UROLOGICAL SURVEY   ( Download pdf )

 

RECONSTRUCTIVE UROLOGY

Laparoscopic ureteroneocystostomy and psoas hitch for post-hysterectomy ureterovaginal fistula
Modi P, Gupta R, Rizvi SJ
Department of Urology and Transplantation Surgery, Institute of Kidney Diseases and Research Centre, Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
J Urol. 2008; 180: 615-7

  • Purpose: We assessed the results of laparoscopic ureteroneocystostomy with a psoas hitch for iatrogenic lower ureteral injuries leading to a ureterovaginal fistula.
  • Materials and Methods: Between July 2003 and November 2007, 18 patients with iatrogenic lower ureteral injuries during hysterectomy leading to ureterovaginal fistula underwent laparoscopic ureteroneocystostomy with a psoas hitch. Of the patients 17 underwent abdominal or vaginal hysterectomy, while in 1 with a ruptured gravid uterus emergency hysterectomy was done for uncontrolled bleeding. Mean patient age was 35.5 years (range 23 to 45) and mean time to surgery since the injury was 2.2 months (range 1.5 to 3.5). Transperitoneal 3 or 4 port laparoscopic ureteroneocystostomy with a psoas hitch was performed.
  • Results: Of the procedures 17 were completed successfully. Intraoperative cardiac arrhythmia occurred in 1 patient due to pneumoperitoneum and hypercarbia, requiring open conversion. Mean operative time was 2.5 hours (range 1.9 to 2.8) hours, mean blood loss was 90 ml (range 45 to 150) and total hospital stay was 5.3 days (range 2.9 to 8). The nephrostomy tube was blocked on the table in all patients and it was removed on day 7. At an average followup of 26.4 months (range 3 to 52) postoperative excretory urography did not reveal obstruction in any patient. One patient had vesicoureteral reflux on voiding cystogram.
  • Conclusions: Laparoscopic ureteroneocystostomy with a psoas hitch for ureterovaginal fistula secondary to hysterectomy is safe and effective, and associated with a low incidence of postoperative reflux and obstruction.

  • Editorial Comment
    Using a minimally invasive approach, a laparoscopic ureter reimplantation in an anti-refluxive fashion, is a logical approach if a fistula occurs after a transvaginal hysterectomy. Mondi et al. presented 18 cases using a laparoscopic ureteroneocystostomy in a psoas hitch technique with a no-refluxing Lich-Gregoir only technique, which seems to be very convincing and is supported with the recent publication of Patill et al. (1,2).
    With the increased integration of laparoscopic surgery in our department, similar cases have been treated. From our recent experiences, we propose a modified approach: because of the fistula tissue we try to avoid any foreign material and comparatively use a clip at the distal ureter thermofusion to seal the ureter (3). Further, most commonly the fistula is not associated with an obstruction or even stricture of the ureter. A double-J-stent usually secures drainage of the kidney without the requirement of a nephrostomy tube. Only in those cases with a stricture a nephrostomy tube is required, which will be replaced intraoperatively while performing the ureteroneocystostomy into the bladder dome using a double-J-stent. After four weeks in particular, in women the double-J-stent can be removed without the need of anesthesia. In the context of mini-percutaneous nephrolithomy, we evaluated the patient’s preference and concluded that the double-J-stents causes less pain, its removal is less traumatic to the patient than a nephrostomy tube and also needs to stay in place even if it is only for a week (4).
    Overall we believe the laparoscopic approach to treat distal uretral fistulas or strictures are feasible. As the authors mentioned, the patient recovers faster. However, the laparoscopic approach with the implantation of the ureter into the ventral bladder wall - with a bigger distance to the former fistula location -, compared to the open procedure where the ureter is placed dorsally, needs to be evaluated over time and compared against the open procedure.

References
1. Modi P, Gupta R, Rizvi SJ: Laparoscopic ureteroneocystostomy and psoas hitch for post-hysterectomy ureterovaginal fistula. J Urol. 2008; 180: 615-7.
2. Patil NN, Mottrie A, Sundaram B, Patel VR: Robotic-assisted laparoscopic ureteral reimplantation with psoas hitch: a multi-institutional, multinational evaluation. Urology. 2008; 72: 47-50; discussion 50.
3. Nagele U, Merseburger AS, Horstmann M, Amend A, Schilling D, Kuczyk M, et al.: Thermofused bladder cuff resection in nephroureterectomy - a new approach, J Urol. 2008; 179: 346 (Abst# V1058).
4. Nagele U, Schilling D, Anastasiadis AG, Corvin S, Seibold J, Kuczyk M, et al.: Closing the tract of mini-percutaneous nephrolithotomy with gelatine matrix hemostatic sealant can replace nephrostomy tube placement. Urology. 2006; 68: 489-93; discussion 493-4.

Dr. Karl-Dietrich Sievert,
Dr. Udo Nagele & Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany
E-mail: arnulf.stenzl@med.uni-tuebingen.de