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JOURNAL OF ENDOUROLOGY Volume 29, Number 4, April 2015 ª Mary Ann Liebert, Inc. Pp. 415–421 DOI: 10.1089/end.2014.0474
Endoscopic Rendezvous Procedure for Ureteral Iatrogenic Detachment: Report of a Case Series with Long-Term Outcomes Antonio Luigi Pastore, MD, PhD, Giovanni Palleschi, MD, PhD, Luigi Silvestri, MD, Antonino Leto, MD, Domenico Autieri, MD, Andrea Ripoli, MD, Cristina Maggioni, MD, Yazan Al Salhi, MD, and Antonio Carbone, MD
Abstract
Background and Purpose: Injury to the ureter is the most common urologic complication of pelvic surgery, with an incidence that ranges from 1% to 10%. Most cases of ureteral injuries are related to gynecologic procedures. The ureter is particularly vulnerable to detachment or ligation during hysterectomy because of its position from the lateral edge of the cervix. We report a case series of female patients who underwent the ureteral rendezvous procedure for ureteral detachment. Patients and Methods: Between January 2009 and April 2013, 18 ureteral rendezvous procedures were performed for patients with complete detachment. We assessed the operative and clinical outcomes of these patients over a mean follow-up duration of 26.5 months and describe the three most representative cases. Results: The endoscopic rendezvous technique was performed in all cases to manage ureteral detachment. CT urography at discharge and 6 and 12 months after discharge confirmed the restoration of ureteral integrity without any leakage in 66% (12/18) patients, indicated ureteral stenosis in 22% (4/18) patients, and indicated ureteral leakage in 12% (2/18) patients. The overall long-term success rate for all 18 patients was 78% (14/18) at a mean follow-up of 26.5 months. Conclusions: The endoscopic rendezvous procedure reduces the need for invasive open surgical repair and represents the optimal initial option in patients with iatrogenic ureteral lesions before invasive procedures with higher morbidity are attempted. Introduction
I
atrogenic injury to the urinary tract during pelvic and retroperitoneal surgery most commonly involves the ureter, followed by the bladder and urethra.1 Injury to the ureter is the most common urologic complication of pelvic surgery, with an incidence that ranges from 1% to 10%.1 Studies have indicated that the risk of urinary tract injury is higher in patients who have previously undergone pelvic surgery and in patients with extensive neoplasms that cause distortion of normal anatomic structures.2,3 Most of the cases of ureteral injury are related to gynecologic procedures. The ureter is particularly vulnerable to detachment or ligation during hysterectomy because of its position from the lateral edge of the cervix. The reported incidence of ureteral injuries during laparoscopic hysterectomy ranges from 0.4% to 2.5%4; moreover, the incidence of ureteral injuries for vaginal hysterectomy is reportedly 0.2
injuries per 1000 cases and that for total abdominal hysterectomy is reportedly 1.3 injuries per 1000 cases.5 The other surgical procedures that account for iatrogenic ureteral injuries include pelvic surgeries for colon and rectal pathology. Colon and rectal procedures, such as low anterior resection and abdominal perineal resection, are responsible for 9% of all cases of ureteral injury.1 Although ureteral injuries are commonly identified and managed at the time of injury, many lesions are not recognized intraoperatively, and hence necessitate delayed repair. These injuries have been traditionally repaired through standard open surgery, but are currently repaired through the laparoscopic or robotic approach.6 As reported in the literature, a minimally invasive endoscopic approach is feasible for the management of ureteral iatrogenic injuries.7,8 An integrated management approach involving a radiologist and urologist can successfully be used to treat ureteral iatrogenic detachment through a minimally
Department of Medico-Surgical Sciences and Biotechnologies, Urology Unit, ICOT, Faculty of Pharmacy and Medicine, Sapienza University of Rome, Latina, Italy.
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invasive (radiology–guided endoscopic procedure) radioendoscopic intervention, which is known as a ‘‘ureteral rendezvous.’’ In the present report, we describe our experience with the rendezvous technique in 18 women who had been referred to our institution with complete ureteral detachment after gynecologic surgery.
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Patients and Methods
Between January 2009 and April 2013, 18 women (mean age, 47.6 – 9.7 years; range, 30–66 years; body mass index, 26.4 – 3.4 kg/m2) were referred to our department with iatrogenic ureteral detachment. The ureteral injuries were secondary to gynecologic surgery in all cases: Vaginal hysterectomy in 2, laparoscopic transperitoneal hysterectomy in 12, and open abdominal hysterectomy in 4 patients. Injuries were noted on the left side in 11 patients and right side in 7 patients. Moreover, injuries were noted on the lower third of the ureter in 16 patients, on the middle third of the ureter in 1 patient, and on the upper third of the ureter in 1 patient. The time from the original surgery to the diagnosis of ureteral injury ranged from 3 days to 52 days (mean, 13.6 – 12.2 days). In most cases, the initial management consisted of the placement of a percutaneous nephrostomy tube, which enabled the alleviation of postsurgical/infective inflammation, before the rendezvous procedure was attempted. In such cases, the clinical diagnosis is always supported by imaging findings, and therefore, CT urography (CTU) or intravenous urography CT is the most useful tool. Extravasation of contrast medium represents the hallmark sign of ureteral injury and indicates the site and length of the injury; in certain cases, the injury eventually results in an urinoma, which can also be detected. Only three patients reported abnormally increased levels of blood urea and creatinine. In the present report, we have provided a detailed description of these three most representative cases to illustrate the typical presentation and diagnosis of an iatrogenic ureteral injury and the steps involved in the rendezvous technique. The clinical features of all patients are summarized in Table 1. Case 1
A 42-year-old Caucasian woman underwent laparoscopic hysterectomy for the treatment of early stage cervical cancer. On the third day after discharge, the patient experienced referred pain at the right flank and fever. After recovery in the emergency room, we detected a right ureteral iatrogenic lesion (length, 2.1 cm) at 4 cm from the bladder on CTU. Thereafter, the patient underwent the placement of a percutaneous nephrostomy tube, and a 0.035-inch J-shaped guidewire was left in situ to facilitate access to the ureteral lesion (Figs. 1A, B). Endoscopy was performed under fluoroscopic control using a 7.5F semirigid ureteroscope through the distal stump until the ureteral lesion was reached. We then retrieved the end of the guidewire via ureteroscopy with grasping forceps, and realigned the ureter with an 8F Double-J ureteral stent (Figs. 1C, D). The patient was discharged 2 days after the surgery. The nephrostomy tube was removed 5 days after the procedure, whereas the Double-J stent was left in the ureter for 3 months. Case 2
A 30-year-old Caucasian woman underwent hysterectomy for the treatment of infiltrative cervix uterine cancer. She was
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readmitted to the hospital 5 days after discharge because of fever, leucocytosis, and left flank pain. CT indicated complete left ureteral detachment at 6 cm from the bladder, and we performed the procedure involving positioning of the nephrostomy tube with J-shaped guidewire insertion, similar to Case 1. The 0.035-inch guidewire was placed through the proximal stump into the retroperitoneum. We then retrieved the end of the guidewire via ureteroscopy with grasping forceps, to realign the ureter with an 8F Double-J ureteral stent. Because of incorrect retrograde Double-J stent placement and its intussusception (Fig. 2A), we performed transnephrostomic Double-J stent placement in an antegrade manner and assessed for accurate positioning (Fig. 2B) with radiography. No complications were noted during the postoperative course, and the patient was discharged on the third day after the endoscopic procedure. Case 3
A 45-year-old woman who had undergone hysteroannessiectomy for the treatment of infiltrative uterine cancer experienced referred left flank pain and fever 7 days after discharge. CT scan indicated complete left iatrogenic detachment, including ureteral detachment at the crossing of the iliac vessels. Therefore, a percutaneous nephrostomy tube was placed and left in situ for 4 weeks, and no attempt was made for surgical or endoscopic repair. When the patient was referred to our department, we attempted to perform the ureteral rendezvous procedure, which failed because of the difficulty in locating the transnephrostomic guidewire that was previously placed in the retroperitoneal space. During the second attempt, we performed explorative retroperitoneoscopy using a 5-mm trocar, which was positioned in the left flank through a 1.5-cm incision made in the midaxillary line, 1 cm above the iliac crest. Ureteroscopy was then performed, and the guidewire was easily detected in the retroperitoneal space with the 30degree laparoscope. Finally, an 8F Double-J stent was successfully positioned. Results
Between January 2009 and April 2013, 18 minimally invasive rendezvous procedures were performed. None of the procedures needed conversion to an open procedure, and there were no intraoperative complications. The average operative time was 69.1 – 20.5 minutes. The average recovery time was 3.8 – 1.2 days. The nephrostomy tube was normally removed on the second day after endoscopic realignment; it was left in situ for a maximum of 5 days after endoscopic realignment. The Double-J ureteral stent was left in situ for a mean duration of 124.7 – 14.8 days. Renal ultrasonography was performed at 1, 3, 6, 12, and 24 months after surgery, which indicated the absence of hydronephrosis. CT was performed at the time of discharge and at 6 and 12 months after discharge, which confirmed the restored integrity of the ureter without any leakage in 66% (12/18) patients, indicated ureteral stricture in 22% (4/18) patients, and showed ureteral leakage in 12% (2/18) patients. Balloon dilatation and holmium:yttrium-aluminum-garnet laser endoureterotomy were successfully performed in all patients with ureteral strictures (the length of the strictures was 12, 16, 18, and 21 mm in the four patients, and the location was the pelvic tract in the first three patients and the middle third of the ureter in the other patient), and complete resolution was
417
42 30 45
32 61
36 45 46 48 51
54
57
58
66 46 49 52 39 47.6
1 2 3
4 5
6 7 8 9 10
11
12
13
14 15 16 17 18 Means
Case
21 24.7 25.8 31.3 30.6 26.4
22.9
23
25
29 29 33 27 24
24 27
26.4 19.6 29
Body Age mass index
Left
Left Left Left Right Right
Fever and leucocytosis Left flank pain Left flank pain Left flank pain Fever and leucocytosis
Right Left Left Left Left
Fever and leucocytosis Right
Fever and leucocytosis Left
Left flank pain
Left flank pain Fever and leucocytosis Fever and leucocytosis Fever and leucocytosis Right flank pain
Fever and leucocytosis Right Right flank pain Right
Right flank pain Right Fever and leucocytosis Left Left flank pain Left
Clinical onset
Side lesion
Lower Lower Lower Lower Lower
Lower
Lower
Lower
Lower Upper Lower Lower Lower
Lower Middle
Lower Lower Lower
6 7 13 11 4 13.6
52
21
33
4 3 5 6 18
9 11
5 15 22
52 51 61 53 48 69.16
113
89
82
67 40 45 60 77
85 70
65 82 105
6 5 4 4 3 4.3
8
4
5
5 6 3 3 5
4 5
2 3 4
127 129 113 108 125 124.7
123
121
143
116 122 112 128 155
139 140
120 90 135
Days from Intraoperative Hospital Time of stent Ureteral stay removal injury gynecologic time (days) (days) iatrogenic lesion (minutes) site
Table 1. Patient Demographic and Clinical-Surgery Data
Success Success Failure (12 mm ureteral stricture, successfully treated with endoureterotomy) Success Failure (16 mm ureteral stricture, successfully treated with endoureterotomy) Success Success Success Success Failure (18 mm ureteral stricture, successfully treated with endoureterotomy) Failure (urinary leakage, treated with laparoscopic ureteroneocystostomy) Failure (21 mm ureteral stricture, successfully treated with endoureterotomy) Failure (urinary leakage, treated with laparoscopic ureteroneocystostomy) Success Success Success Success Success
Success or failure of endoscopic rendezvous procedure
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FIG. 1. (A) Placement of the percutaneous nephrostomy tube; (B) low ureteral detachment on transnephrostomic urography; (C) ureteroscopic visualization of the guidewire in the retroperitoneal space; and (D) positioning of the 8F Double-J ( JJ) ureteral stent.
achieved in all patients at a mean follow-up duration of 24 months. In two patients, CT revealed urinary leakage after discharge, and laparoscopic ureteroneocystostomy according to the Lich-Gregoir reimplantation technique was performed.9 Long-term success was defined as the lack of the need for a surgical procedure and the complete restoration of ureteral patency at the end of the follow-up period. The overall longterm success rate for all 18 patients was 88% (16/18) at a mean follow-up duration of 26.5 months (range, 14–52 months). At the most recent follow-up, all patients were alive and asymptomatic. Discussion
Iatrogenic injury to the urinary tract during pelvic and retroperitoneal surgery most commonly involves the ureter, followed by the bladder and urethra.1 In total, 50% of cases of iatrogenic ureteral lesions are related to gynecologic surgical procedures. Only one-third of cases of iatrogenic ureteral lesions are detected during the procedure, however, and delayed diagnosis may lead to the progressive deterioration of renal function. Some authors recommend that the ureter be
FIG. 2. (A) Intussusception of the Double-J ( JJ) 8F ureteral stent; and (B) antegrade Double-J 8F ureteral stent placement.
protected before performing surgical procedures that are associated with a risk of ureteral injury, such as colectomy or hysterectomy.10,11 Therefore, prevention is clearly the best defense against ureteral trauma.11 The incidence of ureteral lesions varies between 0.1% and 30%, depending on the type of surgical intervention used and the skill and experience of the surgeon. Patient characteristics such as obesity, intraoperative bleeding, adhesions from previous surgery, and the presence of pelvic masses can increase the technical difficulty of the operation and distort urinary tract anatomy. In the study of Ha¨rkki-Sire´n and associates,2 at least one of these contributing factors was present in 35 of the 60 cases of ureteral injury. Bleeding was the most common factor (57%), followed by an enlarged uterus, endometriosis, adhesions, and obesity. An enlarged uterus was a common predisposing factor (24%) in the abdominal hysterectomy group, which emphasizes the need for extra care and uterine debulking before ligation or clamping of the uterine arteries. In more than 40% of all cases of ureteral injury, however, there are no identifiable predisposing factors, and a routine surgical procedure is performed. Ureteral injury in these cases is a reflection of the intrinsic risk of operating within the
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RENDEZVOUS FOR URETERAL DETACHMENT: CASE SERIES
pelvic region, where the urinary and genital tracts are very closely aligned. Gray and colleagues12 were the first to describe a technique of grasping a wire that had been placed cystoscopically through an obstructed distal ureteral segment; in this method, a guidewire was introduced via a percutaneous nephrostomy tube in an antegrade manner and was pulled back through the nephrostomy site, thus allowing the placement of a ureteral stent. The anterograde-retrograde endoscopic rendezvous procedure is a minimally invasive technique that enables the restoration of ureteral integrity, thus avoiding an invasive procedure.7 In some cases, this can be a challenging maneuver and necessitates an integrated radiourologic approach. The advantage of the rendezvous procedure includes its combined ureteroscopic/fluoroscopic approach, which makes it a relatively noninvasive procedure compared with major surgical repair.7,8 Thus, patients may be offered a long-term solution, instead of long-term nephrostomy treatment that may potentially result in complications and gradual renal deterioration, and may thus necessitate future nephrectomy. Our results suggested that complete ureteral detachment could be effectively restored using the aforementioned radioendoscopic approach. The technique yielded encouraging results with a short hospital stay (mean, 3.8 – 1.2 days) and no perioperative complications, thus avoiding the need for an open surgical procedure. Based on the reported outcomes, we believe that most of the patients with complete ureteral transection injuries should undergo endoscopic rendezvous realignment as a first option, as soon as possible. Although secondary ureteral strictures may develop in some patients after the rendezvous procedure, as observed in the present case series, the technique appears to prevent the complete ureteral obstruction associated with iatrogenic injuries. In case of failure of the procedure, open surgical repair can still be performed. Correct stent positioning is always considered necessary to ensure ureteral patency in the postintervention period.12–14 The reasons underlying stent use is to achieve ureteral healing, prevent urinary extravasation, and avoid or reduce the possibility of stricture relapse.14–16 The optimal stent size and removal time remain controversial, however. Stents of several sizes have been used after the endoscopic rendezvous procedure and range from 5F to 16F.14 It is unclear, however, whether larger stents might yield better results.14,16 Larger stents could mechanically compromise ureteral segment vascularization, with subsequent ischemic damage.13–16 In the patients in the present study, we consistently used the same hydrophilic Double-J stent with a diameter of 8F. We hypothesized that this size was optimal to reduce the risk of compromising ureteral vascularization, and this shape may facilitate ureteral healing. In our case series, stents were removed after a mean duration of 4 months (124.7 – 14.8 days) with an 88% long-term (follow-up duration, 26.5 months) success rate. The prolonged time of ureteral stent placement, in cases where the stent was left in situ for at least 4 months, may be one of the key causes of our overall high success rate. The other crucial cause of the high success rate may be the size of the stent, as mentioned above. These two factors may have promoted ureteral healing, thus leading to higher long-term success rates, as supported by other previous case series.7,8,10
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As observed in the third patient, it is necessary to identify these lesions as soon as possible to avoid retroperitoneal inflammation, which can lead to tissue imbibition and fibrosis, and to closure of the ureteral stumps. In the present case, a simple rendezvous maneuver was particularly difficult because of the rigidity of the ureteral stump and presence of inflamed tissue, which did not allow for endoscopic recognition of the transnephrostomic guidewire. In this case, however, contextual retroperitoneoscopy enabled integrated endoscopic and laparoscopic visualization, which was essential for identifying the ureteral stump. In the present case series, the endoscopic rendezvous realignment procedure had a high success rate. Its success was directly related to correct indications, however. The main factors that determine the indication of this minimally invasive technique are the time of diagnosis, patient status, site and type of injury, renal function, patient’s personal preferences, and surgeon’s personal skill and experience. The main limitations of this study are the small number of patients included and its retrospective nature. These limitations did not allow for a detailed statistical analysis. We included only a small number of patients in the present study because of the rarity of this iatrogenic injury. It will be unlikely that a larger group of patients can be enrolled, and that a randomized clinical trial comparing the various minimally invasive or major surgical approaches can be performed. Further case series would help to support our encouraging results, however. Conclusions
The rendezvous technique is an effective, combined radiologic and endourologic procedure that can be used to manage ureteral injuries in the early postoperative period in patients with appropriate indications. This minimally invasive maneuver can restore the continuity of the ureter and reduce the need for open surgical repair that is associated with higher morbidity. We believe that this procedure may represent the optimal initial solution in patients with iatrogenic ureteral lesions, before attempting invasive procedures. Acknowledgment
We would like to acknowledge the patients for their willingness to collaborate with the physicians. Disclosure Statement
No competing financial interests exist. References
1. St Lezin MA, Stoller ML. Surgical ureteral injuries. Urology 1991;38:497–506. 2. Ha¨rkki-Sire´n P, Sjo¨berg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol 1998;92:113–118. 3. Mteta KA, Mbwambo J, Mvungi M. Iatrogenic ureteric and bladder injuries in obstetric and gynaecologic surgeries. East Afr Med J 2006;83:79–85. 4. Ostrzenski A, Radolinski B, Ostrzenska KM. A review of laparoscopic ureteral injury in pelvic surgery. Obstet Gynecol Surv 2003;58:794–799. 5. Gilmour D, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol 2006;92:1366–1372.
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6. Delacroix SE Jr, Winters JC. Urinary tract injuries: Recognition and management. Clin Colon Rectal Surg 2010;23:221. 7. Macrı` A, Magno C, Certo A, et al. Combined antegrade and retrograde ureteral stenting: The rendezvous technique. Clin Radiol 2005;60:257–260. 8. Yates B, Mehta SS, Spencer PA, Parys BT. Combined antegrade and retrograde endoscopic retroperitoneal bypass of ureteric strictures: A modification of the ‘rendezvous’ procedure. BJU Int 2010;105:992–997. 9. Gregoir W. The surgical treatment of congenital vesicoureteral reflux. Acta Chir Belg 1964;63:431–439. 10. Liatsikos EN, Karnabatidis D, Katsanos K, et al. Ureteral injuries during gynaecologic surgery: Treatment with a minimally invasive approach. J Endourol 2006;20:1062–1067. 11. Chan JK, Morrow J, Manetta A. Prevention of ureteral injuries in gynecologic surgery. Am J Obstet Gynecol 2003;188: 1273–1277. 12. Gray RJ, Intriere L, Dolmatch BL, et al. Combined retrogradeantegrade ureteral stent passage: Salvage procedure for a ureteral leak. J Vasc Interv Radiol 1992;3:557–558. 13. Koukouras D, Petsas T, Liatsikos E, et al. Percutaneous minimally invasive management of iatrogenic ureteral injuries. J Endourol 2010;24:1921–1927. 14. Hwang TK, Yoon JY, Ahn JH, Park YH. Percutaneous endoscopic management of upper ureteral stricture size of stent. J Urol 1996;155:882–884.
15. Wolf JS Jr, Elashry OM, Clayman RV. Long-term results of endoureterotomy for benign ureteral and ureteroenteric strictures. J Urol 1997;158:759–764. 16. Moon YT, Kerbl K, Pearle MS, et al. Evaluation of optimal stent size after endourologic incision of ureteral strictures. J Endourol 1995;9:15–22.
Address correspondence to: Antonio Luigi Pastore, MD, PhD Department of Medico-Surgical Sciences and Biotechnologies Urology Unit, ICOT Faculty of Pharmacy and Medicine Sapienza University of Rome Via Franco Faggiana 1668 Latina 04100 Italy Email: [email protected]
Abbreviations Used CT ¼ computed tomography CTU ¼ computed tomography urography
DOI: 10.1089/end.2015.0009
Editorial Comment for Pastore et al. Constantino Leonardo, MD, PhD,1 Cosimo De Nunzio, MD, PhD,1 and Giuseppe Simone, MD, FEBU 2
astore and colleagues1 presented the outcomes of 18 consecutive patients undergoing endoscopic rendezvous for iatrogenic ureteral detachment secondary to pelvic surgery. The authors should be congratulated for collecting and reporting a significant series of patients with this rare complication (0.4%–2.5% after pelvic surgery). Iatrogenic injury to the ureter is a potentially devastating complication of modern surgery. The ureters are most often injured in gynecologic surgery as reported by the authors, although colorectal and vascular pelvic surgery injuries have been reported. There is also potential for considerable ureteral injury during endoscopic procedures for ureteral pathology such as tumor or lithiasis. As recently reported, distal ureteral injuries are best managed with ureteroneocystostomy with or without a vesicopsoas hitch; midureteral and proximal ureteral injuries
P
1 2
can potentially be managed with ureteroureterostomy. Laparoscopic and minimally invasive techniques have been also used to manage iatrogenic ureteral injuries.2 In this series, all patients were females, and the ureteral lesions were related to a previous hysterectomy and are located at 4 to 6 cm from the bladder. So far, the results obtained by the authors and their experience could be extended to patients with a different ureteral injury (i.e, male patients, distal or proximal ureteral damage, postendoscopic ureteral damage). Furthermore, although the 24 month success rate using this minimally invasive approach is acceptable, it is significantly lower when compared with patients treated with an ureterocystostomy. The risk of ureteral stenosis from an intensive fibrosis still remains an important issue after endoscopic rendezvous. It often necessitated further endoscopic or surgical
Department of Urology, ‘‘La Sapienza’’ University of Rome, Rome, Italy. Department of Urology, ‘‘San Giovanni Bosco’’ Hospital, Turin, Italy.
JOURNAL OF ENDOUROLOGY Volume 29, Number 4, April 2015 ª Mary Ann Liebert, Inc. Pp. 415–421 DOI: 10.1089/end.2014.0474
Endoscopic Rendezvous Procedure for Ureteral Iatrogenic Detachment: Report of a Case Series with Long-Term Outcomes Antonio Luigi Pastore, MD, PhD, Giovanni Palleschi, MD, PhD, Luigi Silvestri, MD, Antonino Leto, MD, Domenico Autieri, MD, Andrea Ripoli, MD, Cristina Maggioni, MD, Yazan Al Salhi, MD, and Antonio Carbone, MD
Abstract
Background and Purpose: Injury to the ureter is the most common urologic complication of pelvic surgery, with an incidence that ranges from 1% to 10%. Most cases of ureteral injuries are related to gynecologic procedures. The ureter is particularly vulnerable to detachment or ligation during hysterectomy because of its position from the lateral edge of the cervix. We report a case series of female patients who underwent the ureteral rendezvous procedure for ureteral detachment. Patients and Methods: Between January 2009 and April 2013, 18 ureteral rendezvous procedures were performed for patients with complete detachment. We assessed the operative and clinical outcomes of these patients over a mean follow-up duration of 26.5 months and describe the three most representative cases. Results: The endoscopic rendezvous technique was performed in all cases to manage ureteral detachment. CT urography at discharge and 6 and 12 months after discharge confirmed the restoration of ureteral integrity without any leakage in 66% (12/18) patients, indicated ureteral stenosis in 22% (4/18) patients, and indicated ureteral leakage in 12% (2/18) patients. The overall long-term success rate for all 18 patients was 78% (14/18) at a mean follow-up of 26.5 months. Conclusions: The endoscopic rendezvous procedure reduces the need for invasive open surgical repair and represents the optimal initial option in patients with iatrogenic ureteral lesions before invasive procedures with higher morbidity are attempted. Introduction
I
atrogenic injury to the urinary tract during pelvic and retroperitoneal surgery most commonly involves the ureter, followed by the bladder and urethra.1 Injury to the ureter is the most common urologic complication of pelvic surgery, with an incidence that ranges from 1% to 10%.1 Studies have indicated that the risk of urinary tract injury is higher in patients who have previously undergone pelvic surgery and in patients with extensive neoplasms that cause distortion of normal anatomic structures.2,3 Most of the cases of ureteral injury are related to gynecologic procedures. The ureter is particularly vulnerable to detachment or ligation during hysterectomy because of its position from the lateral edge of the cervix. The reported incidence of ureteral injuries during laparoscopic hysterectomy ranges from 0.4% to 2.5%4; moreover, the incidence of ureteral injuries for vaginal hysterectomy is reportedly 0.2
injuries per 1000 cases and that for total abdominal hysterectomy is reportedly 1.3 injuries per 1000 cases.5 The other surgical procedures that account for iatrogenic ureteral injuries include pelvic surgeries for colon and rectal pathology. Colon and rectal procedures, such as low anterior resection and abdominal perineal resection, are responsible for 9% of all cases of ureteral injury.1 Although ureteral injuries are commonly identified and managed at the time of injury, many lesions are not recognized intraoperatively, and hence necessitate delayed repair. These injuries have been traditionally repaired through standard open surgery, but are currently repaired through the laparoscopic or robotic approach.6 As reported in the literature, a minimally invasive endoscopic approach is feasible for the management of ureteral iatrogenic injuries.7,8 An integrated management approach involving a radiologist and urologist can successfully be used to treat ureteral iatrogenic detachment through a minimally
Department of Medico-Surgical Sciences and Biotechnologies, Urology Unit, ICOT, Faculty of Pharmacy and Medicine, Sapienza University of Rome, Latina, Italy.
415
416
invasive (radiology–guided endoscopic procedure) radioendoscopic intervention, which is known as a ‘‘ureteral rendezvous.’’ In the present report, we describe our experience with the rendezvous technique in 18 women who had been referred to our institution with complete ureteral detachment after gynecologic surgery.
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Patients and Methods
Between January 2009 and April 2013, 18 women (mean age, 47.6 – 9.7 years; range, 30–66 years; body mass index, 26.4 – 3.4 kg/m2) were referred to our department with iatrogenic ureteral detachment. The ureteral injuries were secondary to gynecologic surgery in all cases: Vaginal hysterectomy in 2, laparoscopic transperitoneal hysterectomy in 12, and open abdominal hysterectomy in 4 patients. Injuries were noted on the left side in 11 patients and right side in 7 patients. Moreover, injuries were noted on the lower third of the ureter in 16 patients, on the middle third of the ureter in 1 patient, and on the upper third of the ureter in 1 patient. The time from the original surgery to the diagnosis of ureteral injury ranged from 3 days to 52 days (mean, 13.6 – 12.2 days). In most cases, the initial management consisted of the placement of a percutaneous nephrostomy tube, which enabled the alleviation of postsurgical/infective inflammation, before the rendezvous procedure was attempted. In such cases, the clinical diagnosis is always supported by imaging findings, and therefore, CT urography (CTU) or intravenous urography CT is the most useful tool. Extravasation of contrast medium represents the hallmark sign of ureteral injury and indicates the site and length of the injury; in certain cases, the injury eventually results in an urinoma, which can also be detected. Only three patients reported abnormally increased levels of blood urea and creatinine. In the present report, we have provided a detailed description of these three most representative cases to illustrate the typical presentation and diagnosis of an iatrogenic ureteral injury and the steps involved in the rendezvous technique. The clinical features of all patients are summarized in Table 1. Case 1
A 42-year-old Caucasian woman underwent laparoscopic hysterectomy for the treatment of early stage cervical cancer. On the third day after discharge, the patient experienced referred pain at the right flank and fever. After recovery in the emergency room, we detected a right ureteral iatrogenic lesion (length, 2.1 cm) at 4 cm from the bladder on CTU. Thereafter, the patient underwent the placement of a percutaneous nephrostomy tube, and a 0.035-inch J-shaped guidewire was left in situ to facilitate access to the ureteral lesion (Figs. 1A, B). Endoscopy was performed under fluoroscopic control using a 7.5F semirigid ureteroscope through the distal stump until the ureteral lesion was reached. We then retrieved the end of the guidewire via ureteroscopy with grasping forceps, and realigned the ureter with an 8F Double-J ureteral stent (Figs. 1C, D). The patient was discharged 2 days after the surgery. The nephrostomy tube was removed 5 days after the procedure, whereas the Double-J stent was left in the ureter for 3 months. Case 2
A 30-year-old Caucasian woman underwent hysterectomy for the treatment of infiltrative cervix uterine cancer. She was
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readmitted to the hospital 5 days after discharge because of fever, leucocytosis, and left flank pain. CT indicated complete left ureteral detachment at 6 cm from the bladder, and we performed the procedure involving positioning of the nephrostomy tube with J-shaped guidewire insertion, similar to Case 1. The 0.035-inch guidewire was placed through the proximal stump into the retroperitoneum. We then retrieved the end of the guidewire via ureteroscopy with grasping forceps, to realign the ureter with an 8F Double-J ureteral stent. Because of incorrect retrograde Double-J stent placement and its intussusception (Fig. 2A), we performed transnephrostomic Double-J stent placement in an antegrade manner and assessed for accurate positioning (Fig. 2B) with radiography. No complications were noted during the postoperative course, and the patient was discharged on the third day after the endoscopic procedure. Case 3
A 45-year-old woman who had undergone hysteroannessiectomy for the treatment of infiltrative uterine cancer experienced referred left flank pain and fever 7 days after discharge. CT scan indicated complete left iatrogenic detachment, including ureteral detachment at the crossing of the iliac vessels. Therefore, a percutaneous nephrostomy tube was placed and left in situ for 4 weeks, and no attempt was made for surgical or endoscopic repair. When the patient was referred to our department, we attempted to perform the ureteral rendezvous procedure, which failed because of the difficulty in locating the transnephrostomic guidewire that was previously placed in the retroperitoneal space. During the second attempt, we performed explorative retroperitoneoscopy using a 5-mm trocar, which was positioned in the left flank through a 1.5-cm incision made in the midaxillary line, 1 cm above the iliac crest. Ureteroscopy was then performed, and the guidewire was easily detected in the retroperitoneal space with the 30degree laparoscope. Finally, an 8F Double-J stent was successfully positioned. Results
Between January 2009 and April 2013, 18 minimally invasive rendezvous procedures were performed. None of the procedures needed conversion to an open procedure, and there were no intraoperative complications. The average operative time was 69.1 – 20.5 minutes. The average recovery time was 3.8 – 1.2 days. The nephrostomy tube was normally removed on the second day after endoscopic realignment; it was left in situ for a maximum of 5 days after endoscopic realignment. The Double-J ureteral stent was left in situ for a mean duration of 124.7 – 14.8 days. Renal ultrasonography was performed at 1, 3, 6, 12, and 24 months after surgery, which indicated the absence of hydronephrosis. CT was performed at the time of discharge and at 6 and 12 months after discharge, which confirmed the restored integrity of the ureter without any leakage in 66% (12/18) patients, indicated ureteral stricture in 22% (4/18) patients, and showed ureteral leakage in 12% (2/18) patients. Balloon dilatation and holmium:yttrium-aluminum-garnet laser endoureterotomy were successfully performed in all patients with ureteral strictures (the length of the strictures was 12, 16, 18, and 21 mm in the four patients, and the location was the pelvic tract in the first three patients and the middle third of the ureter in the other patient), and complete resolution was
417
42 30 45
32 61
36 45 46 48 51
54
57
58
66 46 49 52 39 47.6
1 2 3
4 5
6 7 8 9 10
11
12
13
14 15 16 17 18 Means
Case
21 24.7 25.8 31.3 30.6 26.4
22.9
23
25
29 29 33 27 24
24 27
26.4 19.6 29
Body Age mass index
Left
Left Left Left Right Right
Fever and leucocytosis Left flank pain Left flank pain Left flank pain Fever and leucocytosis
Right Left Left Left Left
Fever and leucocytosis Right
Fever and leucocytosis Left
Left flank pain
Left flank pain Fever and leucocytosis Fever and leucocytosis Fever and leucocytosis Right flank pain
Fever and leucocytosis Right Right flank pain Right
Right flank pain Right Fever and leucocytosis Left Left flank pain Left
Clinical onset
Side lesion
Lower Lower Lower Lower Lower
Lower
Lower
Lower
Lower Upper Lower Lower Lower
Lower Middle
Lower Lower Lower
6 7 13 11 4 13.6
52
21
33
4 3 5 6 18
9 11
5 15 22
52 51 61 53 48 69.16
113
89
82
67 40 45 60 77
85 70
65 82 105
6 5 4 4 3 4.3
8
4
5
5 6 3 3 5
4 5
2 3 4
127 129 113 108 125 124.7
123
121
143
116 122 112 128 155
139 140
120 90 135
Days from Intraoperative Hospital Time of stent Ureteral stay removal injury gynecologic time (days) (days) iatrogenic lesion (minutes) site
Table 1. Patient Demographic and Clinical-Surgery Data
Success Success Failure (12 mm ureteral stricture, successfully treated with endoureterotomy) Success Failure (16 mm ureteral stricture, successfully treated with endoureterotomy) Success Success Success Success Failure (18 mm ureteral stricture, successfully treated with endoureterotomy) Failure (urinary leakage, treated with laparoscopic ureteroneocystostomy) Failure (21 mm ureteral stricture, successfully treated with endoureterotomy) Failure (urinary leakage, treated with laparoscopic ureteroneocystostomy) Success Success Success Success Success
Success or failure of endoscopic rendezvous procedure
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FIG. 1. (A) Placement of the percutaneous nephrostomy tube; (B) low ureteral detachment on transnephrostomic urography; (C) ureteroscopic visualization of the guidewire in the retroperitoneal space; and (D) positioning of the 8F Double-J ( JJ) ureteral stent.
achieved in all patients at a mean follow-up duration of 24 months. In two patients, CT revealed urinary leakage after discharge, and laparoscopic ureteroneocystostomy according to the Lich-Gregoir reimplantation technique was performed.9 Long-term success was defined as the lack of the need for a surgical procedure and the complete restoration of ureteral patency at the end of the follow-up period. The overall longterm success rate for all 18 patients was 88% (16/18) at a mean follow-up duration of 26.5 months (range, 14–52 months). At the most recent follow-up, all patients were alive and asymptomatic. Discussion
Iatrogenic injury to the urinary tract during pelvic and retroperitoneal surgery most commonly involves the ureter, followed by the bladder and urethra.1 In total, 50% of cases of iatrogenic ureteral lesions are related to gynecologic surgical procedures. Only one-third of cases of iatrogenic ureteral lesions are detected during the procedure, however, and delayed diagnosis may lead to the progressive deterioration of renal function. Some authors recommend that the ureter be
FIG. 2. (A) Intussusception of the Double-J ( JJ) 8F ureteral stent; and (B) antegrade Double-J 8F ureteral stent placement.
protected before performing surgical procedures that are associated with a risk of ureteral injury, such as colectomy or hysterectomy.10,11 Therefore, prevention is clearly the best defense against ureteral trauma.11 The incidence of ureteral lesions varies between 0.1% and 30%, depending on the type of surgical intervention used and the skill and experience of the surgeon. Patient characteristics such as obesity, intraoperative bleeding, adhesions from previous surgery, and the presence of pelvic masses can increase the technical difficulty of the operation and distort urinary tract anatomy. In the study of Ha¨rkki-Sire´n and associates,2 at least one of these contributing factors was present in 35 of the 60 cases of ureteral injury. Bleeding was the most common factor (57%), followed by an enlarged uterus, endometriosis, adhesions, and obesity. An enlarged uterus was a common predisposing factor (24%) in the abdominal hysterectomy group, which emphasizes the need for extra care and uterine debulking before ligation or clamping of the uterine arteries. In more than 40% of all cases of ureteral injury, however, there are no identifiable predisposing factors, and a routine surgical procedure is performed. Ureteral injury in these cases is a reflection of the intrinsic risk of operating within the
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RENDEZVOUS FOR URETERAL DETACHMENT: CASE SERIES
pelvic region, where the urinary and genital tracts are very closely aligned. Gray and colleagues12 were the first to describe a technique of grasping a wire that had been placed cystoscopically through an obstructed distal ureteral segment; in this method, a guidewire was introduced via a percutaneous nephrostomy tube in an antegrade manner and was pulled back through the nephrostomy site, thus allowing the placement of a ureteral stent. The anterograde-retrograde endoscopic rendezvous procedure is a minimally invasive technique that enables the restoration of ureteral integrity, thus avoiding an invasive procedure.7 In some cases, this can be a challenging maneuver and necessitates an integrated radiourologic approach. The advantage of the rendezvous procedure includes its combined ureteroscopic/fluoroscopic approach, which makes it a relatively noninvasive procedure compared with major surgical repair.7,8 Thus, patients may be offered a long-term solution, instead of long-term nephrostomy treatment that may potentially result in complications and gradual renal deterioration, and may thus necessitate future nephrectomy. Our results suggested that complete ureteral detachment could be effectively restored using the aforementioned radioendoscopic approach. The technique yielded encouraging results with a short hospital stay (mean, 3.8 – 1.2 days) and no perioperative complications, thus avoiding the need for an open surgical procedure. Based on the reported outcomes, we believe that most of the patients with complete ureteral transection injuries should undergo endoscopic rendezvous realignment as a first option, as soon as possible. Although secondary ureteral strictures may develop in some patients after the rendezvous procedure, as observed in the present case series, the technique appears to prevent the complete ureteral obstruction associated with iatrogenic injuries. In case of failure of the procedure, open surgical repair can still be performed. Correct stent positioning is always considered necessary to ensure ureteral patency in the postintervention period.12–14 The reasons underlying stent use is to achieve ureteral healing, prevent urinary extravasation, and avoid or reduce the possibility of stricture relapse.14–16 The optimal stent size and removal time remain controversial, however. Stents of several sizes have been used after the endoscopic rendezvous procedure and range from 5F to 16F.14 It is unclear, however, whether larger stents might yield better results.14,16 Larger stents could mechanically compromise ureteral segment vascularization, with subsequent ischemic damage.13–16 In the patients in the present study, we consistently used the same hydrophilic Double-J stent with a diameter of 8F. We hypothesized that this size was optimal to reduce the risk of compromising ureteral vascularization, and this shape may facilitate ureteral healing. In our case series, stents were removed after a mean duration of 4 months (124.7 – 14.8 days) with an 88% long-term (follow-up duration, 26.5 months) success rate. The prolonged time of ureteral stent placement, in cases where the stent was left in situ for at least 4 months, may be one of the key causes of our overall high success rate. The other crucial cause of the high success rate may be the size of the stent, as mentioned above. These two factors may have promoted ureteral healing, thus leading to higher long-term success rates, as supported by other previous case series.7,8,10
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As observed in the third patient, it is necessary to identify these lesions as soon as possible to avoid retroperitoneal inflammation, which can lead to tissue imbibition and fibrosis, and to closure of the ureteral stumps. In the present case, a simple rendezvous maneuver was particularly difficult because of the rigidity of the ureteral stump and presence of inflamed tissue, which did not allow for endoscopic recognition of the transnephrostomic guidewire. In this case, however, contextual retroperitoneoscopy enabled integrated endoscopic and laparoscopic visualization, which was essential for identifying the ureteral stump. In the present case series, the endoscopic rendezvous realignment procedure had a high success rate. Its success was directly related to correct indications, however. The main factors that determine the indication of this minimally invasive technique are the time of diagnosis, patient status, site and type of injury, renal function, patient’s personal preferences, and surgeon’s personal skill and experience. The main limitations of this study are the small number of patients included and its retrospective nature. These limitations did not allow for a detailed statistical analysis. We included only a small number of patients in the present study because of the rarity of this iatrogenic injury. It will be unlikely that a larger group of patients can be enrolled, and that a randomized clinical trial comparing the various minimally invasive or major surgical approaches can be performed. Further case series would help to support our encouraging results, however. Conclusions
The rendezvous technique is an effective, combined radiologic and endourologic procedure that can be used to manage ureteral injuries in the early postoperative period in patients with appropriate indications. This minimally invasive maneuver can restore the continuity of the ureter and reduce the need for open surgical repair that is associated with higher morbidity. We believe that this procedure may represent the optimal initial solution in patients with iatrogenic ureteral lesions, before attempting invasive procedures. Acknowledgment
We would like to acknowledge the patients for their willingness to collaborate with the physicians. Disclosure Statement
No competing financial interests exist. References
1. St Lezin MA, Stoller ML. Surgical ureteral injuries. Urology 1991;38:497–506. 2. Ha¨rkki-Sire´n P, Sjo¨berg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol 1998;92:113–118. 3. Mteta KA, Mbwambo J, Mvungi M. Iatrogenic ureteric and bladder injuries in obstetric and gynaecologic surgeries. East Afr Med J 2006;83:79–85. 4. Ostrzenski A, Radolinski B, Ostrzenska KM. A review of laparoscopic ureteral injury in pelvic surgery. Obstet Gynecol Surv 2003;58:794–799. 5. Gilmour D, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol 2006;92:1366–1372.
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6. Delacroix SE Jr, Winters JC. Urinary tract injuries: Recognition and management. Clin Colon Rectal Surg 2010;23:221. 7. Macrı` A, Magno C, Certo A, et al. Combined antegrade and retrograde ureteral stenting: The rendezvous technique. Clin Radiol 2005;60:257–260. 8. Yates B, Mehta SS, Spencer PA, Parys BT. Combined antegrade and retrograde endoscopic retroperitoneal bypass of ureteric strictures: A modification of the ‘rendezvous’ procedure. BJU Int 2010;105:992–997. 9. Gregoir W. The surgical treatment of congenital vesicoureteral reflux. Acta Chir Belg 1964;63:431–439. 10. Liatsikos EN, Karnabatidis D, Katsanos K, et al. Ureteral injuries during gynaecologic surgery: Treatment with a minimally invasive approach. J Endourol 2006;20:1062–1067. 11. Chan JK, Morrow J, Manetta A. Prevention of ureteral injuries in gynecologic surgery. Am J Obstet Gynecol 2003;188: 1273–1277. 12. Gray RJ, Intriere L, Dolmatch BL, et al. Combined retrogradeantegrade ureteral stent passage: Salvage procedure for a ureteral leak. J Vasc Interv Radiol 1992;3:557–558. 13. Koukouras D, Petsas T, Liatsikos E, et al. Percutaneous minimally invasive management of iatrogenic ureteral injuries. J Endourol 2010;24:1921–1927. 14. Hwang TK, Yoon JY, Ahn JH, Park YH. Percutaneous endoscopic management of upper ureteral stricture size of stent. J Urol 1996;155:882–884.
15. Wolf JS Jr, Elashry OM, Clayman RV. Long-term results of endoureterotomy for benign ureteral and ureteroenteric strictures. J Urol 1997;158:759–764. 16. Moon YT, Kerbl K, Pearle MS, et al. Evaluation of optimal stent size after endourologic incision of ureteral strictures. J Endourol 1995;9:15–22.
Address correspondence to: Antonio Luigi Pastore, MD, PhD Department of Medico-Surgical Sciences and Biotechnologies Urology Unit, ICOT Faculty of Pharmacy and Medicine Sapienza University of Rome Via Franco Faggiana 1668 Latina 04100 Italy Email: [email protected]
Abbreviations Used CT ¼ computed tomography CTU ¼ computed tomography urography
DOI: 10.1089/end.2015.0009
Editorial Comment for Pastore et al. Constantino Leonardo, MD, PhD,1 Cosimo De Nunzio, MD, PhD,1 and Giuseppe Simone, MD, FEBU 2
astore and colleagues1 presented the outcomes of 18 consecutive patients undergoing endoscopic rendezvous for iatrogenic ureteral detachment secondary to pelvic surgery. The authors should be congratulated for collecting and reporting a significant series of patients with this rare complication (0.4%–2.5% after pelvic surgery). Iatrogenic injury to the ureter is a potentially devastating complication of modern surgery. The ureters are most often injured in gynecologic surgery as reported by the authors, although colorectal and vascular pelvic surgery injuries have been reported. There is also potential for considerable ureteral injury during endoscopic procedures for ureteral pathology such as tumor or lithiasis. As recently reported, distal ureteral injuries are best managed with ureteroneocystostomy with or without a vesicopsoas hitch; midureteral and proximal ureteral injuries
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1 2
can potentially be managed with ureteroureterostomy. Laparoscopic and minimally invasive techniques have been also used to manage iatrogenic ureteral injuries.2 In this series, all patients were females, and the ureteral lesions were related to a previous hysterectomy and are located at 4 to 6 cm from the bladder. So far, the results obtained by the authors and their experience could be extended to patients with a different ureteral injury (i.e, male patients, distal or proximal ureteral damage, postendoscopic ureteral damage). Furthermore, although the 24 month success rate using this minimally invasive approach is acceptable, it is significantly lower when compared with patients treated with an ureterocystostomy. The risk of ureteral stenosis from an intensive fibrosis still remains an important issue after endoscopic rendezvous. It often necessitated further endoscopic or surgical
Department of Urology, ‘‘La Sapienza’’ University of Rome, Rome, Italy. Department of Urology, ‘‘San Giovanni Bosco’’ Hospital, Turin, Italy.
