Ureteral Resection Research Articles

V11-12 ROBOT-ASSISTED LAPAROSCOPIC DISTAL TUMOR-URETERECTOMY, PSOAS HITCH AND BOARI-FLAP URETERAL RECONSTRUCTION.

INTRODUCTION AND OBJECTIVES: Reconstruction of the lower ureter can be achieved by a Boari-flap either by open surgery or a laparoscopic procedure. Robot assisted surgery offers multiple intraoperative advantages including wristed movements with additional degrees of freedom and three dimensional visualization with magnification. The video shows a robot-assisted approach for ureteric resection according to a malignant ureteral tumor, the creation of a Boari-flap and the ureteral reimplantation. METHODS: We used 4 robot and 2 assistant trocars similar to radical cystectomy in a 10 degree Trendelenburg position. The distal ureter (10cm) was resected, the distal part of the remaining ureter sent for frozen section. After filling the bladder with saline, the Boari-flap was created and fixed at the psoas-fascia in a psoas-hitch manner. Then the antirefluxive ureteral reimplanatation was performed intraabdominally. RESULTS: Recovery was uneventful. Histologic examination of the specimen revealed a transitional carcinoma of the ureter pT2, high grade, R0 L0 V0. There was no leakage at the time of removal of the ureteric splint on the 10th postoperative day. Follow up at 14 months showed no recurrence of the tumor. CONCLUSIONS: Robot assisted oncological surgery of ureter and bladder is a safe and effective alternative to open and conventional laparoscopic surgery. It offers fast and uncomplicated recovery, minimal blood loss and optimal cosmesis.

Hematoureter due to endometriosis

To report the laparoscopic management of a rare case of hematoureter due to endometriosis in a young woman with multiple genitourinary anomalies. Video demonstration of a surgical technique and review of genitourinary endometriosis. Hospital. A 17-year-old nulliparous woman with multiple genitourinary anomalies presented with pelvic pain and unilateral retroperitoneal mass. The patient had uterine didelphys, a history of left nephrectomy, and partial ureter resection as an infant. She had a partial resection of a left transverse vaginal septum due to hematocolpos at age 12. A preoperative magnetic resonance imaging (MRI) scan revealed a left retroperitoneal mass with extension to the paravesical region, reaccumulation of the hematocolpos behind the partially resected left transverse vaginal septum, and a dilated left uterine horn with hematometra. Laparoscopic management of hematoureter due to intrinsic endometriosis. Intraoperative findings showed uterus didelphys with dilated left horn, normal right horn, and normal right and left fallopian tubes and ovaries. The left transverse vaginal septum was resected vaginally, and the hematocolpos and hematometra drained. The left uterine horn and cervix were laparoscopically resected. The left-side serpiginous retroperitoneal mass was dissected from the pelvic sidewall, ligated, and transected, with spillage of thick, brown liquid. The pathology of the mass wall was smooth muscle and transitional epithelium consistent with ureter, in addition to hemorrhage and glandular structures consistent with endometriosis. Endometriosis was also present in the serosa of the left uterine horn. Thus, the left retroperitoneal mass was the left ureter remnant, which acquired endometriosis and collected menstrual debris, resulting in hematoureter. Two major pathologic types of ureteral endometriosis have been described: intrinsic, as occurred in this patient, and extrinsic. Women with müllerian anomalies, vaginal obstruction, or imperforate hymen are at higher risk of endometriosis. Prior urogenital surgery can further complicate and distort the anatomy. Thus, a preoperative understanding of the patient's urogenital anomalies is important to consider the differential diagnoses and anticipate surgical needs.

Editorial Comment

This manuscript presents an aggressive clinical pathway in a large number of patients who underwent robotic nephroureterectomy. The pathway involves no placement of a pelvic drain, Foley catheter removal on postoperative day 1 (POD#1), and discharge home on POD#1. The authors were able to achieve POD#1 discharge in 93% of patients and all 3 criteria of no drain, early catheter removal, and POD#1 discharge in 90% of patients. The authors attribute using a robotic approach to perform the distal ureteral resection and bladder closure as the major contributor to the success of this pathway.

Experience with multidisciplinary laparoscopic surgery in patients with deep infiltrating colorectal endometriosis

Deep infiltrating endometriosis is a particular form of endometriosis that penetrates the peritoneal surface or it reaches the subserosal neurovascular plexus. The aim of the authors was to analyze the results of segmental colorectal resections performed for deep infiltrating endometriosis. Between 2009 and 2012, 50 patients underwent segmental rectum or/and sigmoid resection for endometriosis. 21 patients had ultralow rectal resection and 29 patients had low colorectal anastomosis or anterior resection. Concomitant intervention in other organs was required in all cases, including gynecologic procedures (n = 50), additional gynecologic (n = 47), vesical (n = 9) and ureteral (n = 18) resections. The mean number of endometriosis lesions was 2.4±1.8 per patient. In all patients fertility was preserved. Severe surgical complications (Clavien-Dindo stage III or more severe) occurred in 3 patients (6%). The results confirm that segmental bowel resection is an efficient and safe method for the treatment of deep infiltrating colorectal endometriosis. Orv. Hetil., 2014, 155(5), 182-186.

Intrinsic Ureteral Endometriosis: Description of a Striking Instance

Intrinsic ureteral endometriosis is a very rare condition. A 41 y. o. woman with right hydroureteronephrosis and other aspecific symptoms came to our attention. The CT scan showed an ureteral obstacle causing the hydroureteronephrosis. She underwent ureterorenoscopy with biopsies of the lesion that did not result to be diriment. Suspecting a ureteral neoplasm, the patient then underwent ureteral resection and ureterocystoneostomy, and the extemporary histological examination resulted as endometriosis. The abdominal exploration showed a parametrial and a peritoneal growth - both compatible with the extemporary histological examination - that were also excised. The post-operative course was uneventful. The definitive hystological examination confirmed the perioperatory diagnosis. Intrinsic ureteral endometriosis is confirmed as a rare pathology with an indefinite clinical presentation; its typical presentation, namely cyclic hematuria, seems to be an anecdotal feature. Therefore the diagnostics of intrinsic ureteral endometriosis is still difficult even despite such a striking presentation.

Lack of usefulness of ureteral reconstruction with free bladder mucosa flap in dogs confirmed by microangiography.

BackgroundThere is a paucity of data addressing the blood supply in the surgically reconstructed ureter, and complete lack of microangiographic studies of the reconstructed ureter with the use of a free bladder mucosa flap. The present study evaluated the blood supply in the reconstructed dog ureter after a 5-centimeter segment resection, supplemented by a tube constructed from a free bladder mucosa flap.Material/MethodsFemale mongrel dogs (n=29) were used in this study. Under general anaesthesia, a 5-centimeter autologous free bladder mucosa flap was used to construct a tube, which was afterwards grafted to replace a 5-centimeter ureter resection. After a period of 3 months (n=2) and after 1 year (n=2), microangiography was performed to assess the revascularization of the grafted ureter.ResultsIn our study, we observed the continuity of the ureter, but the grafted reconstruction was narrowed by the cicatrization in about 86% (n=25) of cases. This resulted in the development of hydronephrosis, as described in previous publications. The ureteral wall was covered by a normal urothelium, but consisted of fibrous connective tissue, which failed to restore a regular (normal) coat. The reconstructed segment showed no smooth muscle cells. A few smooth monocytes were found only at the border with intact portions of the ureter. The microangiography performed at the end of the experiments showed no vascularization of the restored segment of the ureter.ConclusionsThe experiments showed a whole regeneration of urothelium in the transected and reanastomosed ureters. However, there was no regeneration of the muscular coat and a complete lack of revascularization.

Genitourinary Resection at the Time of Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis Is Not Associated with Increased Morbidity or Worsened Oncologic Outcomes: A Case-matched Study

Cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) has gained acceptance in the treatment of peritoneal carcinomatosis with reported morbidity and mortality rates of 27-56 and 0-11 %, respectively. The safety and oncologic outcome of genitourinary repair at the time of CRS and HIPEC remains unclear. We identified 170 patients who underwent CRS-HIPEC at our institution between July 2007 and August 2011 with a minimum follow-up of 6 months. Thirty-four (20 %) underwent concomitant urologic reconstruction at the time of CRS-HIPEC and were matched by disease burden (intraoperative peritoneal cancer index [PCI]) and extent of surgery (ΔPCI) with a cohort of 38 (22.3 %) subjects without genitourinary involvement. The primary end points considered for this analysis included the development of major surgical (Clavien-Dindo Class III-V) complications and overall survival. Median follow-up was 9.4 months. The most commonly performed urologic interventions included partial cystectomy with primary repair in 23 (65.7 %) and segmental ureteral resection and repair in 11 (31.4 %). Patients with genitourinary reconstruction had more total organ involvement (6.5 vs. 4.3, p < 0.001) and more commonly underwent enteric anastomoses (82.4 vs. 57.9 %, p = 0.025). No significant differences were observed with regard to major morbidity, need for transfusion, operative time, intensive care unit admission, or length of stay. Among patients with appendiceal or colonic tumors (n = 46), overall survival was similar between genitourinary reconstruction and matched cohorts: 22.5 versus 15.1 months, respectively (p = 0.66). Genitourinary reconstruction at the time of CRS-HIPEC occurs more commonly in patients with extensive disease burden undergoing radical debulking, yet does not adversely influence surgical morbidity or survival.

Indwelling double pigtail ureteral stent combined or not with surgery for feline ureterolithiasis: complications and outcome in 15 cases.

Ureteral obstruction secondary to ureterolithiasis in cats is a challenging situation. Ureteral stenting has recently been introduced to prevent complications that often occurred after ureterotomy or other invasive surgeries. The purpose of this study is to describe the stenting technique and perioperative difficulties, as well as long-term outcome and complications with ureteral stenting in 12 cats with ureteroliths. Fifteen 2.5 Fr soft double pigtail multi-fenestrated ureteral stents were placed in an anterograde fashion under open surgical approaches and with fluoroscopic guidance in 12 cats. Nine cats received a unilateral stent and three received bilateral stents. Ureterotomy or ureteral resection and end-to-end anastomosis were performed in three and four cases, respectively. In six cats, papillotomy was performed to facilitate dilatator and stent placement. All cats recovered well from the surgical procedure, except one cat, which died during the anaesthesia recovery period. Postoperative complications included dysuria (three cases, diagnosed at 15 days, 1 month and 3 months, respectively), urinary tract infection (one case, 1 month after surgery), stent migration requiring stent replacement (one case, 19 months after surgery) and stent obstruction requiring stent removal (three cases with previously end-to-end anastomosis between 2 and 8 months after surgery). Nine cats (75%) were alive at a mean follow-up of 453 ± 194 (123-720) days. The median survival time was >415 days. Stent placement appeared to be a valuable and safe option for treating ureteral obstruction in cats. However, periodic and long-term monitoring of stents is warranted.

Laparoscopic ureteral replacement by Boari flap: Multi-institutional experience in 30 cases

IntroductionThe Boari flap is an excellent technique for replacement of distal ureteral injuries. There are few reports with the use of laparoscopic surgery, especially with long term results. Our goal is to present the results of a multi-institutional study of 30 cases. Materials and methodsWe analyzed 30 patients treated between December 2001 and January 2009 who underwent a laparoscopic intracorporeal Boari flap, in three Latin American centers. In all cases the same surgical technique was employed. The database was recorded prospectively and analyzed retrospectively. ResultsThe mean age was 43.2 years (range 9–71 years). Most were women (22 of 30) with a slight predominance of left-side lesions (17 of 30). The most common cause of ureteral injury was hysterectomy in 14 patients (46.6%) and endoscopic ureterolithotomy in 9 patients (30%). The mean length of ureteral resection was 7cm (5–20cm). The average operative time was 161.16min (90–280min). The average estimated blood loss was 123mL (0–500mL), and hospital stay was 4.86 days (2–10 days). There were no intraoperative complications or conversion to open surgery. Postoperative complications occurred in 5 patients (16.6%), Clavien 1 in 2 patients (6.6%) and Clavien 3 in three patients (10%). The success rate was 96.6% (29 patients) with a mean follow up of 32 months (5–60 months). ConclusionsLaparoscopic Boari flap in our hands had good short and long term results.

An atypical hydronephrosis revealing urinary tract involvement in antiphospholipid syndrome

Urinary tract involvement is rarely described in APS. We report the case of a 40 year-old man with primitive APS who was diagnosed an arterial and venous unilateral ureteral ischemia, revealed by a hydronephrosis. He had been on oral anticoagulation for six years because of two deep venous thromboses. He developed then a massive splenic infarct and an acute myocardial infarct, which required intensification of his anticoagulation, add of aspirin and high doses of corticosteroids. Three months later, he was explored for a latero-thoracic pain. Biology found an acute renal failure and microscopic haematuria. CT scan showed hypoperfusion of the left kidney, an ostial defect on renal artery and left hydronephrosis. Retrograde pyelography found a proximal ureteral stenosis. A dilatation with stenting failed, leading to a partial left ureteral resection. Histology confirmed ureteral segmental organized arterial thrombosis and venous thrombosis. Evolution was favourable with stabilization of creatinine level.Urinary tract involvement is rarely described in antiphospholipid syndrome (APS). We report the case of a 40 year-old man with primitive APS who developed an arterial and venous unilateral ureteral ischemia revealed by painful unilateral hydronephrosis. The patient was on oral anticoagulation for six years because of two deep venous thromboses. He developed then a massive splenic infarct and an acute myocardial infarct, which required the intensification of his anticoagulation and high doses of corticosteroids. Three months later, he was explored for a latero-thoracic pain. Biology found an acute renal failure and microscopic haematuria. CT scan showed a hypoperfusion of the left kidney, an ostial defect on renal artery and a left hydronephrosis. Retrograde pyelography found a stenosis of the proximal ureter. A dilatation with stenting failed, leading to a partial left ureteral resection. Histology confirmed ureteral segmental organized arterial thrombosis and venous thrombosis. Evolution was favourable with stabilization of creatinine. DOI: http://dx.doi.org/10.3126/jaim.v2i2.7659 Journal of Advances in Internal Medicine 2013;02(02):78-80

Reemplazo ureteral con colgajo de Boari laparoscópico: experiencia multi-institucional en 30 casos

IntroductionThe Boari flap is an excellent technique for replacement of distal ureteral injuries. There are few reports with the use of laparoscopic surgery, especially with long term results. Our goal is to present the results of a multi-institutional study of 30 cases. Material and methodsWe analyzed 30 patients treated between December 2001 and January 2009 who underwent a laparoscopic intracorporeal Boari flap, in three Latin American centers. In all cases the same surgical technique wasemployed. The database was recorded prospectively and analyzed retrospectively. ResultsThe mean age was 43.2 years (range 9 to 71 years). Most were women (22 of 30) with a slight predominance of left-side lesions (17 of 30). The most common cause of ureteral injury was hysterectomy in 14 patients (46.6%) and endoscopic ureterolithotomy in 9 patients (30%). The mean length of ureteral resection was 7cm. (5 to 20cm). The average operative time was 161.16minutes (90 to 280minutes). The average estimated blood loss was 123mL. (0 to 500mL), and hospital stay was 4.86 days (2 to 10 days). There were no intraoperative complications or conversion to open surgery. Postoperative complications occurred in 5 patients (16.6%), Clavien 1 in 2 patients (6.6%) and Clavien 3 in three patients (10%). The success rate was 96.6% (29 patients) with a mean follow up of 32 months (5 to 60 months). ConclusionsLaparoscopic Boari flap in our hands had good short and long term results.

IgG4-related disease of the ureter: report of two cases and review of the literature

IgG4-related disease (IgG4-RD) is a recently recognized multi-organ fibro-inflammatory lesion characterized by elevated IgG4 serum levels and mass-forming lesions. This condition shows similar histological features independently of the site of origin including storiform fibrosis, obliterative phlebitis, and dense lymphoplasmacytic infiltrate with a conspicuous IgG4-positive plasma cell component. Since this disease has only recently been categorized as a single specific nosologic entity, lesions with these typical morphological features have previously been named in different ways, creating some confusion and making it difficult to identify cases published in the literature. Lesions with features suggesting IgG4-RDs have very rarely been reported in the ureter, and they have been named using the terms "inflammatory pseudotumor" and "idiopathic segmental ureteritis." Herein, we describe the clinicopathological features of ureteral IgG4-RD found in two different patients. An 82-year-old female and a 77-year-old male underwent ureteral resection due to severe ureteral wall thickness and lumen stenosis suggestive of urothelial carcinoma. However, histological examinations showed transmural fibro-inflammatory lesions, with abundant IgG4 plasma cells intermixed with histiocytes, lymphocytes, fibroblasts, and scattered eosinophils. We have also accurately reviewed the literature in order to identify, among lesions diagnosed with different names, examples of ureteral IgG4-related lesions to give the reader a comprehensive overview of this relatively rare inflammatory disease. We suggest using the name "ureteral IgG4-RD" for those lesions showing the same morphological features as IgG4-RDs located elsewhere.

Laparoscopic En Bloc Resection of Ureter with a Cuff of Bladder During Radical Nephroureterectomy for Lower Ureteric Tumors: A Matched-Paired Analysis

Surgical management of the lower end of the ureter during laparoscopic nephroureterectomy remains a matter of debate. The commonest method during laparoscopic nephroureterectomy-endoscopic incision-has been shown to have a higher recurrence rate compared with open surgical excision with a cuff of bladder. In addition, the literature still lacks comparative studies between different approaches to support and guide the current clinical practice. Three consecutive series of patients undergoing laparoscopic radical nephrectomy for transitional cell carcinoma located in the lower one-third of the ureter with different methods (laparoscopic en bloc resection of ureter with a cuff of bladder, open surgical excision, and endoscopic incision) of dealing with the lower end were compared in their short-term surgical and oncological outcomes. The primary outcome was recurrence at 12 months of follow-up. The secondary outcomes were hospital stay, positive surgical margins, and duration of catheterization. Analysis of perioperative and postoperative outcomes revealed laparoscopic en bloc resection of the lower end of the ureter with a cuff of bladder is a safe and feasible approach with the advantages of the laparoscopic approach such as less hospital stay compared with the open approach. The analysis of oncological outcomes in this feasibility study showed a higher rate of recurrences in the endoscopic approach. Laparoscopic en bloc resection of the lower end of the ureter with a cuff of bladder during nephroureterectomy for tumors located in the lower one-third of ureters is safe and feasible in terms of perioperative outcomes and early oncological results. We acknowledge that the small sample size and the nonrandomized design are a limit of the study. Thus, prospective randomized controlled trials are recommended to prove the superiority of one approach over the others.

Editorial Comment

Patients harboring upper tract urothelial cancer (UTUC) with coexistent medical renal disease are at an increased risk of progression to endstage renal disease after a radical surgery. For this reason, nephron-sparing approaches in the form of either retrograde or percutaneous endoscopic ablation or resection, as well as segmental ureteral resection with anastomosis, reimplantation, or even ureteral replacement have all been used to achieve oncological control as well as maintain acceptable residual renal function. Comparative Analysis of Oncologic Outcomes of Partial Ureterectomy vs Radical Nephroureterectomy in Upper Tract Urothelial CarcinomaUrologyVol. 81Issue 5PreviewTo compare oncologic outcomes in an international cohort of patients who underwent either partial ureterectomy (PU) or radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Full-Text PDF ReplyUrologyVol. 81Issue 5PreviewThe rarity of upper tract urothelial carcinoma (UTUC) makes it a difficult disease process to study and, until a recent large multi-institutional collaboration in 2009,1 our basic understanding of pathological characteristics, risk factors, and clinical outcomes for UTUC were extrapolated from small, single-institution studies. The American Cancer Society reports that approximately 5212 renal pelvic tumors and 2710 new cases of ureteral UTUC will be diagnosed in the United States in 2013.2 Thus, approximately one third of UTUCs are ureteral tumors. Full-Text PDF

Reply

The rarity of upper tract urothelial carcinoma (UTUC) makes it a difficult disease process to study and, until a recent large multi-institutional collaboration in 2009, 1 Margulis V. Shariat S.F. Matin S.F. et al. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer. 2009; 115: 1224-1233 Crossref PubMed Scopus (773) Google Scholar our basic understanding of pathological characteristics, risk factors, and clinical outcomes for UTUC were extrapolated from small, single-institution studies. The American Cancer Society reports that approximately 5212 renal pelvic tumors and 2710 new cases of ureteral UTUC will be diagnosed in the United States in 2013. 2 Siegel R. Naishadham D. Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013; 63: 11-30 Crossref PubMed Scopus (11434) Google Scholar Thus, approximately one third of UTUCs are ureteral tumors. Our study and another population-based investigation indicate that actuarial utilization of partial ureterectomy (PU) is approximately 10%. 3 Lughezzani G. Jeldres C. Isbarn H. et al. Nephroureterectomy and segmental ureterectomy in the treatment of invasive upper tract urothelial carcinoma: a population-based study of 2299 patients. Eur J Cancer. 2009; 45: 3291-3297 Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar Although all ureteral tumors are certainly not amenable to PU, the discrepancy between incidence of ureteral tumors and utilization of PU suggests that PU may be underutilized, and this warrants a closer look. Current evidence-based recommendations for incorporation of PU for UTUC are limited but do indicate that PU may be used for both low and high-risk tumors. 4 Rouprêt M. Zigeuner R. Palou J. et al. European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update. Eur Urol. 2011; 59: 584-594 Abstract Full Text Full Text PDF PubMed Scopus (323) Google Scholar Our data supports the concept of expanding the indication for PU to maintain glomerular reserve while not compromising oncologic efficacy. Along with the attendant health benefits of better renal function, PU may also allow for administration of effective adjuvant chemotherapy regimens in patients with advanced stage disease that have greater than 50% mortality at 5 years. 1 Margulis V. Shariat S.F. Matin S.F. et al. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer. 2009; 115: 1224-1233 Crossref PubMed Scopus (773) Google Scholar Our data highlights considering alternative management options as opposed to reflexively performing radical nephroureterectomy (RNU). Editorial CommentUrologyVol. 81Issue 5PreviewPatients harboring upper tract urothelial cancer (UTUC) with coexistent medical renal disease are at an increased risk of progression to endstage renal disease after a radical surgery. For this reason, nephron-sparing approaches in the form of either retrograde or percutaneous endoscopic ablation or resection, as well as segmental ureteral resection with anastomosis, reimplantation, or even ureteral replacement have all been used to achieve oncological control as well as maintain acceptable residual renal function. Full-Text PDF

Conservative Nephron-Sparing Treatment of Upper-Tract Tumors

While radical nephroureterectomy represents the gold standard for managing upper-tract urothelial carcinoma, nephron-sparing approaches have increasingly been utilized in the elective setting. Such considerations are accentuated by contemporary studies highlighting sequelae related to chronic kidney disease following nephrectomy. Kidney sparing treatments including segmental ureteral resection and endoscopic ablation may therefore be appropriate in select patients with small, solitary, low-grade upper-tract tumors. Bladder and ipsilateral upper-tract recurrences are frequent after nephron-sparing treatments for UTUC, thereby underscoring the need to maintain strict radiographic and endoscopic surveillance protocols in patients amenable to this rigorous compliance program.

Benign fibroepithelial polyp of the ureter.

Benign tumors of the ureter are rare and most often appear in the form of fibroepithelial polyps [1]. Fibroepithelial polyps represent from 2 to 6% of all benign tumors of the urinary tract [2]. The Authors report on two cases of fibroepithelial polyps of the ureter, which they treated between 1993–2009. One case was presented by acute urinary retention and gross hematuria. In the second case, hematuria and flank pain were observed. The first case was treated with open surgery and partial resection of the ureter, the second was treated endoscopically when the base of the polyp was well identified.

A primary arterial–ureteral fistula after an aortic-bifemoral bypass

INTRODUCTIONPrimary arterial–ureteral fistula is a rare and diagnostically challenging condition which may present with massive hematuria. PRESENTATION OF CASEA case of primary arterial–ureteral fistula (AUF) is presented in a patient with a previous prosthetic aortic-bifemoral bypass. The AUF treated with arterial and ureteral resection, arterial ligation and ureteral reconstruction. DISCUSSIONPrimary AUF are more frequently associated with aneurysmal degeneration of the arterial wall. The development of a primary fistula due to an iliac artery aneurysm many years after an aortic-bifemoral bypass performed due to atherosclerotic obstructive disease is a very unusual presentation of this entity. Multiple surgical strategies can be employed in achieving hemorrhage and infection control, urinary tract continuity, and vascular reconstruction. CONCLUSIONA multidisciplinary approach and the achievement of a pre-operative diagnosis are essential for an effective management of this condition with prognostic implications.

Left Ureterovaginal Fistula Repair after Partial Ureteral Resection and End-to-End Anastomosis for Deep Infiltrating Endometriosis (DIE)

Left Ureterovaginal Fistula Repair after Partial Ureteral Resection and End-to-End Anastomosis for Deep Infiltrating Endometriosis (DIE)

Outcome of Laparoscopic Repair of Ureteral Injury: Follow-Up of Twelve Cases

To review the feasibility of laparoscopic repair in cases of ureteral injuries occurring during gynecologic laparoscopy. Retrospective study (Canadian Task Force classification II-3). Institution-specific retrospective review of data from a tertiary referral medical center. Patients suffering from iatrogenic ureteral injuries diagnosed during or after surgery, and cases with deliberate ureteral resection and repair because of underlying disease. We conducted a retrospective review of all (10 345) laparoscopic gynecologic surgeries performed in our institute between February 2004 and November 2008. Twelve cases (median: 45.5 years, range: 27–63) of ureter transections were diagnosed and repaired laparoscopically by endoscopists. Of these, 10 had previous surgeries, pelvic adhesions, or a large pelvic-abdominal mass. One patient had undergone a segmental resection and laparoscopic ureteroureterostomy for deep infiltrative endometriosis. Of the remaining 11 iatrogenic ureteral transections, 10 were repaired via laparoscopic ureteroureterostomy, whereas 1 had undergone a laparoscopic ureteroneocystostomy. One injury was recognized on the second postoperative day, but intraoperative recognition was attained in 11 cases. The median duration of double J stenting was 73 days. Three patients had development of strictures (between 42 and 79 days after surgery) treated with restenting, but 1 had to undergo an ureteroneocystostomy for ureter disruption when trying to restent. One patient had development of leakage of the anastomotic site but recovered with a change of the double J stent. Only 1 case required another laparotomy for ureteroneocystostomy. Laparoscopic primary repair of ureteral injury was successful for 11 of 12 patients. All the patients were well and symptom free at the conclusion of the study period. Early recognition and treatment of ureteral injuries are important to prevent morbidity. Laparoscopic ureteroureterostomy could be considered in transections of the ureter where technical expertise is available.