Ureteral complications and aortoiliac reconstruction Dennis J. Wright, M D , Calvin B. Ernst, M D , James R. Evans, M D , R o g e r F. Smith, M D , Daniel J. Reddy, M D , Alexander D. Shepard, M D , and Joseph P. Elliott, Jr., M D , Detroit, Mich. A 33-year experience with 58 ureteral complications in 50 of 3580 patients undergoing aortoiliac reconstruction was analyzed. Ureteral obstruction was treated before or in conjunction with aneurysm repair in six patients with aneurysmal disease. The remaining 44 patients had 46 ureteral complications after aortic reconstruction; complications included hydronephrosis (42), ureteral leak (3), and ureteral necrosis (1). A high incidence of associated graft complications was noted. Graft thrombosis developed in one of the six patients undergoing prior or simultaneous ureteral procedures, and graft infection developed in another. Thirty-six graft complications developed in 24 (55%) of the 44 patients with postoperative ureteral complications. The complications included 19 anastomotic aneurysms, eight graft limb thromboses, six graft infections, and three aortoenteric fistulas. Twenty-nine of the 44 patients with postoperative ureteral complications underwent ureteral or graft operations or both. These included five patients having ureteral operations alone, seven with a ureteral procedure and subsequent graft operation, eight requiring simultaneous uretera/and graft procedures, and nine undergoing a graft operation with ureteral observation. Six of these 29 patients (21%) died after operation, all from graft complications including aortoenteric fistulas (three), ruptured anastomotic aneurysms (two), and graft infection (one). Graft complications affected 55% of 44 patients with postoperative ureteral complications, compared to 12% of 3536 patients without ureteral complications (p < 0.0001). Patients with postoperative ureteral complications were 4.4 times as likely to have graft complications compared to those without ureteral complications (p < 0.0001). These data suggest that such urologic complications may be markers for recognition of or harbingers for graft complications. (J VASe SURG 1990;11:29-37.) Ureteral complications occur infrequently during management of aortoiliac atherosclerosis. Fewer than 100 cases of preoperative hydronephrosis associated ~vith aortic aneurysms have been reported. In additi~i.~, the incidence of hydronephrosis caused by ureteral obstruction after aortoiliac reconstruction is also low, ranging from 2% to 14% in several prospective studies.l-4 These reports have mainly addressed only the incidence o f ureteral complications, suggesting that progression to persistent ureteral obstruction is rare, especially if hydronephrosis occurs early in the postoperative period. From these analyses it has been assumed that postoperative ureteral complications
have little bearing on ultimate morbidity or mortality after aortic reconstruction. Recently, hydronephrosis caused by ureteral obstruction after aortic reconstruction has been suggested to be associated with graft complications. S To further characterize this relationship and determine the natural history ofureteral complications after aortoiliac reconstruction, a 33-year experience with aortoiliac reconstruction was retrospectively reviewed. The relationships between ureteral and graft complications and outcome of specific management o f these complications were analyzed and form the basis of this article. CLINICAL MATERIAL
.From the Division of Vascular Surgery, Henry Ford Hospital. Presented at the Thirty-seventh ScientificMeeting of the No~.h American Chapter, International Society for Cardiovascular Surgery, New York, N.Y., June 19-20, 1989. Reprint requests: Calvin B. Ernst, MD, Division of Vascular Surgery, Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI 48202. 24/6/16662
Beginning in 1954, data have been recorded a n d tracked for patients undergoing vascular surgical procedures at the Henry Ford Hospital by means of a computerized vascular registry. Through periodic patient recall and by following established clinical examination and arteriographic protocols, such data 29
30
Journal of VASCULAR SURGERY
Wright et al.
Table I. Aortic reconstruction in 50 patients with ureteral complications Aneurysmal Occlusive disease disease Total Aortobifemoral reconstruction Aortobiliac reconstruction Other* Total
5 18 1 24
22 1 3 26
27 19 4 50
*One mycotic aneurysm figation; three aortoiliac endarterectomies.
have been regularly updated. 6 Information derived from more than 13,000 vascular surgical procedures have been entered into the registry, and from this database, 3580 patients undergoing 3660 aortoiliac reconstructive procedures were identified. Fifty of the 3580 patients undergoing aortoiliac reconstruction were found to have significant ureteral complications, and their records were scrutinized. Ureteral involvement was documented by urography during aortography, intravenous pyelography (IVP), retrograde pyelography, or operation. Patients were followed by a protocol that included yearly examination. During the first 2 decades of the study, routine translumbar aortography was performed in the immediate postoperative period before hospital discharge in 1958 patients and was repeated at 2- to 3year intervals. All 50 patients were followed through 1988 or until death. Follow-up averaged 7.4 years and ranged from 1 month to 20.3 years. The incidence and type of graft complications were assessed, and the outcome of both the graft and ureteral complication was determined in each patient. The incidence of graft complications was also determined for all 3580 patients entered into the database during the period of this study. Statistical methods. Statistical analysis focused on patients with postoperative ureteral complications. Patients with preoperative ureteral complications were counted as patients without postoperative complications. To assess the association between postoperative ureteral and graft complications, each patient was included as having any type of graft complication or any ureteral complication or both. Thus each patient was counted only once regardless of the number of procedures performed or complications identified. A relative risk with a 95% confidence interval was computed. Log-rank analysis and Kaplan-Meier curves, 7 which adjust for varying lengths of follow-up, were used to compare graft complication rates between patients with (n = 44) and without (n = 3536)
postoperative ureteral complications. In this analysis only graft complications occurring after the first operation were used. The length of follow-up was cal-~ culated as the time from first operation to graft complication, date of last examination, or death. Cox proportional hazards regression analysis 8 was used to adjust for age, sex, race, and length of followup and to compare graft complication rates for those patients with and without postoperative ureteral complications. Again, only the first operation was used in this analysis. Risk estimates and confidence intervals were calculated by use of the results from Cox regression. A p value of less than 0.05 was considered statistically significant. RESULTS
Fifty-eight ureteral complications were identified in 50 patients. There were 29 men and 21 w ~ e n with an average age of 61.3 years, ranging from 42 to 78 years. The overall incidence of ureteral complications was 1.4% (50/3580). Twenty-six patients underwent aortoiliac reconstruction for occlusive disease, and 24 patients underwent reconstruction for aneurysmal disease (Table I). Six patients had preoperative ureteral obstruction, graft complications developed in two. The remaining 44 patients had 46 postoperative ureteral complications manifest by hydronephrosis in 42, ureteral leak in three, and ureterat necrosis in one. Ureteral complications were identiffed from 2 weeks to 12 years postoperatively (average, 18.9 months). Early ureteral complications were arbitrarily defined as those detected within 1 year of aortic reconstruction, and late complications were defined as those detected beyond 1 year. Twenty-four patients (55%) had early ureteral c~mplications, and 20 (45%) had late complications discovered from 14 months to 12 years after operation. Thirty-six graft complications developed in 24 of the 44 patients. Graft complications were identifiec~ from 4 weeks to 12.8 years after surgery (average, 3.3 years). Graft complications were evenly divided between the early ureteral complication group and the late ureteral complication group. Twenty-nine of the 44 patients with postoperative ureteral complications underwent ureteral or graft operations or both. These included five patients undergoing ureteral operations alone, seven undergoing a ureteral procedure and subsequent graft operation, eight undergoing simultaneous ureteral and graft procedures, and nine undergoing graft operation and ureteral observation (Table II). SIX of tb_.7
Volume 11 Number 1 January 1990
Ureteral complications and aortoiliac reconstruction
Table II. Patients undergoing graft and/or ureteral operations (n = 29)
20 Patientsureteral operations
5 Ureteral operations alone 7 Ureteral operations with subsequent graft operataon 8 Simultaneous ureteral/graft operations 9 Graft operations / ureters observed
Table I l L Management of postoperative ureteral complications in 44 patients Management
24 Patientsgraft operations
31
Observation, initially Improved or unchanged Progressive obstruction requiring operation Operation, initially Primary urologic indication Associated with graft revision
No. patients
Ureteral entrapment
28 24 4
0
16 8 8
3 3
Operative mortality 6/29 = 21%.
29 patients (21%) died after operation, all of graft complications, including three aortoenteric fistulas, two ruptured anastomotic aneurysms, and one graft in£f~fion. URETERAL COMPLICATIONS Preoperative ureteral complications. Six patients with preoperative ureteral obstruction included two who were anuric, one with pyohydronephrosis, and three with asymptomatic hydronephrosis. All had evidence of retroperitoneal inflammation at the time of their aortic reconstruction manifest by localized edema, hyperemia, and thickened retroperi~oneal tissues. One patient had an inflammatory abdominal aortic aneurysm, and another had an infected iliac artery aneurysm associated with an aortic aneurysm. One patient underwent nephroureterectomy 1 month before aortic aneurysm repair for pyohydrofiephrosis caused by ureteral compression by the aneu ,,'sm. In four of the remaining five, ureteral operations were performed during aneurysm repair, including two ureterolyses, one segmental ureterectomy and reanastomosis, and one cutaneous ureterostomy. One patient underwent aneurysm repair with ureteral stenting alone. Five of the six required no further urologic operations. The patient who underwent a cutaneous ureterostomy during repair of an aortic and infected iliac artery aneurysm required nephrectomy 1 month after operation for unrelenting urosepsis. All patients had normal postoperative renal fimction except one of the two who were anuric before operation. Postoperative ureteral complications. Fortyfour patients had 46 ureteral complications after aortoiliac reconstruction. Twenty-eight patients, all with asymptomatic hydronephrosis, were initially ob~ . v e d (Table III). In 24 of these, the obstruction
either did not progress in 10, or it resolved spontaneously in 14. Operation for progressive ureteral obstruction was required in the remaining four patients (14%). Three underwent ureterolysis and the fourth underwent segmental ureteral resection and reanastomosis. None of these patients had ureteral entrapment between the graft and host iliac artery. Sixteen patients, eight with no symptoms and eight with symptoms, had 18 ureteral complications and were operated upon when the complication was first recognized (Table III). Eight patients, three of whom were found to have the ureter lying behind the prosthetic graft, underwent ureteral procedures during graft revision, including four ureterolyses and four ureteral resections and reanastomoses. Those with entrapped ureters all underwent ureteral division, transposition, and reanastomosis. The other eight patients underwent urologic operations alone for hydronephrosis, with partial ureteral obstruction in four, hydronephrosis with ureteral leak in three, and an obstructed, nonfimctioning kidney in one. Three of these had ureteral entrapment between the graft and iliac artery. Ureterolysis was performed in four patients, including one with an entrapped ureter who also underwent graft division, ureteral transposition, and graft reanastomosis. Ureteral division and reanastomosis were performed in two patients including one with an entrapped ureter, and nephroureterectomies were performed in two including one with an entrapped ureter. Therefore six of these 16 (38%) patients and six of all 20 (30%) eventually requiring ureteral operations were found to have the ureter lying between the prosthetic graft and host iliac artery (Table III). All patients undergoing ureteral reconstruction had documented improvement by follow-up urographic studies. No patient experienced chronic renal failure. Among 24 of the 44 patients (55%) the ureteral complications were recognized within a year of aortic
32
Journal of VASCULAR SURGERY
Wright et al.
Table IV. Graft complications in 3580 patients undergoing aortoiliac reconstruction with and without postoperative ureteral complications
Table V. Postoperative ureteral complications vs graft complications Graft complication
Complication Patients ~ 44 Patients with postoperative ureteral complications Anastomotic aneurysm Graft thrombosis Graft infection Aortoenteric fistula 3536 Patients without postoperative ureteral complications Anastomotic aneurysm Graft thrombosis Graft infection Aortoenteric fistula
19 8 6 3
16 7 6 3
395 218 25 19
270 202 25 19
~Some patients had more than one graft complication.
reconstruction. Nine (38%) of these required ureteral reconstructions, three of which were performed during aortic graft revision. In 20 patients (45%) the ureteral complications were recognized more than 1 year after aortic reconstruction. Eleven (55%) required ureteral reconstructive procedures, five during aortic graft revisions. These differences were not statistically significant. Graft complications Twenty-four of the 44 patients (55%) with postoperative ureteral complications experienced 36 graft complications, an average of 3.3 years after operation, ranging from 1 month to 12.8 years. Some patients had more than one graft complication. Nineteen anastomotic aneurysms developed in 16 patients, three of whom had two anastomotic aneurysms (Table IV). Eight graft limb thromboses occurred in seven patients. Graft infections developed in six patients, and aortoenteric fistulas developed in three. There were six postoperative deaths in these 24 patients resulting from the graft complications. Graft complications developed in 12 patients with early ureteral complications. In two of these patients, both with anastomotic aneurysms, the ureteral complication was recognized during management of the anastomotic aneurysm. In the remaining 10, ureteral complications were identified before graft complications were noted. Similarly, graft complications developed among 12 patients with late ureteral complications. The ureteral complication preceded the diagnosis of graft complication in five of these patients and was recognized during management of the graft problem in the other seven.
Ureteral complication Yes No Total
Yes 24 438 462
No 20 3098 3118
44 3536 3580
Relative Risk = 4.4; 95% Confidence Interval = (3.3, 5.8); p =
have little bearing on ultimate morbidity or mortality after aortic reconstruction. Recently, hydronephrosis caused by ureteral obstruction after aortic reconstruction has been suggested to be associated with graft complications. S To further characterize this relationship and determine the natural history ofureteral complications after aortoiliac reconstruction, a 33-year experience with aortoiliac reconstruction was retrospectively reviewed. The relationships between ureteral and graft complications and outcome of specific management o f these complications were analyzed and form the basis of this article. CLINICAL MATERIAL
.From the Division of Vascular Surgery, Henry Ford Hospital. Presented at the Thirty-seventh ScientificMeeting of the No~.h American Chapter, International Society for Cardiovascular Surgery, New York, N.Y., June 19-20, 1989. Reprint requests: Calvin B. Ernst, MD, Division of Vascular Surgery, Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI 48202. 24/6/16662
Beginning in 1954, data have been recorded a n d tracked for patients undergoing vascular surgical procedures at the Henry Ford Hospital by means of a computerized vascular registry. Through periodic patient recall and by following established clinical examination and arteriographic protocols, such data 29
30
Journal of VASCULAR SURGERY
Wright et al.
Table I. Aortic reconstruction in 50 patients with ureteral complications Aneurysmal Occlusive disease disease Total Aortobifemoral reconstruction Aortobiliac reconstruction Other* Total
5 18 1 24
22 1 3 26
27 19 4 50
*One mycotic aneurysm figation; three aortoiliac endarterectomies.
have been regularly updated. 6 Information derived from more than 13,000 vascular surgical procedures have been entered into the registry, and from this database, 3580 patients undergoing 3660 aortoiliac reconstructive procedures were identified. Fifty of the 3580 patients undergoing aortoiliac reconstruction were found to have significant ureteral complications, and their records were scrutinized. Ureteral involvement was documented by urography during aortography, intravenous pyelography (IVP), retrograde pyelography, or operation. Patients were followed by a protocol that included yearly examination. During the first 2 decades of the study, routine translumbar aortography was performed in the immediate postoperative period before hospital discharge in 1958 patients and was repeated at 2- to 3year intervals. All 50 patients were followed through 1988 or until death. Follow-up averaged 7.4 years and ranged from 1 month to 20.3 years. The incidence and type of graft complications were assessed, and the outcome of both the graft and ureteral complication was determined in each patient. The incidence of graft complications was also determined for all 3580 patients entered into the database during the period of this study. Statistical methods. Statistical analysis focused on patients with postoperative ureteral complications. Patients with preoperative ureteral complications were counted as patients without postoperative complications. To assess the association between postoperative ureteral and graft complications, each patient was included as having any type of graft complication or any ureteral complication or both. Thus each patient was counted only once regardless of the number of procedures performed or complications identified. A relative risk with a 95% confidence interval was computed. Log-rank analysis and Kaplan-Meier curves, 7 which adjust for varying lengths of follow-up, were used to compare graft complication rates between patients with (n = 44) and without (n = 3536)
postoperative ureteral complications. In this analysis only graft complications occurring after the first operation were used. The length of follow-up was cal-~ culated as the time from first operation to graft complication, date of last examination, or death. Cox proportional hazards regression analysis 8 was used to adjust for age, sex, race, and length of followup and to compare graft complication rates for those patients with and without postoperative ureteral complications. Again, only the first operation was used in this analysis. Risk estimates and confidence intervals were calculated by use of the results from Cox regression. A p value of less than 0.05 was considered statistically significant. RESULTS
Fifty-eight ureteral complications were identified in 50 patients. There were 29 men and 21 w ~ e n with an average age of 61.3 years, ranging from 42 to 78 years. The overall incidence of ureteral complications was 1.4% (50/3580). Twenty-six patients underwent aortoiliac reconstruction for occlusive disease, and 24 patients underwent reconstruction for aneurysmal disease (Table I). Six patients had preoperative ureteral obstruction, graft complications developed in two. The remaining 44 patients had 46 postoperative ureteral complications manifest by hydronephrosis in 42, ureteral leak in three, and ureterat necrosis in one. Ureteral complications were identiffed from 2 weeks to 12 years postoperatively (average, 18.9 months). Early ureteral complications were arbitrarily defined as those detected within 1 year of aortic reconstruction, and late complications were defined as those detected beyond 1 year. Twenty-four patients (55%) had early ureteral c~mplications, and 20 (45%) had late complications discovered from 14 months to 12 years after operation. Thirty-six graft complications developed in 24 of the 44 patients. Graft complications were identifiec~ from 4 weeks to 12.8 years after surgery (average, 3.3 years). Graft complications were evenly divided between the early ureteral complication group and the late ureteral complication group. Twenty-nine of the 44 patients with postoperative ureteral complications underwent ureteral or graft operations or both. These included five patients undergoing ureteral operations alone, seven undergoing a ureteral procedure and subsequent graft operation, eight undergoing simultaneous ureteral and graft procedures, and nine undergoing graft operation and ureteral observation (Table II). SIX of tb_.7
Volume 11 Number 1 January 1990
Ureteral complications and aortoiliac reconstruction
Table II. Patients undergoing graft and/or ureteral operations (n = 29)
20 Patientsureteral operations
5 Ureteral operations alone 7 Ureteral operations with subsequent graft operataon 8 Simultaneous ureteral/graft operations 9 Graft operations / ureters observed
Table I l L Management of postoperative ureteral complications in 44 patients Management
24 Patientsgraft operations
31
Observation, initially Improved or unchanged Progressive obstruction requiring operation Operation, initially Primary urologic indication Associated with graft revision
No. patients
Ureteral entrapment
28 24 4
0
16 8 8
3 3
Operative mortality 6/29 = 21%.
29 patients (21%) died after operation, all of graft complications, including three aortoenteric fistulas, two ruptured anastomotic aneurysms, and one graft in£f~fion. URETERAL COMPLICATIONS Preoperative ureteral complications. Six patients with preoperative ureteral obstruction included two who were anuric, one with pyohydronephrosis, and three with asymptomatic hydronephrosis. All had evidence of retroperitoneal inflammation at the time of their aortic reconstruction manifest by localized edema, hyperemia, and thickened retroperi~oneal tissues. One patient had an inflammatory abdominal aortic aneurysm, and another had an infected iliac artery aneurysm associated with an aortic aneurysm. One patient underwent nephroureterectomy 1 month before aortic aneurysm repair for pyohydrofiephrosis caused by ureteral compression by the aneu ,,'sm. In four of the remaining five, ureteral operations were performed during aneurysm repair, including two ureterolyses, one segmental ureterectomy and reanastomosis, and one cutaneous ureterostomy. One patient underwent aneurysm repair with ureteral stenting alone. Five of the six required no further urologic operations. The patient who underwent a cutaneous ureterostomy during repair of an aortic and infected iliac artery aneurysm required nephrectomy 1 month after operation for unrelenting urosepsis. All patients had normal postoperative renal fimction except one of the two who were anuric before operation. Postoperative ureteral complications. Fortyfour patients had 46 ureteral complications after aortoiliac reconstruction. Twenty-eight patients, all with asymptomatic hydronephrosis, were initially ob~ . v e d (Table III). In 24 of these, the obstruction
either did not progress in 10, or it resolved spontaneously in 14. Operation for progressive ureteral obstruction was required in the remaining four patients (14%). Three underwent ureterolysis and the fourth underwent segmental ureteral resection and reanastomosis. None of these patients had ureteral entrapment between the graft and host iliac artery. Sixteen patients, eight with no symptoms and eight with symptoms, had 18 ureteral complications and were operated upon when the complication was first recognized (Table III). Eight patients, three of whom were found to have the ureter lying behind the prosthetic graft, underwent ureteral procedures during graft revision, including four ureterolyses and four ureteral resections and reanastomoses. Those with entrapped ureters all underwent ureteral division, transposition, and reanastomosis. The other eight patients underwent urologic operations alone for hydronephrosis, with partial ureteral obstruction in four, hydronephrosis with ureteral leak in three, and an obstructed, nonfimctioning kidney in one. Three of these had ureteral entrapment between the graft and iliac artery. Ureterolysis was performed in four patients, including one with an entrapped ureter who also underwent graft division, ureteral transposition, and graft reanastomosis. Ureteral division and reanastomosis were performed in two patients including one with an entrapped ureter, and nephroureterectomies were performed in two including one with an entrapped ureter. Therefore six of these 16 (38%) patients and six of all 20 (30%) eventually requiring ureteral operations were found to have the ureter lying between the prosthetic graft and host iliac artery (Table III). All patients undergoing ureteral reconstruction had documented improvement by follow-up urographic studies. No patient experienced chronic renal failure. Among 24 of the 44 patients (55%) the ureteral complications were recognized within a year of aortic
32
Journal of VASCULAR SURGERY
Wright et al.
Table IV. Graft complications in 3580 patients undergoing aortoiliac reconstruction with and without postoperative ureteral complications
Table V. Postoperative ureteral complications vs graft complications Graft complication
Complication Patients ~ 44 Patients with postoperative ureteral complications Anastomotic aneurysm Graft thrombosis Graft infection Aortoenteric fistula 3536 Patients without postoperative ureteral complications Anastomotic aneurysm Graft thrombosis Graft infection Aortoenteric fistula
19 8 6 3
16 7 6 3
395 218 25 19
270 202 25 19
~Some patients had more than one graft complication.
reconstruction. Nine (38%) of these required ureteral reconstructions, three of which were performed during aortic graft revision. In 20 patients (45%) the ureteral complications were recognized more than 1 year after aortic reconstruction. Eleven (55%) required ureteral reconstructive procedures, five during aortic graft revisions. These differences were not statistically significant. Graft complications Twenty-four of the 44 patients (55%) with postoperative ureteral complications experienced 36 graft complications, an average of 3.3 years after operation, ranging from 1 month to 12.8 years. Some patients had more than one graft complication. Nineteen anastomotic aneurysms developed in 16 patients, three of whom had two anastomotic aneurysms (Table IV). Eight graft limb thromboses occurred in seven patients. Graft infections developed in six patients, and aortoenteric fistulas developed in three. There were six postoperative deaths in these 24 patients resulting from the graft complications. Graft complications developed in 12 patients with early ureteral complications. In two of these patients, both with anastomotic aneurysms, the ureteral complication was recognized during management of the anastomotic aneurysm. In the remaining 10, ureteral complications were identified before graft complications were noted. Similarly, graft complications developed among 12 patients with late ureteral complications. The ureteral complication preceded the diagnosis of graft complication in five of these patients and was recognized during management of the graft problem in the other seven.
Ureteral complication Yes No Total
Yes 24 438 462
No 20 3098 3118
44 3536 3580
Relative Risk = 4.4; 95% Confidence Interval = (3.3, 5.8); p =
