Original Paper
Urologia
Received: December 16, 2013 Accepted after revision: February 17, 2014 Published online: August 8, 2014
Urol Int DOI: 10.1159/000360644
Internationalis
Laparoscopic Ureteral Reimplantation underneath Broad Ligament Tunnel for Female Vesicoureteral Stenosis: A Technical Innovation Chuangliang Xu a Shuxiong Zeng a Zhensheng Zhang a Tie Zhou a Huizhen Li a Haihang Li a Rongchao Wei a Ruixiang Song a Qingsong Yang b Xiaowen Yu c Yinghao Sun a
Departments of a Urology, b Radiology and c Geriatrics, Changhai Hospital, Second Military Medical University, Shanghai, PR China
Key Words Laparoscopic ureteral reimplantation · Broad ligament tunnel · Females · Vesicoureteral junction obstruction
broad ligament tunnel is safe and effective, allowing for anatomical reconstruction of ureter defects. However, a larger clinical sample and longer follow-up period will be needed. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0042–1138/14/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
Laparoscopic surgery has been successfully used to manage various urological diseases during the last decade. Reimplantation of the ureter is now a commonly performed urological procedure. The indications for ureteral reimplantation include distal strictures secondary to pelvic surgery, endoscopic procedures, endometriosis, and distal ureteral tumors [1–5]. Unfortunately, more and more ureteroneocystostomies have been performed and most of these procedures can be attributed to iatrogenic ureter injuries such as ureteroscopic procedures and complex pelvic laparoscopy [6, 7].
Chuanliang Xu, Shuxiong Zeng and Zhensheng Zhang contributed equally to the paper and are co-first authors.
Yinghao Sun, PhD, MD Department of Urology, Changhai Hospital Second Military Medical University, 168 Changhai Road Shanghai 200433 (PR China) E-Mail sunyh @ medmail.com.cn
Downloaded by: UCSF Library & CKM 169.230.243.252 - 11/27/2014 1:02:20 PM
Abstract Introduction: In order to anatomically reconstruct ureteral stenosis, we present a novel technique for laparoscopic ureteral reimplantation. Patients and Methods: Three young females, who were diagnosed with hydroureteronephrosis caused by congenital vesicoureteral junction obstruction, were treated by laparoscopic ureteral reimplantation with a tunnel underneath the broad ligament. Results: Surgery was performed successfully without conversion to open surgery. No major intra- or postoperative complications occurred. Postoperative follow-up was 38, 33 and 26 months, respectively. The operative time was between 220 and 260 min. The mean estimated blood loss was less than 20 ml. Subsequent imaging performed 3 months after surgery revealed relief of hydroureteronephrosis for all patients. The patients all gave birth to healthy neonates and showed normal urinary tract sonogram and urine analysis during the gestation period. Conclusion: Laparoscopic ureteral reimplantation with
Color version available online
Depending on the length and position of the ureteral injury, various treatment options are available such as a Boari flap, ileal interposition and autotransplantation [8]. Short distal ureteric defects can be managed by laparoscopic ureteroneocystostomy [4, 7]. Recently, surgeons have proposed several modifications for laparoscopic ureteroneocystostomy so as to shorten the operation time and reduce the complexity of this operation [9–13]. Nevertheless, Austenfeld and Snow [14] and Mor et al. [15] found that women who underwent ureteral reimplantation as children were at higher risk of ureteral obstruction and renal failure during pregnancy. To date, few studies have been reported to address ureteral obstruction during pregnancy in women who had a previous ureteral reimplantation [15–19]. Awareness of this late and rare complication for ureteral reimplantation enabled us to consider reimplanting the ureter in an anatomical way. Thus, we proposed a novel technique for laparoscopic ureteral reimplantation named ‘broad ligament tunnel technique’ by creating a tunnel underneath the broad ligament. We report our initial experience of this procedure for 3 patients.
a
Patients and Methods From March 2010 to September 2011, 3 young females who presented with flank pain were diagnosed with hydroureteronephrosis caused by congenital vesicoureteral junction obstruction based on intravenous urography, ultrasonography and cystourethrogram. Ultrasonography and intravenous urography showed left-sided hydroureteronephrosis in 2 patients; the other was rightsided. Voiding cystourethrogram demonstrated that none of them had vesicoureteral reflux. They were 22, 26 and 27 years old, respectively. None of them had ever been pregnant before. All 3 patients were treated with an intracorporeal and transperitoneal laparoscopic approach with broad ligament tunnel technique by the same surgical team.
2
Urol Int DOI: 10.1159/000360644
b
Fig. 1. Schematic drawing of laparoscopic port site placement and broad band tunnel method. a Trocar placement for left ureteral reim-
plantation; the hollow asterisk denotes the assistant trocar site for right ureteral reimplantation. b Laparoscopic ureteral reimplantation with a tunnel underneath the broad ligament; the solid asterisk denotes the broad band ligament. U = Ureter; UT = uterus; BL = bladder.
The colon was reflected medially to expose the retroperitoneum. The peritoneum was incised at the level of the crossing of the iliac vessels to identify the ureter. The healthy ureter was then mobilized to a place where it passed through the cardinal ligament. Then the uterus was uplifted with an atraumatic grasper, and a
Xu/Zeng/Zhang/Zhou/Li/Li/Wei/Song/ Yang/Yu/Sun
Downloaded by: UCSF Library & CKM 169.230.243.252 - 11/27/2014 1:02:20 PM
Surgical Technique Under general anesthesia, the patients were positioned in a supine position. An F20 Foley catheter and an orogastric tube were placed to decompress the bladder and the stomach, respectively. An incision was made along the lower lip of the umbilicus in the midline. A Veress needle was used to establish pneumoperitoneum with a pressure of 14–15 mm Hg and maximum flow of 15 liters/min. Then a 12-mm optical trocar was inserted into the incision and used as camera port. Under direct vision, 2 secondary ports (12 mm each) were inserted in the left and right margins of the lateral rectus abdominis at a level of 2 cm caudally to the umbilicus. Finally, an assistant port was differently placed for the leftand right-sided ureter reimplantation. A 5-mm trocar for right (left) reimplantation was placed 4 cm under the umbilicus in the left (right) vertical line of the midpoint of the left (right) inguinal ligament (fig. 1a).
Color version available online
a
ryl suture. The bladder was instilled with 200 ml of saline, and the serosa and muscular layers of the bladder were opened along the posterolateral side or the base of the bladder according to the ureter length. Approximately 1 cm of mucosa was excised at the distalmost end of the incision. The spatulated ureter was delivered through the broad ligament tunnel with an atraumatic grasper. Subsequently, the distal end of the double-J stent was inserted into the bladder, and mucosa-to-mucosa ureterovesical anastomosis was completed using a 4-0 Vicryl suture in continuous fashion (fig. 1b, 2b). Detrusor and serosal layers overlying the implanted ureter were closed using 3-0 Vicryl in interrupted fashion (fig. 2c). After anastomosis, the peritoneum overlying the bladder was closed and saline was instilled to confirm watertight anastomosis. Finally, a drainage catheter was placed in the paravesical space via the 5-mm trocar.
Results
c
Fig. 2. A novel technique for ureteral reimplantation with broad ligament tunnel; the solid asterisk denotes the broad band ligament. U = Ureter; UT = uterus; BL = bladder. a A broad ligament tunnel was made around the site where the ureter passed through the cardinal ligament (dashed circle). b The spatulated ureter was delivered through the broad ligament tunnel and anastomosed to the posterolateral or base of the bladder. c The peritoneum overlying the bladder was closed.
tunnel 2–2.5 cm in diameter was made underneath the broad ligament around the ureter (fig. 2a). The peritoneum overlying the bladder was then incised at the site approximately over the uterus artery to expose this artery and the ureter below it. A broad ligament tunnel was created and the ureter was mobilized from the iliac vessel bifurcation to the ureterovesical junction. Of note, periureteral adventitia should be preserved during these procedures to ensure sufficient blood supply. The ureter was ligated proximal to the stenosis site and transected proximally. The ureter was spatulated, and a 7-Fr double-J stent was then placed into the ureter with the help of a guidewire inserted into the renal pelvis and fixed to the ureter with a 4-0 Vic-
Broad Ligament Tunnel for Female Vesicoureteral Stenosis
Discussion
Laparoscopic surgery is an effective and safe minimally invasive technique for treating urinary system diseases. Laparoscopy has extended to almost every field of urological surgery. Since Nezhat and Nezhat [2] reported the first laparoscopic ureteroureterostomy, laparoscopic ureUrol Int DOI: 10.1159/000360644
3
Downloaded by: UCSF Library & CKM 169.230.243.252 - 11/27/2014 1:02:20 PM
b
Surgery was performed successfully in all 3 patients by a laparoscopic approach without conversion to open surgery. No major intra- or postoperative complications occurred for all patients. Patient results are summarized in table 1. Postoperative follow-up was 38, 33 and 26 months, respectively. The operative time averaged was between 220 and 260 min, which included 20–25 min to create the broad ligament tunnel. The mean estimated blood loss was less than 20 ml. The orogastric tube was removed 2 days after surgery and patients began oral intake. Drainage and catheter were removed 4–5 days after surgery. The length of hospital stay was 7–8 days. Flank pain was relieved after surgery and urine analysis did not demonstrate the evidence of urinary tract infection. The double-J stents were removed 8 weeks after surgery. Subsequent follow-up imaging was performed in all patients 3 months after surgery, and renal ultrasound scan or intravenous urography examination revealed relief of hydroureteronephrosis for all patients. During pregnancy and 3 months postpartum, all 3 patients showed normal urinary tract sonogram and urine analysis. The patients all gave birth to healthy neonates after 38–40 weeks of gestation.
Table 1. Patient results
Patient
Age, years
Ureteral location
Follow-up, months
Estimated blood loss, ml
Operation time, min
Hospital stay, days
Pregnancy
Complications during pregnancy
1 2 3
22 26 27
left left right
38 33 26
Urologia
Received: December 16, 2013 Accepted after revision: February 17, 2014 Published online: August 8, 2014
Urol Int DOI: 10.1159/000360644
Internationalis
Laparoscopic Ureteral Reimplantation underneath Broad Ligament Tunnel for Female Vesicoureteral Stenosis: A Technical Innovation Chuangliang Xu a Shuxiong Zeng a Zhensheng Zhang a Tie Zhou a Huizhen Li a Haihang Li a Rongchao Wei a Ruixiang Song a Qingsong Yang b Xiaowen Yu c Yinghao Sun a
Departments of a Urology, b Radiology and c Geriatrics, Changhai Hospital, Second Military Medical University, Shanghai, PR China
Key Words Laparoscopic ureteral reimplantation · Broad ligament tunnel · Females · Vesicoureteral junction obstruction
broad ligament tunnel is safe and effective, allowing for anatomical reconstruction of ureter defects. However, a larger clinical sample and longer follow-up period will be needed. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0042–1138/14/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
Laparoscopic surgery has been successfully used to manage various urological diseases during the last decade. Reimplantation of the ureter is now a commonly performed urological procedure. The indications for ureteral reimplantation include distal strictures secondary to pelvic surgery, endoscopic procedures, endometriosis, and distal ureteral tumors [1–5]. Unfortunately, more and more ureteroneocystostomies have been performed and most of these procedures can be attributed to iatrogenic ureter injuries such as ureteroscopic procedures and complex pelvic laparoscopy [6, 7].
Chuanliang Xu, Shuxiong Zeng and Zhensheng Zhang contributed equally to the paper and are co-first authors.
Yinghao Sun, PhD, MD Department of Urology, Changhai Hospital Second Military Medical University, 168 Changhai Road Shanghai 200433 (PR China) E-Mail sunyh @ medmail.com.cn
Downloaded by: UCSF Library & CKM 169.230.243.252 - 11/27/2014 1:02:20 PM
Abstract Introduction: In order to anatomically reconstruct ureteral stenosis, we present a novel technique for laparoscopic ureteral reimplantation. Patients and Methods: Three young females, who were diagnosed with hydroureteronephrosis caused by congenital vesicoureteral junction obstruction, were treated by laparoscopic ureteral reimplantation with a tunnel underneath the broad ligament. Results: Surgery was performed successfully without conversion to open surgery. No major intra- or postoperative complications occurred. Postoperative follow-up was 38, 33 and 26 months, respectively. The operative time was between 220 and 260 min. The mean estimated blood loss was less than 20 ml. Subsequent imaging performed 3 months after surgery revealed relief of hydroureteronephrosis for all patients. The patients all gave birth to healthy neonates and showed normal urinary tract sonogram and urine analysis during the gestation period. Conclusion: Laparoscopic ureteral reimplantation with
Color version available online
Depending on the length and position of the ureteral injury, various treatment options are available such as a Boari flap, ileal interposition and autotransplantation [8]. Short distal ureteric defects can be managed by laparoscopic ureteroneocystostomy [4, 7]. Recently, surgeons have proposed several modifications for laparoscopic ureteroneocystostomy so as to shorten the operation time and reduce the complexity of this operation [9–13]. Nevertheless, Austenfeld and Snow [14] and Mor et al. [15] found that women who underwent ureteral reimplantation as children were at higher risk of ureteral obstruction and renal failure during pregnancy. To date, few studies have been reported to address ureteral obstruction during pregnancy in women who had a previous ureteral reimplantation [15–19]. Awareness of this late and rare complication for ureteral reimplantation enabled us to consider reimplanting the ureter in an anatomical way. Thus, we proposed a novel technique for laparoscopic ureteral reimplantation named ‘broad ligament tunnel technique’ by creating a tunnel underneath the broad ligament. We report our initial experience of this procedure for 3 patients.
a
Patients and Methods From March 2010 to September 2011, 3 young females who presented with flank pain were diagnosed with hydroureteronephrosis caused by congenital vesicoureteral junction obstruction based on intravenous urography, ultrasonography and cystourethrogram. Ultrasonography and intravenous urography showed left-sided hydroureteronephrosis in 2 patients; the other was rightsided. Voiding cystourethrogram demonstrated that none of them had vesicoureteral reflux. They were 22, 26 and 27 years old, respectively. None of them had ever been pregnant before. All 3 patients were treated with an intracorporeal and transperitoneal laparoscopic approach with broad ligament tunnel technique by the same surgical team.
2
Urol Int DOI: 10.1159/000360644
b
Fig. 1. Schematic drawing of laparoscopic port site placement and broad band tunnel method. a Trocar placement for left ureteral reim-
plantation; the hollow asterisk denotes the assistant trocar site for right ureteral reimplantation. b Laparoscopic ureteral reimplantation with a tunnel underneath the broad ligament; the solid asterisk denotes the broad band ligament. U = Ureter; UT = uterus; BL = bladder.
The colon was reflected medially to expose the retroperitoneum. The peritoneum was incised at the level of the crossing of the iliac vessels to identify the ureter. The healthy ureter was then mobilized to a place where it passed through the cardinal ligament. Then the uterus was uplifted with an atraumatic grasper, and a
Xu/Zeng/Zhang/Zhou/Li/Li/Wei/Song/ Yang/Yu/Sun
Downloaded by: UCSF Library & CKM 169.230.243.252 - 11/27/2014 1:02:20 PM
Surgical Technique Under general anesthesia, the patients were positioned in a supine position. An F20 Foley catheter and an orogastric tube were placed to decompress the bladder and the stomach, respectively. An incision was made along the lower lip of the umbilicus in the midline. A Veress needle was used to establish pneumoperitoneum with a pressure of 14–15 mm Hg and maximum flow of 15 liters/min. Then a 12-mm optical trocar was inserted into the incision and used as camera port. Under direct vision, 2 secondary ports (12 mm each) were inserted in the left and right margins of the lateral rectus abdominis at a level of 2 cm caudally to the umbilicus. Finally, an assistant port was differently placed for the leftand right-sided ureter reimplantation. A 5-mm trocar for right (left) reimplantation was placed 4 cm under the umbilicus in the left (right) vertical line of the midpoint of the left (right) inguinal ligament (fig. 1a).
Color version available online
a
ryl suture. The bladder was instilled with 200 ml of saline, and the serosa and muscular layers of the bladder were opened along the posterolateral side or the base of the bladder according to the ureter length. Approximately 1 cm of mucosa was excised at the distalmost end of the incision. The spatulated ureter was delivered through the broad ligament tunnel with an atraumatic grasper. Subsequently, the distal end of the double-J stent was inserted into the bladder, and mucosa-to-mucosa ureterovesical anastomosis was completed using a 4-0 Vicryl suture in continuous fashion (fig. 1b, 2b). Detrusor and serosal layers overlying the implanted ureter were closed using 3-0 Vicryl in interrupted fashion (fig. 2c). After anastomosis, the peritoneum overlying the bladder was closed and saline was instilled to confirm watertight anastomosis. Finally, a drainage catheter was placed in the paravesical space via the 5-mm trocar.
Results
c
Fig. 2. A novel technique for ureteral reimplantation with broad ligament tunnel; the solid asterisk denotes the broad band ligament. U = Ureter; UT = uterus; BL = bladder. a A broad ligament tunnel was made around the site where the ureter passed through the cardinal ligament (dashed circle). b The spatulated ureter was delivered through the broad ligament tunnel and anastomosed to the posterolateral or base of the bladder. c The peritoneum overlying the bladder was closed.
tunnel 2–2.5 cm in diameter was made underneath the broad ligament around the ureter (fig. 2a). The peritoneum overlying the bladder was then incised at the site approximately over the uterus artery to expose this artery and the ureter below it. A broad ligament tunnel was created and the ureter was mobilized from the iliac vessel bifurcation to the ureterovesical junction. Of note, periureteral adventitia should be preserved during these procedures to ensure sufficient blood supply. The ureter was ligated proximal to the stenosis site and transected proximally. The ureter was spatulated, and a 7-Fr double-J stent was then placed into the ureter with the help of a guidewire inserted into the renal pelvis and fixed to the ureter with a 4-0 Vic-
Broad Ligament Tunnel for Female Vesicoureteral Stenosis
Discussion
Laparoscopic surgery is an effective and safe minimally invasive technique for treating urinary system diseases. Laparoscopy has extended to almost every field of urological surgery. Since Nezhat and Nezhat [2] reported the first laparoscopic ureteroureterostomy, laparoscopic ureUrol Int DOI: 10.1159/000360644
3
Downloaded by: UCSF Library & CKM 169.230.243.252 - 11/27/2014 1:02:20 PM
b
Surgery was performed successfully in all 3 patients by a laparoscopic approach without conversion to open surgery. No major intra- or postoperative complications occurred for all patients. Patient results are summarized in table 1. Postoperative follow-up was 38, 33 and 26 months, respectively. The operative time averaged was between 220 and 260 min, which included 20–25 min to create the broad ligament tunnel. The mean estimated blood loss was less than 20 ml. The orogastric tube was removed 2 days after surgery and patients began oral intake. Drainage and catheter were removed 4–5 days after surgery. The length of hospital stay was 7–8 days. Flank pain was relieved after surgery and urine analysis did not demonstrate the evidence of urinary tract infection. The double-J stents were removed 8 weeks after surgery. Subsequent follow-up imaging was performed in all patients 3 months after surgery, and renal ultrasound scan or intravenous urography examination revealed relief of hydroureteronephrosis for all patients. During pregnancy and 3 months postpartum, all 3 patients showed normal urinary tract sonogram and urine analysis. The patients all gave birth to healthy neonates after 38–40 weeks of gestation.
Table 1. Patient results
Patient
Age, years
Ureteral location
Follow-up, months
Estimated blood loss, ml
Operation time, min
Hospital stay, days
Pregnancy
Complications during pregnancy
1 2 3
22 26 27
left left right
38 33 26
