segment of the aorta was noted. Another coronal re-construction (206% enlargement of area of interest) at a slightly more posterior level shows the entire left ureter dilated by gas (Figure-3). A sagittal re-construction shows the dilated gas-filled left ureter (Figure-4).Fistula from the GI tract to the ureter is un-common. Uretero-ileal fistulae as consequence of Crohn’s disease occur with higher frequency then uretero-colonic fistulae (1,2). Uretero-colonic fistu-lae may be secondary to inflammatory disease of the large bowel, such as diverticulitis, obstructing ureteral calculi, or neoplasm of the colon that con-tiguously involves the ureter (3,4). A non-function-ing kidney and ureter are often the consequence. CT is the modality of choice in working up uro-sepsis or renal colic, while antegrade or retrograde ureterogram is the most sensitive in the detection and characterization of a fistulous tract (5). In a like pathologic process, fistulization to the fallopian tubes can occur from diverticular abscesses. How-ever, the incidence of colo-vesical fistulae caused by diverticulitis is higher (6).

Urinary tract fistulas in radical surgery for cervical cancer: The importance of early diagnosis

BackgroundUrinary fistulas are a well-recognised complication of radical gynaecological oncology surgery for cervical cancer. Reported incidence varies between 0.6 and 5.1%. MethodsA retrospective case-note review of vesical and ureteric fistulas diagnosed in cases that underwent radical surgery for the new diagnosis of early stage cervical cancer between January 2000 and June 2010. ResultsA total of 323 radical procedures for cervical cancer were performed during the study period. There were nine urinary tract fistulas found in eight women undergoing radical surgery for stage 1b1 cervical cancer, giving an incidence of 2.7%. Haemorrhage was the commonest associated factor and the commonest presenting symptom for fistula was leaking of urine per vagina. The fistulas were managed conservatively or surgically depending on their nature and severity. The longer the delay in confirming the diagnosis and initiating treatment the more severe were the long-term symptoms and morbidity. ConclusionIdentification of predisposing factors, high index of suspicion, early investigations and multidisciplinary team management of urinary tract fistula are necessary to reduce post-operative morbidity and minimise renal loss.

A Rare and Late Complication of an Appendectomy: Distal Ureteral Fistula with Stenosis

A Rare and Late Complication of an Appendectomy: Distal Ureteral Fistula with Stenosis

Ureteral fistulae after kidney transplantation: Experience with 224 cases

Ureteral fistulae after kidney transplantation represent major early urological complications with reported incidence from 1.2% to 12% in large series. The aim of the study is to establish the incidence, types and ureteral fistula related morbidity and lethality rates, by donor type. From 1995. to 2001, a total of 224 kidney transplantations (171 from living and 53 from cadaveric donor) have been performed at the Institute of Urology and Nephrology in Belgrade. Mean patients age was 36,67 years (11-64; SD = 10.69). Ureteral fistulae appeared only after living donor transplantation in a total of five patients (2.2%) (p > 0.05). In all patients open fistula repair was performed. Two patients had recidive ureteral fistula after primary and after secondary open repair. Following the third open repair one patient had lethal outcome. Ureteral fistulae after kidney transplantation still remain challenging urological problem with considerable morbidity and lethality rates.

Endovascular Treatment of a Right-Sided Ureteroiliac Fistula in a Patient with a Simultaneous Left-Sided Ureteroileal Fistula

We describe an 80-year-old female with a left ureteroileal fistula and simultaneously a right ureteroiliac fistula. Her history highlights the predisposing factors of radiation, major surgery in the region, and presence of bilateral double-J-stents. She was successfully treated with an endovascular approach after being initially misdiagnosed. There seems to be an increase in reporting ureteral fistulas, however this entity remains a rare clinical condition that can lead to life-threatening situations. A fast and accurate diagnosis of an ureteroarterial fistula remains a challenge.

Ureteral endometriosis: clinical and radiological follow-up after laparoscopic ureterocystoneostomy

Ureteral endometriosis is a rare entity that may lead to progressive hydroureteronephrosis and renal loss. When the localization of ureteral stenosis is close to the ureterovesical junction, ureterocystoneostomy may be required. The aim of the present study was to evaluate post-operative complication rates and clinical outcomes at 1- and 6-month follow-up after laparoscopic ureterocystoneostomy. Twenty patients who underwent ureterocystoneostomy for pelvic endometriosis in our tertiary referral centre for endoscopic surgery during 1 year were studied. A cystography was performed on Day 7 after surgery to verify the integrity of anastomosis and a satisfactory bladder capacity. Follow-up consisted of gynaecological examination and transvaginal ultrasound at 1 and 6 months after surgery. At 6 months, urography and cystography were also performed. Measurements included results of a pre-operative clinical and instrumental assessment, intra- and post-operative complications, post-operative bladder capacity at cystography and improvement of pain, using a visual analogue scale for the main symptoms related to endometriosis and uro-specific pain. Neither a case of ureteral fistula nor other complications requiring re-intervention were reported. Post-operative transient deficit of bladder voiding occurred in five cases (25%), urinary infection in one and post-operative pyrexia in four (20%) patients. The median time to resuming voiding function was 3 days (range 1-20 days). In six cases, a mild vesico-ureteral reflux at the operated side was observed at 7-day cystography. Post-operative symptomatology was improved significantly (P<0.05) for all symptoms. Urography and cystography performed at 6 months confirmed good post-operative reconstructions in all cases. The objective of surgical treatment of ureteral endometriosis is to remove the stenotic tract and to preserve renal function. In cases of intrinsic ureteral endometriosis, the procedure of laparoscopic ureterocystoneostomy is feasible and has good outcomes at short- and medium-term follow-up.

Robotic radical hysterectomy: applying principles of the laparoscopic Pune technique.

Minimal access surgery is an accepted treatment modality in cervical cancer. Despite the advantages of laparoscopy, the surgical technique of laparoscopic radical hysterectomy is not very commonly performed. Robotic surgery is an emerging field with rapid acceptance because of the 3-dimensional image, dexterity of instruments and autonomy of camera control. We report here our technique of performing robotic radical hysterectomy using the Da Vinci surgical system. Twenty patients with cervical cancer stage 1a1-1b2 underwent robotic radical hysterectomy since December 2009. The median duration of surgery was 122min, and the average blood loss was 100ml. Postoperative ureteric fistulas occurred in two patients and were managed by ureteric stenting. The median lymph node retrieval was 30 nodes (range 18-38). We compared our robotic results with our published data on laparoscopic radical hysterectomy (Pune technique). We were able to complete all 20 cases robotically with minimal morbidity, and could duplicate our laparoscopic steps in robotic radical hysterectomy.

Laparoscopic ileocecal resection for bowel endometriosis

Ileocecal endometriosis is a very rare entity, and its diagnosis is usually made during surgery for other endometriosis sites or, rarely, because of direct complications of ileal involvement. This study was designed to analyze perioperative and long-term outcomes after bowel resection for ileocecal endometriosis. All patients who underwent surgery for ileocecal endometriosis between October 2004 and January 2008 were prospectively collected and analyzed. Thirty-one women (median age, 34 (range, 25-40) years) were identified. Ileocecal endometriosis was diagnosed during surgery in all patients, and it was associated with colorectal endometriosis in 29 patients (94%). All patients underwent laparoscopic ileocecal resection with no laparotomic conversion. Rectosigmoid or rectal resections was associated in 28 patients (90%) and nodulectomy for sigmoid endometriosis in 1 patient. Median duration of surgery was 301 (range, 90-480) min. Other associated surgical procedures included total hysterectomy (n = 3, 14%), ureterolysis (n = 7, 23%), excision of vesical (n = 4, 13%), vaginal (n = 8, 26%), and parametrial (n = 3, 14%) nodules. There was no mortality. Four patients (13%) required blood transfusions and one a reoperation for bleeding. In a patient who performed ureterolysis, a ureteral fistula occurred. The median hospital stay was 7 (range, 5-18) days. Long-term (>12 months) follow-up data were available for 18 patients. After a median follow-up of 27 months, in 12 of 18 patients (67%) defecation after surgery was normal. Only one patient developed recurrence, which is under medical treatment. Laparoscopic ileocecal resection is safe and feasible and should be considered as part of surgery for endometriosis with radical intent.

Laparoscopy and Body Mass Index: Feasibility and Outcome in Obese Patients Treated for Gynecologic Diseases

Study Objective To compare feasibility and surgical outcome of laparoscopic gynecologic surgery between obese, overweight, normal-weight, and underweight women. Design Retrospective case control study (Canadian Task Force classification II-3). Setting Surgery Unit of Minimally Invasive Gynaecology. Patients A total of 503 women who underwent laparoscopic procedures for both benign disease and malignancies. Interventions Four main categories of gynecologic disease were identified: uterine fibroids, benign adnexal masses, endometriosis, and endometrial cancer (stage I). For each category patients were divided into 4 groups: underweight (BMI <18.5 kg/m 2), normal-weight (BMI 18.5–24.9 kg/m 2), overweight (BMI 25–29.9 kg/m 2), and obese (BMI ≥30 kg/m 2). Measurements and Main Results Selected outcomes were duration of surgery, rate of laparotomy conversion, intraoperative and postoperative complications, and duration of hospital stay. No statistical difference regarding demographic data, surgical and medical history, and intraoperative findings was present between groups. No laparotomy conversion occurred. Regarding duration of surgery, we found no statistical difference among the BMI groups with regard to benign diseases, whereas pelvic lymphadenectomy in obese patients with endometrial cancer had a statistically significant longer duration than in the control group (122 ± 47min vs 65 ± 21 min, p <.001). The postoperative complication rate was 0.01%: 3 cases of blood transfusion and 1 case of hemoperitoneum among myomectomies; 1 ureteral fistula in surgery for pelvic endometriosis; and 1 case of postoperative lymphocele in endometrial cancer group. No statistically significant difference was found in duration of hospital stay among the BMI groups in any of the categories of disease. For each category we conducted an analysis to identify any possible risk factors other than BMI in the surgical outcomes. Conclusion Laparoscopic approach in the various applications of gynecologic surgery does not appear to be significantly influenced by BMI in terms of surgical outcomes, laparotomy conversion rate, intraoperative and postoperative complications rate, and duration of hospital stay. The technical difficulties can be solved if skilled surgeons and anesthetists are available.

Urinary bladder injuries during vascular surgery

Urologic complications related to vascular surgery involving the ureter have been well recognized. These include ureteral compression from aneurysms, congenital anomalies such as retrocaval ureter, obstruction from retroperitoneal fibrosis, iatrogenic injury, and ureteric fistulas. Complications involving the bladder are more infrequent. Most of these bladder-related complications involve the use of tunneling devices for synthetic bypass grafts. We report an unusual case of a transvesically placed femoral-femoral bypass graft with delayed presentation. We also reviewed the English literature for experience with diagnosis and treatment of bladder injuries during vascular surgical procedures.

Therapeutic Option for Infected Urinary Tract Fistulas in Renal Transplantation

Background Approximately 20% of urinary tract fistulas after renal allografting are complicated by urinary tract infection, which presents a therapeutic challenge. Objective To evaluate an option for treatment of urinary tract fistulas associated with urinary tract infection and unsuitable for minimally invasive or primary surgical urinary tract repair. Patients and Methods The study included 650 recipients who underwent transplantation over 17 years. Urinary leakage was initially treated with indwelling bladder catheterization. Patients with fistulas refractory to treatment underwent surgical intervention to repair the urinary tract. In patients who were not candidates for primary repair of the urinary tract, temporary urinary diversion was performed, rather than classic percutaneous or open nephrostomy, using a ureteral stent (ie, a 6F or 8F Foley catheter with the balloon placed inside the renal pelvis). Results Overall, urinary leakage occurred in 36 patients (5.5%). Conservative management was successful in 14 vesical fistulas (42.4%) and no ureteral fistulas (0%). Three patients died of sepsis during conservative treatment, before the new surgical approach. Five of 36 urinary leaks (13.9%) were managed using ureteral intubation with an 8F Foley catheter, with a success rate of 80%. Conclusion Ureteral catheterization with an 8F Foley catheter is a feasible therapeutic option to treat complicated urinary tract fistulas unsuitable for primary surgical repair of the urinary tract.

Do we need new surgical techniques to repair vesico-vaginal fistulas?

The urogenital fistula is a devastating condition for women. Despite advances in medical care, the vesicovaginal fistula continues to be a distressful problem. Complex vesicovaginal fistulae repair may need tissue interposition. It can be achieved by vaginal or abdominal approach and depends on the surgeon's experience and local factors like size, location, and previous radiotherapy. The aim of this study was to demonstrate that using traditional approaches is possible and reasonable to treat any sort of vesicovaginal fistula. Between January 2004 and August 2007, we treated 23 patients with complex urogenital fistulae. Of those with concomitant ureteral fistula requiring re-implantation or bladder augmentation, the vaginal approach was the first choice in 17 and abdominal approach in six. Patients were clinically evaluated at 1, 4, and 12 weeks postoperatively, then every 3 months in the first year. Seventeen women were treated by vaginal approach and six patients were treated by abdominal approach. Hysterectomy was the major etiology (73.9%). Ten patients (43.5%) had at least one previous abdominal surgery for fistulae repair without success before. In those patients with abdominal approach, the hospitalization was longer than vaginal approach (80.5+/-6 h versus 48+/-3 h). In both, there were no major intraoperative or postoperative complications; 13% developed urgency and 4% developed stress urinary incontinence. No patients have recurrence of fistulae (success rate 100%). Complex vesicovaginal fistulas are a big challenge for the urologist, and there is no gold standard surgical approach. The majority of complex vaginal fistula can be successfully managed by vaginal repair. As the vaginal approach is a minimally invasive procedure with low costs, easy learning curve, and high cure rates, new approaches must be carefully evaluated before being suggested as an alternative.

Laparoscopic conservative management of ureteral endometriosis: a survey of eighty patients submitted to ureterolysis

Backgroundthis study aims to evaluate the effectiveness and safety of laparoscopic conservative management of ureteral endometriosis.MethodsEighty cases of histologically confirmed endometriosis affecting the ureter, 10 of which with bladder involvement were prospectively studied. In detail, patients were 13 women with ureteral stenosis (7 with hydronephrosis), 32 with circular lesions totally encasing the ureter, and 35 with endometriotic foci on the ureteral wall, but not completely encasing it. They were submitted to laparoscopic ureterolysis with or without partial cystectomy, ureteroneocistostomy. The rate of surgical complications, the recurrence rate, the patients' satisfaction rate was assessed during 22 months (median) follow-up.ResultsLaparoscopic ureterolysis was employed for all patients and set free the ureter from the disease in 95% of cases, whereas ureteroneocystostomy was necessary for 4 patients showing severe stenosis with hydronephrosis, among which 2 had intrinsic endometriosis of the ureteral muscularis. Three post-surgery ureteral fistulae occurred in cases with ureteral involvement longer than 4 cm: two cases were successfully treated placing double J catheter, the third needed ureteroneocistostomy. During follow-up, ureteral endometriosis recurred in 2 patients who consequently underwent ureteroneocystostomy. Most patients expressed high satisfaction rate throughout the whole follow-up period.Conclusionlaparoscopic ureterolysis is effective and well tolerated in most cases of ureteral endometriosis. Ureteroneocystostomy is a better strategy for patients with extended (more than 4 cm) ureteral involvement or with severe stenosis with or without hydronephrosis.

Ureteral stents and retrograde studies: a primer for the gynecologist

To review basic techniques and recent advances in endourology for the practicing gynecologist. New ureteral stent designs are available to improve comfort and reduce some of the complications of indwelling ureteral stents. A large prospective study failed to show a significant benefit of prophylactic ureteral catheterization prior to major gynecological surgery to reduce the risk of ureteral injury. There is a shift in the management of some iatrogenic ureteric injuries from surgical reimplantation to more conservative endoscopic management by interventional radiologists and urologists. The indications, techniques, and complications of advanced endourology techniques including the use of indwelling ureteral stents and retrograde pyelography are reviewed. Indwelling ureteral stents are used to establish and maintain patency of the ureters for many indications, including specific gynecological indications such as iatrogenic ureteral injury, ureteric fistula, extrinsic compression from tumor, and prophylactically to prevent ureteric injury. Retrograde pyelography is a very useful technique to image the renal collecting system with particular utility in patients with contraindications to intravenous contrast and to investigate suspected iatrogenic ureteral injuries.

Complications of Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy-Experience of 117 Patients

To describe the combined surgical technique of laparoscopic radical hysterectomy and pelvic lymphadenectomy (LRH + LPL) for cervical cancers and summarize our experiences in prevention and treatment of complications, so as to provide strategies to prevent and appropriately manage the complications that may occur during these procedures. A retrospective study was conducted on LRH + LPL in 117 cases of cervical cancer with International Federation of Gynecology and Obstetrics stages Ib (n = 96) and II a (n = 21) from August 1998 to December 2006. The intraoperative and postoperative complications were analyzed. The overall conversion rate was 1.7% (2/117). Four patients had vessel injuries, 3 of which were treated laparoscopically. One patient had a common iliac vein laceration that could not be controlled laparoscopically after failing to deal with the injured branch of common iliac vein. Cystotomy occurred in 5 patients. One case of stage IIa with a bladder laceration longer than 3 cm was converted to laparotomy during the early stages of the learning curve. The remaining 4 were managed laparoscopically. Postoperative complications occurred in 38.5% (n = 45) of the patients, including 38 patients with urinary retention who exhibited complete resolution within 6 months by intermittent training and catheterization, 4 with lymphocyst who underwent conservation treatment, 1 with ureteral fistula that was treated by cystoscopic placement of double-J ureteral stents, 1 with mild adynamic bowel obstruction who received conservative management, and 1 with vesicovaginal fistula that was closed by conservative treatment. With the continuous skilled laparoscopic technology, mastering the tips of prevention, and treatment of complications, LRH + LPL will be widely performed in the future.

Evolution of the complications of laparoscopic hysterectomy after a decade: A follow up of the Monash experience

A retrospective review of medical records was performed to assess the incidence and types of significant complications encountered during laparoscopic hysterectomy which would affect the use of a laparoscopic approach versus other routes of hysterectomy. A total of 526 consecutive patients' medical data between January 1994 and August 2007 were reviewed. Two hundred and thirty-two laparoscopic-assisted vaginal hysterectomies and 294 total laparoscopic hysterectomies were performed at Monash Medical Centre, a Melbourne tertiary public hospital, and three Melbourne private hospitals, by or under the supervision of three surgeons. Sixteen significant complications occurred. There were two cases of ureteric fistula, two bladder injuries, two bowel obstructions, four postoperative haematomas, one case of a bladder fistula, four conversions to laparotomy and one superficial epigastric artery injury. Inpatient stay ranged from two to six days. Our complication and inpatient stay rates are consistent with the previously reported rates, although there has been a reduction of incidence of visceral injuries with experience and introduction of new equipment.

Sonographic imaging of urinoma

A 72-year-old Hispanic woman with histologically confirmed endometrial adenocarcinoma underwent laparotomy, total hysterectomy (Piver I), bilateral salpingoophorectomy and pelvic lymphadenectomy. During surgery, access and mobilization of the right ureter were complicated by severe pelvic adhesions. Intraoperative tests for bladder and rectal integrity indicated no apparent lesions. The postoperative period was uncomplicated. Twenty days after discharge, the patient was readmitted with abdominal pain, nausea, vomiting, constipation and fever. Physical examination revealed a moderately tender and distended abdomen. Blood count showed moderate leukocytosis (13.0 × 109/L), granulocytosis (11.34 × 109/L) and raised plasma creatinine (3.3 mg/dL; normal value, 0.6–1.2 mg/dL). Contrast-enhanced computed tomography (CT) revealed accumulation of fluid and gas content in the pelvic space on the left obturator fossa, suggesting the diagnosis of distended bowel loops and abscess formation. The proximal segments of the ureters were mildly distended, with evidence of mesenteric and parietal peritoneal edema. The preliminary diagnosis was retroperitoneal abscess, based on fever, leukocytosis and CT findings. Transperineal and transrectal sonography (A.C.T.) revealed a moderately distended right ureter, and profoundly distended left ureter with evidence of hydronephrosis. The pelvis demonstrated a small amount of free intraperitoneal fluid and a left unilocular-solid encapsulated formation, measuring 7.0 × 5.0 cm, with anechogenic content and echogenic protruding tissue. At its upper pole, color Doppler imaging detected a unidirectional intermittent flow entering the formation's cavity (Figure 1, Videoclip S1). These sonographic findings suggested a left ureteral fistula and antegrade pyelography confirmed the presence of a urinoma (Figure 2). Bilateral nephrostomy was performed and the patient's condition gradually improved, with creatinine levels normalizing in 7 days. Her physical condition remained good at 3 months after operation, and at the time of writing she was scheduled to undergo ureteral reconstructive surgery. Sequential color Doppler ultrasound images (a–c) of the ‘intermittent flow’ (arrow) entering the cavity of the pelvic cystic formation, which led to suspicion of ureteral injury. Sequential pyelographic images (a–d) documenting ureteral injury (arrow) at the distal portion of the ureter (medial wall), and the collection of urine in the pelvic formation (circled). Ureteral injury following gynecological and obstetric surgery is a serious complication, with an incidence estimated to be within the range 0.4–4%1, 2. Radical surgery, gynecological malignant tumors, endometriosis, and long duration and technical difficulties in surgery are all associated with long-term complications of ureteral injuries1, 3, 4. Although most ureteral lesions are detected and repaired during surgery4, it has been reported that a small but sizeable proportion are only recognized a variable amount of time after surgery1, 3. Indeed, the diagnosis of ureteral injury can be challenging5. CT scanning is the recommended primary diagnostic procedure2, 5, but in our case contrast-enhanced CT failed to diagnose the ureteral defect and urine leakage; a valve mechanism or dilution of the scant iodate contrast medium, in comparison to the fluid within the cystic pelvic formation, could explain the failure to visualize the ureteral injury. Ultrasound examination was the first diagnostic approach to identify the ureteral injury, based mainly on observation of an ‘intermittent flow’ entering the cavity of the pelvic ‘pseudocyst’ on color Doppler examination. This sign was evident because of the fluid cavity surrounding the ureteral lesion; however, we are aware that such a sign could not be utilized in the presence of direct urine passage into the free peritoneal cavity. Hence, inconclusive CT scan findings during the postoperative period in a symptomatic patient with a pelvic cystic lesion and urine leakage, characterized by an ‘intermittent flow’ Doppler sign, could indicate a ureteric lesion. SUPPORTING INFORMATION ON THE INTERNET The following supporting information may be found in the online version of this article: Videoclip S1 Doppler ultrasound imaging of the ‘intermittent flow‘ (arrow) entering the cavity of the pelvic cystic formation. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. A. C. Testa atesta@rm.unicatt.it* , A. Gaurilcikas?, A. Licameli , C. Di Stasi , D. Lorusso , G. Scambia*, G. Ferrandina?, * Department of Obstetrics and Gynecology, Universitá Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168 Rome, Italy, Gynecologic Oncology Unit, Catholic University of Rome, Rome, Italy, Bioimaging and Radiological Sciences, Catholic University of Rome, Rome, Italy, ? Department of Oncology, Catholic University of Campobasso, Campobasso, Italy, ? Department of Obstetrics and Gynecology, Kaunas University of Medicine, Kaunas, Lithuania

Videolaparoscopic radical hysterectomy approach: a ten-year experience.

Because of the advancements in surgical techniques and laparoscopic instruments, total laparoscopic radical hysterectomy can now be performed for the treatment of uterine cervical carcinoma. We assessed the feasibility, complications, and survival rates of patients who underwent total laparoscopic radical hysterectomy with pelvic lymphadenectomy. We retrospectively collected data from the medical charts of 29 patients who had undergone surgery between 1998 and 2008. The following data were assessed: age, staging, histological type, number of lymph nodes retrieved, parametrial measures, operative time, length of hospital stay, surgical complications, and disease-free time. The mean patient age was 37.07+/-10.45 years. Forty percent of the patients had previously undergone abdominal or pelvic surgeries. Mean operative time was 228.96+/-60.41 minutes, and mean retrieved lymph nodes was 16.9+/-8.12. All patients had free margins. No conversions to laparotomy were necessary. Median time until hospital dismissal was 6.5 days (range 3-38 days). Four patients had intraoperative complications: 2 lacerations of the rectum, 1 laceration of the bladder, and 1 lesion of the ureter. Three patients developed bladder or ureteral fistulas postoperatively that were successfully corrected surgically. Laparoscopic radical hysterectomy is feasible and has acceptable complications. The radicalism of the surgery must be considered, bearing in mind the parametrial measures and the number of lymph nodes retrieved.

Urinary Fistulae after Renal Transplantation1

Summary In 130 consecutive patients treated by renal transplantation in the years 1961 to 1972 there were 9 patients who developed a vesical fistula, 4 developed a ureteric fistula and 3 a calyceal fistula (1 patient had both a ureteric and calyceal fistula). Continuous bladder drainage by an indwelling urethral catheter is recommended for the treatment of a vesical fistula. The treatment of a ureteric fistula may be difficult and a temporary uretero-ileostomy may be of value. Provided that distal obstruction is excluded, omentopexy is valuable for treating a calyceal fistula. Immunosuppressive drug therapy may have to be withdrawn but this is not always followed by rejection of the transplanted kidney.

A case of iliac-artery–ureteral fistula managed with a combined endoscopic approach

A 66-year-old man presented to hospital with gross hematuria and clots. He had previously undergone surgical repair of a right iliac artery aneurysm with placement of a vascular prosthesis at the same hospital, which had resulted in iliac urethral stricture that required the placement of a right ureteral stent. He had attended repeatedly for recurrent ureteral stent replacement, with the most recent replacement having occurred 1 month before the current presentation. Ultrasonography, cystography, retrograde pyelography and provocative arteriography via a percutaneous right femoral arterial approach. An iliac-artery-ureteral fistula between the right ureter and a pseudoaneurysm of the right common iliac artery. The patient underwent placement of a covered, self-expandable vascular stent with angioplasty balloon, which resulted in complete exclusion of the pseudoaneurysm and fistula and resolution of the patient's hematuria. A pigtail catheter was placed in the right ureter for 5 days and replaced with a double-J ureteral stent on day 6 after exclusion of the pseudoaneurysm; the patient was discharged from hospital on the same day. Color-Doppler ultrasonography of the right iliac vessels performed 2 months later showed patency of the right iliac artery. The patient's ureteral stent has been replaced every 2 months since his discharge without recurrence of hematuria.