Lighted stents facilitate robotic-assisted laparoscopic ureterovaginal fistula repair

Three cases of ureterovaginal fistula (UVF) repair were reviewed in order to improve the minimally invasive surgical technique. We successfully repaired UVF robotically using five ports by placing a lighted ureteral stent preoperatively to assist with ureter identification and dissection. Placement of a lacrimal duct probe allowed fistula tract identification and obliteration. Preoperative surgical team planning is useful to avoid errors and delays. A multispecialty and an experienced robotic surgical team were paramount for the success of our robotic repair.     

A tertiary experience of vesico‐vaginal and urethro‐vaginal fistula repair: factors predicting success

OBJECTIVE

To review the outcomes of all patients referred with vesico‐vaginal (V VF) and urethro‐vaginal (UVF) fistulae to a tertiary centre, and to investigate the patient, fistula and surgical factors relevant to success.

PATIENTS AND METHODS

We reviewed retrospectively the case‐notes of 41 consecutive patients (32 with V VF; nine with UVF) treated between January 2000 and January 2006.

RESULTS

All patients were tertiary referrals, eight after failed local repairs. Four patients were unsalvageable and had a supravesical diversion. In all there were 47 repairs (23 transvaginal; 24 transabdominal) on 37 patients by two specialist surgeons. The fistula was closed in 92%; five V VF and one UVF required a second procedure, and one V VF a third procedure. One patient with a V VF awaits a second attempt at repair. In one V VF (one attempt) and one UVF (three attempts) the procedure failed and the patient had a diversion. A transvaginal approach cured all 11 patients with a V VF and eight of nine with a UVF, whilst an abdominal approach used for larger/complex fistulae was successful in 18 of 24 (75%) attempts (P = 0.13). The major determinants of success were fistula size (>3 cm; P = 0.02) and the availability of tissue for interposition. V VF repairs using Martius/omental interposition were mostly successful, whilst abdominal repairs in which omentum was unavailable tended to fail (37.5% cure; P = 0.002).

CONCLUSIONS

Despite varied aetiology, V VF/UVF were repaired successfully in 92% of patients. Complex (V VF) fistulae were challenging and a quarter of these required more than one attempt. Failure of repair was more likely in larger fistulae (>3 cm) requiring an abdominal approach, if omental interposition was not possible. Good‐quality tissue interposition for complex fistula is essential for a successful outcome.     

Martius flap and anterior vaginal wall sling for correction of urethrovaginal fistula (UVF) associated with stress urinary incontinence (SUI) after vaginal delivery

ObjectiveTo determine the efficacy, safety and urodynamic effects of the Martius flap and the anterior vaginal wall sling in treating post-birth trauma in the form of urethra-vaginal fistula (UVF) associated with stress urinary incontinence (SUI).Patients and methodsBetween July 2006 and August 2011, 19 patients underwent repair of UVF by interposition of a Martius flap and correction of associated SUI by a modified anterior vaginal wall sling. The procedure was carried out 3–17 (mean 7) months after post-birth trauma. Pre-operative evaluation consisted of history, voiding diary, physical examination, routine laboratory work-up, abdominopelvic ultrasonography, intravenous urography (IVU), and cystourethrography. The patients were followed up for a mean of 34 months. Follow-up included history, physical examination, urine analysis and pelvic ultrasonography for the assessment of residual urine. Urodynamic evaluation was performed at 3 months post-operatively.ResultsNone of the patients developed recurrence of UVF. SUI was corrected in 16 patients (84%). In the post-operative period, 3 patients (16%) complained of an overactive bladder (OAB) with urodynamic detrusor overactivity (DO) and an obstructed flow. These problems were managed successfully using anticholinergics and urethral dilation. Three patients (16%) complained of mild SUI, but refused further management. Within 3 years following the intervention, 3 patients complained of a recurrence of SUI which was managed successfully by a rectus sheath sling.ConclusionsPatients with a post-birth trauma in the form of UVF should be examined intra-operatively for the presence of associated SUI following correction of UVF. The use of the Martius flap and anterior vaginal wall sling in treating such patients is safe, efficient and reproducible. An anterior vaginal wall sling should be avoided in distal UVF to avoid recurrence of SUI.     

Vaginal vault fixation and prevention of enterocele recurrence by high midline levator myorraphy: physical examination and questionnaire-based follow-up.

OBJECTIVES: To assess outcome following a vaginal repair (high midline levator myorraphy, HMLM) for vaginal vault prolapse. METHODS: Women were identified who had undergone HMLM between December 1995 and September 1998. A structured telephone interview consisting of 5 questions was conducted in all those who could be reached. The most recent results of physical examination, based on office records, were also collected. RESULTS: Thirty-five of 47 women completed the interview (average age 71 years, mean time since surgery, 27.9 months). Five patients had developed recurrent prolapse requiring repair (anterior enterocele in 3, vault prolapse in 1, symptomatic cystocele in 1). Recurrent cystoceles were noted on examination in 7 women (5 grade 1, 2 grade 2). Overall, 17 women were extremely satisfied with the result (>90% satisfied); 6 were dissatisfied (<50%). Five women were noted to have transiently reduced unilateral ureteral drainage intraoperatively, and all cases were resolved after the removal or replacement of one of the levator myorraphy sutures. One patient required re-exploration for ureteral obstruction, which resolved after replacement of a suture and stenting. CONCLUSIONS: Levator myorraphy is safe, effective, and easily taught. The rate of recurrent prolapse associated with this technique is similar to other techniques for vaginal vault fixation, but it avoids the disadvantages of an abdominal approach and is more technically straightforward to perform than sacrospinalis fixation.     

Is the robotic approach feasible for repair of iatrogenic injuries of the lower ureter?

Objectives

To analyze the robotic approach as treatment of iatrogenic ureteral injuries.

Methods

Medical records were reviewed for patients undergoing robotic-assisted laparoscopic ureteral reimplantation at the University of Missouri from 2009 to 2014. Patient charts were analyzed for demographics, prior abdominal surgeries, circumstances of injury, outcomes, and other relevant information.

Results

Nine patients met inclusion criteria. The average age was 44.6. Patients had an average of 4.3 abdominal surgeries. Injury occurred during hysterectomy (open, laparoscopic, or vaginal) in eight patients (88.9 %), five cases were laparoscopic, two utilized robotic assistance, and one injury occurred during uterosacral vault suspension. All cases were related to gynecological procedures. On average, ureteral injury was detected 17.2 days after the initial surgery and repaired 62.3 days after initial operation. The average surgical repair time was 295.9 min (range 168–498) with an average blood loss of 77.2 mL (range 20–150). Four patients required a psoas hitch, with one receiving both a psoas hitch and a Boari flap. Postoperatively, patients had an average hospital stay of 2.7 days. One patient had ileus for greater than 3 days, and another was readmitted within 30 days for pain control and antiemetics following stent removal. One patient underwent open reimplantation 3 years after original surgery for development of ureteral stricture. At follow-up, all patients had returned to baseline renal function.

Conclusions

Robotic approach is feasible and a safe option for distal iatrogenic ureteral injuries occurring during gynecological procedures. Prior abdominal surgery or delayed repair does not preclude a robotic approach.

     

An uncommon case of urethrovaginal fistula resulting from tension-free vaginal tape

Urethrovaginal fistula (UVF) is an uncommon complication after sub-urethral sling placement. This is a report of a 51-year-old woman with stress urinary incontinence who underwent a tension-free vaginal tape (TVT®) in July 2001. Thirty-nine months after the procedure, she complained about pelvic and vaginal pain, bleeding from the vagina and stress urinary incontinence. The gynecological examination revealed a large mid UVF hidden by a 1 cm granuloma. The UVF was closed using simple sutures after removal of the sling. No subsequent treatment was performed.     

腹腔镜治疗宫颈癌术后输尿管阴道瘘的临床体会

目的探讨腹腔镜乳头式输尿管膀胱再植及腹腔镜膀胱肌瓣管输尿管成形术治疗对于保守治疗无效的宫颈癌手术及放疗所致输尿管阴道瘘患者的手术效果及临床价值。方法回顾性分析2014年1月至2018年11月徐州医科大学附属医院泌尿外科诊治的15例在外院或我院试行输尿管支架管置入失败的输尿管阴道瘘患者,15例患者均行CT尿路成像、膀胱镜等检查确诊,其中13例行腹腔镜下乳头式输尿管膀胱再植术,另2例因输尿管下段粘连较重无法分离而改行腹腔镜膀胱肌瓣管输尿管成形术,观察指标包括手术时间、出血量及术后并发症。结果 15例患者均行腹腔镜手术成功,无一例改开放或失败,平均手术时间146(95~208)min,出血量110(60~180)ml,术后3个月拔出双J管,随访3~12个月,均未出现漏尿、进展性肾积水等严重并发症。结论腹腔镜手术治疗对于保守治疗无效的输尿管阴道瘘患者疗效确切、安全可靠,创伤小、出血少、恢复快、成功率高,可明显提高患者生活质量,值得临床推广,但需要娴熟的腹腔镜操作技巧及丰富的解剖学经验。     

Laparoscopic ureteroureterostomy for isolated ureteral injury via retroperitoneal approach following a stab wound: a case report

Ureteral injuries secondary to noniatrogenic trauma are uncommon. Only 2% to 3% of knife stab wounds to the abdomen result in ureteral injury. As a basic rule, ureteral stenting is mostly sufficient for small lesions, and only larger injuries require open reconstructive techniques. We did laparoscopic ureteroureterostomy of an isolated ureteral injury via retroperitoneal approach following a stab wound in a 59-year-old male. This is the first reported case of laparoscopic repair for ureteral injury following a stab wound in the Japanese literature.     

Short-term ureteral catheter stenting after uncomplicated transurethral uretero-lithotomy

Short-term (1 or 2 post-operative days) ureteral catheter stenting after transurethral uretero-lithotomy (TUL) to avoid flank pain due to transient ureteral edema is described. Patients who underwent TUL for middle or distal ureteral stones with a rigid ureteroscope without complications during the procedures were the candidates for short-term ureteral stenting. An end-hole ureteral catheter, used to insert a guide wire during TUL, were used for stenting. The tip of the catheter was located near the renal pelvis and the other end was introduced outside through the urethra with a 14 F urethral catheter. The stent and catheter were removed on post-operative day 1 or 2. For the 18 patients treated using this method, the time of analgesic use after stent removal was 0.6±0.8, indicating a sufficient duration of stenting. Short-term ureteral catheter stenting is a cheap and easy way for post-operative management for uncomplicated TUL.     

Success of ureteral stents for intrinsic ureteral obstruction

PURPOSE: Previous reports suggest a high success rate for retrograde ureteral stenting for intrinsic ureteral obstruction, but few preoperative predictors of success have been offered. We reviewed our experience to look for factors that suggest failure of stents for intrinsic ureteral obstruction. MATERIALS AND METHODS: We retrospectively reviewed the outcome of retrograde ureteral stent placement for intrinsic ureteral obstruction without concurrent or intended definitive management of the obstruction. RESULTS: Thirty-eight patients treated for intrinsic ureteral obstruction, representing 41 ureteral units (UUs), were monitored for an average of 25.5 months. The overall success rate was 88%. Of the successes, 13 UUs had definitive therapy to permanently remove the cause of obstruction, obstruction resolved in 12 UUs after stent placement, and 11 UUs were managed with indwelling stents. Therapy failed in five UUs, with a median time to failure of 1.9 months. Of the UUs in which failure occurred, three failures were caused by misdiagnosis; in the remaining two, the stent did not correct the obstruction. On univariate analysis, male sex (P = 0.006), increased creatinine level as a presenting symptom (P = 0.002), and more severe preoperative hydronephrosis (P = 0.042) were predictive of failure. Adverse events were low, with complications from stenting occurring on only four of 41 UUs. CONCLUSION: If initial stent placement was possible, intrinsic ureteral obstruction was managed successfully in 88% of patients. Given high success and minimal complications, retrograde placement of ureteral stents can be performed to treat patients with intrinsic ureteral obstruction. Treatment failure is more likely to occur in men and patients with severe hydronephrosis or an elevated creatinine level.     

Case report: robot-assisted laparoscopic pyeloureterostomy in a transplanted kidney with ureteral stricture

Ureteral obstruction secondary to ischemia is the most common urologic complication of kidney transplantation. Although endoscopic management has shown satisfactory short-term success rates, surgical repair is considered the definitive therapy. To our knowledge, this procedure has been performed only through open surgery. We present a minimally invasive approach for reconstruction of a ureteral stricture in a renal transplant patient using the Da Vinci robotic system.     

Die Duplex-Doppel-J-Schiene bei intrinsischen und extrinsischen Harnleiterengen

Background

Duplex or twin ureteral stenting has previously been described as a viable option for patients where single double-J ureteral stenting has failed in order to avoid nephrostomies or further surgical intervention. We assessed a series of 20 patients at our institution after unsuccessful primary single ureteral stenting where parallel ureteral stents were inserted.

Methods

Between 2003 and 2009, 20 patients underwent double-J ureteral stenting for ureteral compression or ureteral strictures. After failure of single stenting two ureteral stents were consecutively inserted into the ureter in a parallel fashion after dilating the ureter up to 14 F. The second stent was passed over a hydrophilic guidewire while holding the first stent secure to prevent dislocation.

Results

In all patients the insertion of two parallel stents was technically possible. In 8 of 12 patients with extrinsic tumor compression the stents provided sufficient drainage (67%). When the stricture was due to surgery or radiation two of three patients were successfully diverted with twin stents. In five patients with a ureteral stricture due to malignant disease the stenting did not provide sufficient drainage and a nephrostomy had to be placed after a mean duration of 19 days. Two of those patients were later managed with a pyelovesical bypass. Three patients were later managed with a ureterocystoneostomy (psoas hitch). In four of five patients with benign disease a long-term management was feasible. The patient with retroperitoneal fibrosis developed immediate hydronephrosis and severe flank pain and ultimately underwent an ileal ureter replacement. In three patients with a benign ureteral stenosis after stone therapy, hysterectomy, or colon ureter replacement, a temporary duplex stenting sufficiently resolved the hydronephrosis for spontaneous urine passage. In one patient the duplex stenting prevented a kidney stone from dislocating into the ureter during lithotripsy.

Conclusions

Duplex or twin (double) ureteral stenting is a valid option in selected patients to avoid the placement of a nephrostomy. Severe stenosis may however demand a nephrostomy insertion or more invasive procedures in the later course. For certain benign ureteral strictures a therapeutic dilating effect of the two ureteral stents that makes further intervention unnecessary can be discussed.     

Is antegrade stenting superior to retrograde stenting in laparoscopic pyeloplasty?

PURPOSE: We describe a simple and timesaving technique of antegrade stenting. We compared it with retrograde stenting in laparoscopic pyeloplasty. MATERIALS AND METHODS: From December 2002 to August 2003, 24 patients with mean age of 24.29 years (range 5 to 57) had a Double-J (Medical Engineering Corp., New York, New York) stent placed laparoscopically after finishing the posterior suture line. The stent and ureteral catheter straightened over the guide wire were introduced through the lumen of a 5 mm hook or suction canula via a subcostal port. This technique was compared with retrograde stenting in 21 consecutive patients with mean age of 24.45 years (range 6 to 65) in terms of stenting time and failure to stent leading to conversion. RESULTS: In 23 of 24 cases laparoscopic stenting could be completed in a mean time of 5.2 minutes. In case 1 the stent was lying outside the pelvis because it was placed after ureteropelvic anastomosis was completed. The stent was retrieved after placing the ports again and reinserted with retrograde technique. In subsequent cases the stent was inserted successfully after completing the posterior suture line and visualizing the ureteral lumen. Mean time of retrograde stenting was 39.35 minutes. One case was converted to open pyeloplasty after retrograde stenting failed and in another 5Fr ureteral catheter was left instead. However, this patient required percutaneous stenting on postoperative day 5. With retrograde stenting stent severance and upward migration into the ureter occurred in 1 patient each, while none of the patients with laparoscopic stenting showed such problems. CONCLUSIONS: Laparoscopic stenting is a simple technique that obviates the need for an additional procedure and decreases the risk of the stent being cut or migrating upward. It also provides better anatomical delineation and dissection around the ureteropelvic junction since the pelvis remains distended. In addition, it makes suture placement and knot tying easy.     

Vesicovaginal fistula repair without intentional cystotomy using the laparoscopic robotic approach: a case report.

BACKGROUND AND OBJECTIVES: Fistulas inaccessible from the vagina may require abdominal repair; we sought to evaluate the robotic-assisted laparoscopic approach for this procedure. METHODS: A 41-year-old nulliparous woman presented with urinary incontinence following an abdominal hysterectomy, and office evaluation identified a vesicovaginal fistula. After discussion with the patient regarding the surgical options, the robotic approach was chosen to facilitate precise dissection, fine visualization, and suturing. A stent was placed from the bladder into the vagina, and no intentional cystotomy was made. The bladder was dissected away from the anterior vaginal wall at the fistula site, and the defects were closed independently with interposition of a fatty epiploica from the sigmoid colon. Total operative time was approximately 4 hours, and robotic time was about 2.5 hours. RESULTS: At 3 months after surgery, the patient had no recurrent symptoms. CONCLUSIONS: The robotic-assisted laparoscopic approach is a viable option for successful repair of a vesicovaginal fistula in a patient in whom a vaginal approach is not indicated.     

Value of proximal diversion and ureteral stenting in management of penetrating ureteral trauma

Cases of penetrating ureteral trauma (17 gunshot wounds and 4 stab wounds) seen at two New York City hospitals over a nine-year period were reviewed. Early urologic complications (defined as urine drainage from the wound for greater than 2 weeks or need for a second operation) occurred in 50 percent of patients with a proximal ureteral injury but were less common when a nephrostomy and stent were used in the repair. A similar beneficial effect of stenting was seen in published cases, with a 91 percent complication rate for unstented repairs and a 15 percent rate when stenting and nephrostomy drainage were both used. The effect of stenting on midureteral repairs was less obvious, but the rate of urologic complications was lower in stented cases. None of the patients with distal ureteral injuries suffered a urologic complication. Stenting with and without a nephrostomy tube also produced good results in 2 patients with proximal ureteral injuries diagnosed late. We conclude that repair of penetrating ureteral injuries should include stenting and nephrostomy tube drainage in cases of proximal injuries, as well as generous debridement and water-tight closure. Midureteral injuries accompanied by gastrointestinal, pancreatic, and major vascular injuries should be stented and proximal diversion considered when prosthetic materials are used for vascular repairs.     

Iatrogenic ureteral injury

We treated 27 patients with iatrogenic ureteral injuries during a 6-year period. Gynecological operations were the most common antecedent surgical procedures (52 per cent). The diagnosis of ureteral injury was made immediately in 4 patients and was delayed 1 to 34 days in 23. Three of the 4 injuries recognized during an operation were repaired successfully at the time of injury; the primary repair in the remaining patient leaked and ultimately resulted in a nephrectomy. In the delayed diagnosis group retrograde ureteral catheterization was successful in only 1 of 20 attempts. Of the 23 patients with injuries recognized in the postoperative period 11 were managed successfully with percutaneous nephrostomy (with or without stenting) alone, 3 required surgical repair after temporary percutaneous nephrostomy drainage, 4 were treated surgically without prior nephrostomy drainage and 1 had spontaneous resolution of hydronephrosis. The remaining 3 patients required nephrectomy: 1 because of a urinary fistula in a previously irradiated field, 1 because of a concomitant (ipsilateral) renal cell carcinoma and 1 because of renal hypertension. Percutaneous nephrostomy or ureteral stenting was successful as primary therapy in 73 per cent of the patients in whom it was used.     

Therapie der Harnleiterobstruktion

Ureteral obstruction represents a heterogeneous disease pattern and is treated by ureteral stenting or percutaneous nephrostomy (PCN) depending on the necessity. The benefits of urinary diversion with ureteral stenting or PCN in malignant ureteral obstruction (MUO) for patient survival are only moderate. No differences have been found between ureteral stenting and PCN in MUO with regard to median patient survival and complication rates. In cases of MUO there is currently no evidence that urinary diversion improves the quality of life. Alternative concepts of ureteral stenting, such as tandem ureteral stents, metallic ureteral stents or metal mesh ureteral stents have not yet shown clear benefits. In benign ureteral obstruction, prospective randomized studies have demonstrated comparable quality of life after PCN or ureteral stenting. The method of choice for urinary diversion is influenced by the recommendations, personal experience of the clinician and the availability of the method.     

A case of infected renal cyst suspected of originating from retrograde infection

A 63-year-old man who had undergone Miles' operation for rectal cancer in another hospital was referred due to a high fever and renal failure. Abdominal computed tomographic (CT) scan revealed metastatic liver tumor, paraaortic lymph node swelling, bilateral hydronephrosis and a left simple renal cyst located at the lower pole. Bilateral ureteral stenting was undertaken for relieving ureteral obstruction. Serum creatinine and high fever improved immediately. However, at 11 days after the ureteral stenting the high fever recurred. CT scan and ultrasonography revealed persistent left hydronephrosis and a change of left simple renal cyst into infected cyst. After an exchange of left ureteral stent and percutaneous pus drainage from the left infected renal cyst, high fever declined immediately. A review of the literature suggests that this is the 100th case report of infected renal cyst in Japan. We discuss the clinical features, etiology, imaging study and treatment of infected renal cyst.