Ureteral Injury During Gynecologic Surgery Treatment & Management

No specific medical therapy is warranted for ureteral injury per se; however, potential complications of ureteral injury (ie, infection, kidney failure) should be treated medically.

Depending on the type, duration, and location of the ureteral injury, surgical treatment may range from simple removal of a ligature to ureteroneocystostomy or more complex reconstructive procedures. Surgical treatments for ureteral injury are as follows:

• Simple removal of a ligature
• Ureteral stenting
• Ureteroneocystostomy
• Ureteral resection and ureteroureterostomy
• Transureteroureterostomy

Other less commonly performed procedures include kidney autotransplant or bowel interposition (ileal ureter). Timing of the surgical repair is variable and dependent on etiology and type of injury, patient factors (eg, sepsis), and time to injury recognition.

Observation

If a clamp or ligature constricting the ureter is discovered, the clamp or ligature should be removed immediately, and the ureter should be examined. If ureteral peristalsis is preserved and damage is thought to be minimal, the ureteral injury may be managed with observation.

Ureteral stenting with or without ureterotomy

If tissue ischemia or a partial transection of the ureteral wall is suspected, a ureteral stent should be placed. The purpose of the stent, which is typically placed cystoscopically, is to act as a structural backbone onto which the healing ureter may mold. It improves drainage of urine from the renal pelvis directly into the urinary bladder and may act as a gentle dilator since it moves slightly in an up-and-down motion, associated with breathing, as the renal unit moves. The use of the stent is thought to minimize the rate of obstruction due to ureteral stricture in the injured area.

Choi et al reported on ureteroscopic double-J (DJ) ureteral stenting in 11 consecutive patients with distal ureteral injuries after gynecologic surgery.  Although stents were successfully inserted in all cases, five patients experienced ureteral stricture, which were treated with balloon dilatation or Holmium laser endoureterotomy. ^[10]

Alternatively, a ureterotomy may be made along the length of the injured or strictured section of ureter before placement of a stent. Davis described this technique in 1943 (the Davis intubated ureterotomy) in which a ureterotomy is made and left open over the stent. ^[11] The ureter eventually heals to form a watertight closure over the stent. The stent is withdrawn 6 weeks after it is placed, as it is estimated that all ureteral healing has occurred by that time. ^[12]

The principles of the Davis intubated ureterotomy have been extended to endoscopic treatments of ureteral strictures. Ureteroscopic endoureterotomy and Acucise endoureterotomy are two modalities that are used to attempt to treat the segment of strictured ureter endoscopically by a longitudinal full-thickness ureteral incision, followed by a stent placement. The success of these procedures closely resembles the success of the open Davis intubated ureterotomy, which approaches 80% patency at 3 years. ^[13]

Ureteroneocystostomy

If the ureteral injury occurred below the pelvic brim, where visualization of the ureter is difficult and where the vesical pedicles overlie the ureter, ureteroureterostomy is often too difficult to perform or may compromise the ureteral blood supply. In these cases, ureteroneocystostomy is indicated, with or without a psoas hitch.  If the injury to the ureter has occurred above the pelvic brim a Boari flap further mobilizes the bladder to bridge the ureteral defect and reach the proximal ureter to allow for a tension-free anastomosis. Boari flaps are contraindicated in patients with prior pelvic radiation, reduced bladder capacity, a history of bladder cancer, or any condition that results in a thick, hypertrophied bladder wall.

Ureteral resection and ureteroureterostomy

If the ureter has extensive ischemia or necrosis, it is best treated by excising the injured segment of the ureter and reestablishing continuity with the urinary system. If the ureteral injury occurred above the pelvic brim, the simplest reconstruction is a ureteroureterostomy, a procedure that is indicated for injuries to short segments of the ureter (< 2 cm), in which an anastomosis is performed between the 2 cut edges of the ureter. ^[14]

Transureteroureterostomy

Transureteroureterostomy is an uncommonly performed procedure. However, if ureteroureterostomy cannot be performed technically and the defect is too proximal in the ureter for ureteroneocystostomy, transureteroureterostomy may be performed. ^[14] Absolute contraindications to transureteroureterostomy include the following:

• Urothelial cancer
• Contralateral reflux
• Prior pelvic irradiation
• Retroperitoneal fibrosis
• Chronic pyelonephritis

Stone disease, which was once considered an absolute contraindication, is now considered a relative contraindication by some urologists, based on the current ability to prevent stone formation with medical therapy in over 90% of patients.

Autotransplant and ileal ureter

These procedures are uncommonly performed but may be alternative when the ureteral injury or defect is too proximal or too large for other types of procedures.  

If consultation with a urologist is indicated intraoperatively, the urologist dictates no specific preoperative preparation.

If a ureteral injury is identified after the patient is stabilized following the initial gynecologic operation, a discussion is conducted regarding the possible treatment options. Preoperative antibiotics that target urinary organisms should be administered. If patients are persistently febrile secondary to a potentially infected and obstructed renal unit, percutaneous nephrostomy on the affected side may be indicated. Pertinent radiographic studies (eg, intravenous urography, computed tomography) may be used to help define the location of ureteral injury preoperatively.

Ureteral stent placement with or without ureterotomy

After the perineum is prepared and draped in the standard sterile manner and the patient is sedated adequately or anesthetized, a cystoscope is inserted into the bladder.

After the bladder is examined and the ureteral orifices are identified, the ureteral orifice on the side of the injury is cannulated with a ureteral catheter. A dilute Cystografin or diatrizoate-gentamicin mixture is injected slowly through the ureteral catheter under fluoroscopy, revealing the course of the ureter and identifying potential sites of injury.

A guidewire is placed under fluoroscopic guidance through the ureteral catheter and up the ureter into the renal pelvis. A double-J stent is placed over the wire and is pushed so that its proximal J-hook is placed within the renal pelvis and its distal J-hook is within the bladder. Then, the wire is pulled, and the stent position is reaffirmed fluoroscopically.

Proper length of the stent can be estimated from the measured length of the ureter on retrograde pyelography from the ureteral orifice to the ureteropelvic junction. Allowing for roughly 10% magnification from the radiograph, subtract 2-3 cm and select that length ureteral stent. If, after placement, the stent is not well positioned because of inadequate or surplus length, it is best to replace it with a stent of proper dimensions.

Barrett et al describe an intraoperative radiographic technique for measuring ureteral length that led to selection of stents of appropriate length in 23 of 25 cases (92%). In this technique, a radiographic nipple marker is affixed to the skin over the ureteral orifice (UO) and an angiographic catheter with radiopaque markings at 1 cm intervals is used to measure the distance from the ureteropelvic junction to the marker at the UO. ^[15]

If an endoscopic ureterotomy is to be made, prior to placing the stent, retrograde pyelography is performed (as discussed above) to delineate the ureteral anatomy, and a guidewire, acting as a safety wire, is positioned into the renal pelvis and out through the urethra.

With ureteroscopic endoureterotomy, a flexible or semi-rigid ureteroscope is then placed through the ureteral orifice and into the ureter lumen until the ureteral lesion can be visualized. The ureteral stricture is then cut.  A number of cutting modalities have been described, including holmium or thulium laser. A full-thickness incision through the ureteral wall is made until periureteral fat is visualized. In the proximal ureter an incision is made laterally or posterolateral, and for strictures in the distal ureter the incison is made medial to posteriomedial. Retrograde pyelography is performed; extravasation of contrast outside the ureter should be seen. A wide-caliber ureteral stent (usually 8F) is then placed, in the fashion described above.

If Acucise endoureterotomy is performed, the Acucise device is placed over the safety wire. Once position is confirmed via fluoroscopic guidance and the orientation of the cut is set, the Acucise balloon is inflated and electrocautery is instituted. The Acucise device is withdrawn, retrograde pyelography is performed to confirm extravasation, and a wide-caliber ureteral stent is placed in the fashion described above.

The formal Davis intubated ureterotomy is typically performed intraoperatively only when consultation with a urologist is called for while the patient is open. In this case, the injured ureter is cut sharply in a longitudinal fashion. A stent then can be placed to the kidney and bladder through the ureteral incision.

Ureteroneocystostomy

A Foley catheter is placed and the patient is prepared and draped in a sterile manner. Various incisions are acceptable, including a midline, a Pfannenstiel, or a suprapubic V-shaped incision. A midline incision is preferred if the patient has a pre-existing midline scar from a gynecologic operation. If entering the peritoneal cavity can be avoided, this is preferred.

The peritoneal reflection is dissected off the bladder. Some urologists advocate saline instillation in the subperitoneal connective tissue as a way of facilitating this portion of the dissection. If a peritoneal defect is encountered, it can be closed with a running chromic suture. Once the peritoneum is dissected off the bladder, the peritoneum can be reflected medially.

Attention is then turned to dissection and excision of the diseased ureteral segment. The diseased portion of the ureter is identified, and a clamp is placed on the ureter proximal to it. The diseased portion of ureter is excised, a stay stitch is placed on the proximal segment of the ureter, and the distal stump is ligated.

To gain mobility, the superior pedicle of the bladder can be ligated on the ipsilateral side.  It is important to note, however, that if a Boari flap is planned, the bladder should not be devascularized. The bladder wall is incised transversely, a little more than halfway around the bladder, in an oblique manner across the middle of its anterior wall at the level of its maximum diameter. When this horizontal incision is closed vertically, the effect of the incision is the elongation of the anterior wall of the bladder so that the apex of the bladder can be positioned and fixed to the psoas muscle above the iliac vessels.

After the bladder incision is made, 2 fingers are placed into the bladder to elevate it to the level of the proximal end of the ureter. If the bladder does not reach the proximal ureter, several steps can be performed for additional length. These steps include extending the bladder wall incision laterally to obtain further length, or the peritoneum and connective tissue from the pelvic and lateral walls may be dissected from the contralateral side of the bladder. This dissection may require ligation and division of the superior vesical pedicle on the contralateral side.

With the bladder open, attention is turned to the ureteral reimplant. An incision is made in the bladder mucosa at the proposed site of the new ureteral orifice. A submucosal dissection occurs approximately 3 cm from the incision site so that a tunnel is created. Metz scissors may be used to facilitate this dissection. After achieving a 3-cm tunnel length, the scissors are inverted and the tips are pushed through the bladder wall. An 8F feeding tube is passed over the scissor blades, and the stay suture on the proximal tip of the ureter is tied to the other end of the catheter so that traction on the catheter draws the ureter into the bladder. The ureteral tip is trimmed obliquely, and 4-6 absorbable sutures (4-0) are used to fix the ureter to the bladder mucosa. The ureteral adventitia is tacked to the extravesical bladder wall with several 4-0 absorbable sutures. A double-J ureteral stent may be placed at this time.

A non-tunneled or refluxing reimplant is also an acceptable choice in most adults. The end of the ureter can be reflected back after a small longitudinal incision is made from the tip proximally about 1.5 cm. This will make the end of the ureter into a non-refluxing nipple, which is useful when there is inadequate length for an anti-refluxing submucosal tunnel.

The bladder is closed with a 3-0 running absorbable suture on the mucosa and a running 2-0 suture incorporating the bladder muscle and adventitial layers. The bladder should be drained with a urethral and/or suprapubic catheter. A surgical drain is placed in the pelvis next to the bladder closure. The anterior abdominal fascia and the skin then are closed.

If there if tenson on the ureteral-bladder anastomosis, the surgeon should consider a psoas hitch and/or Boari flap, as described below.

Psoas hitch

If a psoas hitch is required, once adequate mobilization of the bladder has occurred, the bladder is held against the tendinous portion of the psoas minor muscle without tension. Permanent sutures (Prolene or silk) (2-0) are sutured into the bladder wall and to the psoas tendon to fix the bladder in place. Care is taken to ensure the sutures do not enter the lumen of the bladder and to avoid including the genitofemoral nerve as it pierces the psoas muscle. Then the ureteral reimplant is performed as described above.

Boari flap

Once  the proximal extent of ureteral injury is determined, the necessary length of the bladder flap (ie, the distance between the posterior wall of the bladder and the end of the healthy proximal ureter) is measured with umbilical tape, the bladder is filled half full with saline, and the length and shape of the bladder flap are planned. To measure accurately on the dome of the bladder, several stay stitches are placed at the base of the proposed bladder flap and at the apex. The bladder flap should be planned with a large base, because the base will contain the blood supply for the flap. The length of the bladder flap (ie, the distance between the base and apex) should equal the distance between the posterior wall of the bladder and the end of the healthy proximal ureter. The width of the apex should be at least 3 times the diameter of the ureter to prevent constriction after the flap is tubularized. Avoid scarred areas of the bladder.

After proper planning, an outline of the flap is made in the bladder wall with coagulating current, and the bladder flap is remeasured. If the measurements are satisfactory, the bladder flap is cut via cutting current, and the concomitant bleeding vessels are coagulated. See the image below.

After the bladder flap is turned superiorly, Lahey scissors are used to prepare a ureteral tunnel. The tunnel should be at least 3 cm long and is created by placing the Lahey scissors submucosally at the apex of the flap, tunneling the appropriate distance, and coming out through the mucosa. Submucosal injection of saline may aid in this dissection. An 8F feeding tube is pulled through the tunnel by the scissors and the stay suture on the proximal ureter is tied to the feeding tube after the ureteral end is spatulated. The feeding tube is pulled toward the bladder, followed by the ureter. The stay suture is cut after the ureter has traveled completely through the tunnel.

The bladder flap is sutured to the psoas tendon of the psoas minor with a few 2-0 absorbable sutures. These sutures fix the flap in place to prevent tension on the ureteral anastomosis.

The ureter is anastomosed to the bladder mucosa with several 4-0 absorbable sutures. A few of the sutures should include the muscle layer of the bladder to fix the ureter into place. An 8F feeding tube is passed up the ureter into the renal pelvis and out through the bladder and body wall.

Laparoscopic or robotic approach

Robotic techniques have been developed to repair ureteral injuries. In a review of 43 cases of robot-assisted repair of injuries to the ureter or bladder that occurred during obstetric and gynecologic surgical procedures, Gellhaus et al concluded that robotic repair is associated with good outcomes, appears safe and feasible, and can be used immediately after injury recognition or as a salvage procedure after prior attempted repair. ^[16]

A ureteroneocystostomy can also be performed via the robotic approach. The patient is placed in the dorsal lithotomy position. A Foley catheter is placed within sterile field. After obtaining laparoscopic access, the patient is placed in Trendelenburg position. The trocar placement is similar to that of a laparoscopic/robotic prostatectomy. The colon is reflected medially by mobilizing along the white line of Toldt. After creating a peritoneal window, the surgeon identifies the ureter of interest. The ureter is mobilized proximally and distally. Care is taken not to de-vascularize the ureter while dissecting. A vessel loop can be placed around the ureter to aid in manipulation during dissection. After adequate mobilization, the ureter can be transected. The distal end is spatulated about 1.5 cm along the medial-posterior surface.

Intraoperative IV indocyanine green (ICG) (10 mL x 1 mg/1mL) may be used to assess ureteral blood supply. Shortly after administration, well-perfused tissue will glow green under the near-infrared (FireFly) robotic camera.

Distention of the bladder with about 180-200 mL of saline through the catheter can aid in dissection of the bladder from the anterior, posterior, and lateral aspects of the peritoneum. If needed, the contralateral superior and middle vesicle articles can be divided in order to provide more mobilization to ensure a tension-free anastomosis. If additional mobility is needed, a psoas hitch can also be performed laparoscopically/robotically. The authors find that performing a psoas hitch can aid in stabilization of the bladder while performing the ureteroneocystostomy anastomosis.

The bladder is then incised about 3 cm down to the bladder mucosa. The anastomosis is then started. The authors prefer to perform the anastomosis using two running 3.0 Vicryl sutures. Once one side is completed. A 6 Fr double-J stent is placed over a wire. The stent/wire combination can be introduced into the abdomen either through the assistant port or through a 14-gauge angiocatheter. The remainder of the anastomosis is completed.

The anastomosis is tested by backfilling the catheter with at least 250 mL of saline. A 19 Fr surgical drain is placed near the anastomosis. Hemostasis is confirmed and the trocars are removed.

Ureteroureterostomy

If the urologist is asked to evaluate the ureteral lesion during the gynecologic procedure, further dissection of the existing exposure is often necessary, because lack of exposure is the most likely contributor to the injury. Additional blunt and sharp dissection is often necessary to adequately identify the ureter and its course.

If the ureteral injury is discovered after the initial gynecologic procedure, the urologist must decide whether to enter through the original incision and approach the ureter transperitoneally or to make a new incision and approach the ureter using a retroperitoneal approach. Either approach is acceptable, and each has distinct advantages and disadvantages.

With entry through a previous midline incision, intraperitoneal adhesions may complicate the dissection; however, this approach spares the patient an additional incision.

In contrast, if a modified Gibson incision is made to approach the ureter retroperitoneally, the dissection may be less challenging technically because it avoids the adhesions of the peritoneal cavity, but the patient is left with an additional incision.

Regardless of the approach, a Foley catheter is placed and the patient is prepared and draped in a sterile manner.

In the transperitoneal approach, an incision is made though the scar of the old incision. The dissection is extended down to the peritoneal cavity, and, once the small bowel and colon are identified, a vertical incision is made along the left side of the small bowel mesentery. Blunt dissection is performed in the retroperitoneum until the desired ureter is identified. If the inferior mesenteric artery limits the exposure, it can be divided without consequence. If the left lower ureter is the area of the injury, the sigmoid can be mobilized medially to gain adequate exposure.

In the retroperitoneal approach, after the incision is made, the external oblique, internal oblique, and transversus abdominus muscles are dissected in a muscle-splitting manner. Once the transversalis fascia is incised, take care not to enter the peritoneal cavity. The peritoneum and its contents are retracted medially, and the ureter is located in its extraperitoneal position.

The ureter is most consistently found at the bifurcation of the common iliac artery, but it is often difficult to identify, especially when dilated. Steps that can differentiate the ureter from a blood vessel with a similar appearance include pinching the structure with forceps and watching for peristalsis. If peristalsis occurs, the ureter has been identified. Additionally, a fine needle can be placed into the lumen of the questionable structure. If urine is retrieved through aspiration, the ureter has been identified; if blood is aspirated, the structure is a blood vessel.

Once the ureter is identified and dissected from its surrounding tissues, the diseased segment is excised. Take particular care not to disrupt the adventitia of the ureter, because its blood supply is contained within this layer. If difficulty is encountered in identifying the diseased segment, retrograde ureteropyelography can be performed to aid in localizing the lesion. Another option is to place a ureteral catheter cystoscopically up to the lesion; the ureteral catheter can then be palpated during the ureteral dissection.

Stay sutures are placed in each end of the ureter, and the ureter is mobilized enough so that tension-free anastomosis can be performed. Simple ureteroureterostomy is typically performed for ureteral lesions shorter than 2 cm. If the lesion is longer than 2 cm, or if it appears that the ureteral ends will not come together without tension, seek an alternative surgical approach. One or more of the following options may be chosen:

• Further mobilization of the ureter
• Mobilization of the ipsilateral kidney
• Transureteroureterostomy
• Ureteroneocystostomy
• Ileal ureter interposition

Once the ureter appears to have enough length to be anastomosed without tension, both ureteral ends are spatulated. Two 5-0 absorbable sutures are placed in through the apex of the spatulated side of one ureter and out through the nonspatulated side of the opposite ureter. Each suture is tied, and a running stitch is performed on one half of the ureter. The same steps are performed to complete the anastomosis on the opposite half of the anastomosis.

Before completion of the second half, a double-J ureteral stent is placed by first placing a 0.038-cm Teflon-coated guide wire caudally and passing a standard 7F double-J stent over the wire. The wire is pulled after the position of the distal portion of the stent is confirmed within the bladder. Next, a small hole is made within the stent, such that the wire can be passed cephalad, placed into the proximal tip of the stent, and comes out of the created hole in the side of the stent. Once the position of the cephalad tip in the renal pelvis is confirmed, the wire is pulled, leaving a well-positioned stent.

After the anastomosis is completed, a Penrose drain or a Jackson-Pratt (JP) drain is placed in the retroperitoneum and is brought out through the skin. Omentum may be retrieved from a small incision in the posterior peritoneum and can be used to wrap the repair. Adjacent retroperitoneal fat may be used. The anterior abdominal fascia and skin are closed.

Transureteroureterostomy

A transureteroureterostomy is approached best via a midline incision and can be performed using both intraperitoneal and extraperitoneal approaches. A left-to-right intraperitoneal transureteroureterostomy is described.

After a Foley catheter is placed and the patient is prepared and draped in a sterile manner, a midline incision is made, and the peritoneal cavity is opened. The small bowel is packed medially, and the posterior peritoneum lateral to the sigmoid and descending colon is incised to expose the ureter. The ureter is dissected, preserving its adventitia. The diseased portion of the ureter is identified, and a clamp is placed on the ureter proximal to the diseased portion. The diseased portion of ureter is excised, a stay stitch is placed on the proximal segment of the ureter, and the distal stump is ligated. The proximal ureter is dissected for a length of approximately 9-12 cm, while the adventitial vessels are preserved.

Attention is then turned to exposing the right ureter. The ascending colon is retracted medially while an incision is made through the posterior peritoneum lateral to the colon. Blunt dissection aids in the identification of the ureter. Approximately 4-6 cm above the level of transection of the left ureter, the right ureter is exposed to make room for an anastomosis.

A retroperitoneal tunnel is created via blunt dissection, and the left ureter is pulled through the tunnel by the stay suture. When the left ureter is pulled through, taking care not to wedge the ureter between the inferior mesenteric artery (IMA) and the aorta is important, because obstruction may result. Instead, the ureter should be passed either over or under the IMA and should not be angulated or be under any tension. If the ureter is too short and a tension-free anastomosis can only be performed with the ureter firmly wedged between the IMA and the aorta, it is appropriate to consider ligation of the IMA. If this maneuver is not performed and the ureter is left firmly between the IMA and the aorta, a fibrous reaction of the ureter typically occurs, which causes obstruction that must be treated later with a surgical procedure.

The tip of the left ureter is spatulated, and the medial wall of the right ureter is incised using a hook blade for a distance just longer than the diameter of the lumen of the left ureter. Using 4-0 or 5-0 absorbable suture material, a suture is placed at each end of the ureteral incision from the outside in. Each stitch is run over the course of one half of the anastomosis. Before finishing the second side of the anastomosis, a stent is placed along the entire right ureter using the technique described in ureteral stent placement. The 2 stitches are tied to each other.

After the anastomosis is completed, a Penrose drain or a JP drain is placed in the retroperitoneum and is brought out through the skin. Omentum or any adjacent retroperitoneal fat may be used to wrap the repair. The anterior abdominal fascia and skin are closed.

Ureteral stent

After the patient has recovered from anesthesia and is in suitable condition, she may be discharged with instructions to return to the clinic in 14-21 days, when the stent will be removed. The patient is discharged with 3 days of antibiotics (eg, trimethoprim/sulfamethoxazole, nitrofurantoin, ciprofloxacin) and oral analgesics for potential bouts of discomfort from the stent.

Ureteroneocystostomy with or without psoas hitch or Boari flap, ureteroureterostomy, or transureteroureterostomy

Patients' diet may be advanced as determined by the preference of the surgeon. Generally, patients may be started on a clear liquid diet the night or day following surgery and the diet is advanced as tolerates and as dictated by by the return of bowel function.

Postoperative pain management is variable, depending on the type and length of incision. Patients may be managed with an epidural block placed intraoperatively, regional block (ie, transversus abdominis plane block), patient-controlled analgesia (PCA) pump postoperatively, or oral regimen. 

All patients receive a 24-hour course of intravenous antibiotics to prevent wound infections.

Patients are encouraged to ambulate on the first day after surgery. Once the pain is controlled with oral analgesics and patients are tolerating a regular diet, they are eligible for discharge, with or without their drains. If drains are not removed in the hospital, set appointments to assess patients and their drains in the clinic.

In patients who do not require a cystotomy, the Foley catheter or suprapubic tube is left to drain the bladder until the surgical drain output is less than 30 mL per day. If this is achieved, the Foley catheter can be removed or the suprapubic tube can be clamped, and the output from the surgical drain is monitored. If no drainage occurs, the drain can be removed. If drainage increases from the previous level, the Foley catheter is replaced, or the suprapubic tube is unclamped. 

In patients who require cystotomy, the surgical drain is removed once output has dropped below 30 mL/day or the fluid creatinine level is consistent with that of serum. The Foley catheter or suprapubic tube is left in place for 7-14 days after surgery, at which time cystography is usually performed. If no extravasation is observed during the cystogram, the Foley catheter or suprapubic tube can be removed. 

Ureteral stents are left in for 4-6 weeks post procedure to ensure healing of the ureter and can be removed with clinic cystoscopy.

Excess drainage

The most common postoperative complication is excess drainage from a surgically placed drain. This may indicate the presence of a significant urine leak, either at the ureteral anastomosis or at the bladder closure.

Often, if the peritoneum is not closed or is closed incompletely, peritoneal fluid leaks from the drain, which may confound the situation. Although intraoperative efforts are made to avoid this situation, if one needs to differentiate a urine leak from peritoneal fluid, the fluid may be tested for the creatinine level. If the creatinine level is significantly greater than the serum creatinine measurement, a urine leak is suspected. If the fluid creatinine level is identical to the serum creatinine measurement, the fluid is transudative in nature and is likely peritoneal fluid.

The treatment for most cases of excess drainage is observation. Most often, the drainage tapers with time as the ureteral or bladder wall heals and seals the urine from the drain.

Persistent, long-term output from drain occurs occasionally and implies obstruction either at or beyond the anastomotic site. The most common causes of obstruction include a lack of bladder decompression, stricture at the anastomotic site, or technical error.

Urinary tract infections

Urinary tract infections (UTIs) may occur immediately postoperatively, especially after the removal of an indwelling stent. UTIs are easily treated with oral antibiotics.

Ureteral obstruction or reflux

The most common complications of tunneled ureteroneocystostomy are ureteral obstruction or reflux.

Immediate postoperative obstruction can be a result of either edema of the ureter or technical errors (eg, constricting ureteral tunnel, ureteral angulation during fixation of the bladder). If obstruction occurs later in the postoperative course, a ureteral stricture must be considered. Ureteral strictures typically occur at the distal segment of the ureter and are most often due to ischemia. These strictures can be refractory to endoscopic management; when this is the case, repeat ureteroneocystostomy may be considered.

If the ureteral tunnel is too short, reflux can occur. Unless systemic adverse effects from the reflux occur (eg, recurrent bouts of pyelonephritis, worsening kidney function), reflux is typically managed conservatively with observation. Patients may note discomfort or pressure in the flank with voiding on the reimplanted side.

Boari flap complications

Complications specific to Boari flaps include ischemia of the flap, reduced lumen size of the flap secondary to thickened bladder wall, and reflux.

Because the blood supply of the Boari flap emanates from its base, the presence of any devascularization injury of the bladder base may cause flap ischemia and eventual necrosis.

The most common cause of flap ischemia is previous pelvic radiation; for this reason, Boari flaps are contraindicated in patients who have received radiation therapy.

Another possible cause of complications is that the bladder base created is too narrow, resulting in an inadequate blood supply to the distal end of the flap.

Yet another complication is that the bladder wall is too thick to form an adequate lumen for the implanted ureter. This situation should be assessed intraoperatively, and, if found, a Boari flap should not be performed.

Few recent studies have addressed the outcome and prognosis of ureteral injury, but older studies show that all of the surgical treatments mentioned are effective in treating ureteral injury.

Ureteral stents have been shown repeatedly to act as an excellent scaffolding mechanism when a partial ureteral distraction has occurred, with excellent long-term patency rates. In fact, the Davis intubated ureterotomy, which is the basis for current endourologic treatment of ureteral stricture disease, is aimed at incising a full-thickness portion of ureteral wall, followed by ureteral stent placement. As the ureter heals around the stent, the ureteral lumen is larger than the pretreated ureteral lumen.

In a study of initially unrecognized iatrogenic ureteral injury, Chung et al reported that retrograde ureteral stenting with a double-J stent was achieved in 21 of 25 patients (81%). Nephrostomy followed by alternative procedures was performed in the four patients in whom stenting failed. In the 21 patients with successful stenting, follow-up at a median of 9.7 months showed normal anatomy in 12 patients (57%) and stricture in six patients (28%), three of whom required surgical intervention. ^[17]

The urologic literature comprehensively documents the efficacy of ureteroureterostomy in the treatment of ureteral injury. Initial studies of ureteroureterostomy focused on the operative technique and asked what type of anastomosis was superior. End-to-end, side-to-side, end-to-side, spatulated, unspatulated, watertight, and loose approximation anastomoses were attempted. These efforts led to broad acceptance of spatulated watertight anastomoses, with or without stents, as the best ureteral reconstruction technique in terms of long-term outcome.

The literature also demonstrates the long-term efficacy of transureteroureterostomy. Hodges et al reported that, among 100 patients accrued over a 25-year period who had been treated with transureteroureterostomy for various conditions, including ureteral stricture and intraoperative ureteral injury, 77 patients had no complications postoperatively. Of the 23 patients with complications, 5 patients had acute pyelonephritis, 3 patients had tumor blockage at the anastomotic site, 2 patients had inferior mesenteric artery syndrome, and 2 patients had subsequent reflux involving the normal ureter. In this study, 97% of patients had normal bilateral kidneys after a follow-up period of 1-23 years. ^[18]

In a 1997 study by Mathews et al, the psoas hitch reimplantation was shown to be a successful technique for reestablishing ureteral continuity after distal ureteral injury. In their study of 20 patients who underwent psoas hitch reimplantation for various conditions, 13 patients had iatrogenic injuries during surgery, and 17 patients (85%) required no further intervention for urologic problems and retained normal kidney function after an average follow-up period of 6 years (range: 1-14 years). The authors conclude that psoas hitch reimplantation is an excellent treatment option for distal ureteral injuries. ^[19]

In 1975, Konigsberg et al reported on a series of patients; 15 of 21 patients studied had fair or excellent results for an average of 27 months after Boari flap reconstruction. Of the patients who had poor results, 2 patients had previous pelvic radiation, 2 patients had bladder carcinoma that recurred in the flap, and 2 patients had a flap that was not fixed to the psoas muscle. ^[20] With the benefit of modern indications for the use of Boari flaps, fewer poor results have occurred, although the risk of bladder necrosis remains elevated, given the dissection needed to create the flap. As a result of this risk and other technical considerations, many urologists opt for the psoas hitch reimplant as their first choice in ureteral reconstruction after a distal ureteral injury.

In a review of 65 women treated for morbidly adherent placenta, use of a surgical protocol that included rigid ureteral catheters, retrovesical dissection prior to hysterectomy and less invasive surgeries in selected patients resulted in a reduced frequency of ureteral injuries. ^[21]

The use of new technology may change the management of distal ureteral injuries entirely. With the introduction of subintestinal submucosa (SIS) to be used as a tissue scaffold, a new modality to treat ureteral injuries has emerged. While no current studies are being performed using SIS for the treatment of distal ureteral injuries, the placement of SIS may serve as a healing bridge between 2 injured ureteral ends. Although SIS will not drastically affect the management of short ureteral injuries or strictures, it may be useful in treating longer ureteral defects.

The rapid adoption of laparoscopic and robotic techniques over the past 2 decades by urologists and other surgical specialists, along with the increased use of ureteroscopy, has increased the risk of ureteral injury. However, in a study of 459 consecutive robotic gynecologic surgery cases, Jones et al reported that conversion to open surgery because of ureteral injury was required in only one case. ^[22]

New surgical techniques have also increased the need for new preventive techniques. ^{[23, 24]}  For example, lighted stents have been used to assist in identifying the location of the ureters during laparoscopic surgery to help prevent iatrogenic injury. If the lighted stents are not visible during laparoscopic surgery, four options are available, as follows:

• Reduce the intensity of the laparoscopic lighting. By dimming the lights, the light from the stent may become visible
• Change the camera to a different port
• Identify the ureter where it is visible and follow it down to the surgical field
• Convert to an open procedure so that the ureter can be palpated and identified