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The patient was readmitted two weeks later with an asymptomatic yeast cystitis, which was treated with a short course of intravesical irrigation with amphotericin. At that time, the ureteral catheter was removed, and a retrograde pyelogram showed no extravasation (Fig. 2A). Mild narrowing of the ureter in the area of the anastomosis was seen, but was thought to represent edema. An intravenous pyelogram obtained two months postoperatively was essentially unchanged from the preoperative study (Fig. 2B). The patient has continued to do well six months postoperatively. Comment

FIGURE

1.

Preoperative

aortogram.

the aneurysm, the right ureter was inadvertently transected. The proximal ureteral stump was clamped, and the urology service was consulted intraoperatively. The aneurysm was repaired with a Microvel graft. Attention was next directed to the injured ureter. A double-J catheter was easily passed in a retrograde manner into the renal pelvis; however, the catheter could not be easily passed through the distal ureter into the bladder. A cystotomy was performed, and a double-J catheter was passed to the kidney in a retrograde manner over a guide wire. A spatulated, end-to-end ureteroureterostomy was performed with interrupted 5-O chromic suture, and the ureteral anastomotic site was wrapped with fat, as dense adhesions from prior operations prevented adequate mobilization of the omentum. Closed system drains were placed adjacent to the anastomotic site and in the prevesical space. The patient’s early postoperative course was complicated only by a small subcutaneous seroma formation and superficial wound breakdown at the inferior-most aspect of the midline incision. The retroperitoneal drain was removed forty-eight hours postoperatively after minimal output, and the prevesical drain was removed six days postoperatively. A cystogram obtained ten days postoperatively showed no extravasation or hydronephrosis, and there was good reflux via the ureteral stent on the right. The Foley catheter was removed, and the patient was discharged home two weeks postoperatively.

78

Although many reports have addressed the risks, short- and long-term patency rates, and early and late complications of abdominal vascular surgery, ureteral complications are rarely reported. A thirty-year survey of 1,748 aortic reconstructive operations at one hospital reported 14 (0.8 %) “early ureteral complications” and 38 (2.2 % ) late incidences of ureter al stenosis.g Most reports of iatrogenic ureteral injuries, including those occurring during vascular procedures, are found in the urologic literature (Table I). Factors which may increase the risk of ureteral injury during vascular reconstruction include cases associated with perianeurysma1 fibrosis, pseudoaneurysms of the aorta, redo vascular reconstructive procedures, and cases associated with extensive retroperitoneal dissection and hemorrhage. w Entrapment of the ureter in perianeurysmal fibrosis has been reported to occur in 5 to 23 percent of aortic aneurysms. ‘” Preoperatively placed ureteral catheters may assist in ureteral identification; however, dense adhesions may prevent their palpation, and ureters have been severed even in the presence of such catheters.” Direct ureteral injury, including laceration, transection, stitch puncture, clamping, and ligation of the ureter with or without extravasation of urine can lead to wound infection, abscess formation, vascular graft infection, ureteral-graft fistulization, ureterocutaneous fistulization, and periureteral fibrosis with subsequent ureteral obstruction.3.7,s.12 In addition, excessive ureteral adventitial dissection or stripping can result in ureteral ischemia and necrosis with slough and fistula or stricture formation, as the lumbar ureter has a relatively tenuous blood supply. ’ I2 lD The intraoperative identification of the site and extent of the ureteral

UROLOGY

i

JANUARY 1902

/ VOLUMK

XXXIS. Nl~hll3l~:R 1

l:rc:u~wvling. Corriere, and Sandlrri4 ‘1’O~i~Ai.S hl,> A’1 aortrJ!iliac. ‘I~:\cl11flc5 wfiric3 including

10 (32) 16 (18) 8 (19) ‘i I, (38) ;,

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ma\: he facilitated by intravenous injecinjury tion of indigo carmine or methylene blue dye. Frequentlv. ureteral injuries are not discovered at the 6me of an operation (Table I). The most common postoperative symptom of ureteral injury is flank pain, which may be colicky or persistent and dull. Other signs of injury are fever, adynamic ileus, abdominal distention, and fistula formation.‘~“.H~‘4~‘6 The workup should include an intravenous urogram and, if necessary. cystoscopy and retrograde or antegrade pyelography. Postoperative ureteral obstruction can be secondary to ureteral ligation or compression or to the late development of

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retroperitoneal fibrosis, and latent obstruction may be asymptomatic. A vascular graft placed anterior to the ureter can predispose to ureteral obstruction, and current techniques utilize posterior placement of grafts.‘* 2” A review of the literature by Sant et al.lg reported ureteral obstruction after aortic surgery to be secondary to direct surgical injury in only 5 percent of cases and to retroperitoneal fibrosis and/or pseudoaneurysm formation in the remainder. Extensive retroperitoneal dissection \xGth subsequent hematoma formation or devascularization of the ureter can result in extrinsic fibrosis in the periureteral tissue and in intrinsic

recognltlon

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Ureteral Injury suspected postoperatively

in,ury

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Major Ureteral ~n,ury suspected .

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1 Followup Pyelography

Complicated

Ureteral

_

peylography

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I Ureteral catheter placement and observatton

.

ln~ury

+

Perl”;eteral I Abscess and or

Ureteral obslruct1on

F!stula formatIon

Nephreciomy

TUU

1 lndwelllng ureteral catheters dllatatlon

Extra-anatomic vascular bypass

EXCISION of ureteral segment. uu ClYer stent. Omental sleeve

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EXCISION of ureteral segment uu oYer stent Omental

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DIVISION and reposltlonlng Of “” TUU

graft poster,or lo ureter

UreterO”ieteroStomy Transureteroureterostomy

FICURE~. Management thetic vascular grafts.

algorithm for iatrogenic ureteral injuries in presence

sclerosing fibrosis of the ureteral muscularis. 18,~1 A prospective study by Heard and Hindez2 reported an incidence of unilateral or partial obstruction in 10 percent of patients one year after aortic bypass surgery (excluding patients with aortic aneurysms). In addition, 10 percent of patients with ureteral obstruction experienced ultimate renal loss. lg The operative approach to the ureteral injury in the presence of an aortic graft is controversial (Fig. 3). The high morbidity and mortality rates of a prosthetic vascular graft infection3*4 have led some authors to advocate consider-

80

of pros-

ation of a primary nephrectomy on the involved side if contralateral renal function is normal.1~2~11This approach avoids the potential complication of a ureteral anastomotic leak as a source for vascular graft infection. An accurate intraoperative assessment of differential renal function may not be possible without adequate preoperative evaluation. In addition, a loss of 50 percent of functioning nephrons by nephrectomy could prove to be significant in many patients with a marginally elevated serum creatinine level and in others with a normal serum creatinine but a compromised creatinine

UROLOGY

/ JANUARY1992 / VOLUMEXXXIX,NUMBER

1

clearance or as a result of hyperfiltration in the remaining nephron nlass.23 Many authors recommend a primary ureteroureterostomy over an indwelling stent with isolation of the ureteral anastomotic site from the vascular graft by means of an omental sleeve, such as described by Zinman, Libertino. and Roth.” Animal studies by Finney and Rinkerz4 showed that omentum used as a sleeve results in rapid sealing of the anastomosis, thus minimizing the leakage of urine and subsequent development of periureteral cicatrization. The study also showed better results without than with nephrostomy tube drainage, and all reHowever, proximal pairs were stented. nephrostomy tube diversion of urine in the presence of an aortic graft has been recommended bv others.2,” * The use of short-term closed systern drains to prevent early leakage and urinoma formation in these cases is controversial. Ureterolysis is the preferred operative approach to patients with ureteral obstruction secondary to fibrosis in the presence of vascular grafts. 1g.21Dense scarring may require resection of the involved ureteral segment with ureteroIrreterostomy in the same manner as for ureteral injuries. ‘g In addition, ureters may be injured during ureterolysis and require primary repair. Transureteroureterostomy has been proposed as an alternative in cases of unilateral obstruction.20 Anteriorly placed aortoiliac or aortofemoral grafts that secondarily obstruct the ureter are best treated by division and reanastomosis This avoids potential infection of the graft. 11)~25 of the graft by ureteral anastomotic complications, A management algorithm for ureteral injuries in the presence of prosthetic vascular grafts (Fig. 4) summarizes the various potential repair options based on whether the injury is recognized intraoperatively versus postoperatively. Primary repair is a reasonable option when the transected ureteral margins are viable, when the urine is uninfected, and if the contralateral kidney is normal. Other important repair principles include internal ureteral stenting and separation of the ureteral anastomosis from the vascular repair. If the requisite conditions for primary ureteral repair are not present, and if renal salvage is deemed important, ligation of the proximal ureter and nephrostomy insertion may be done, followed by secondary ureteral reconstruction. Because of the potential for both early and late complications following lrreteral repair in the presence of vascular graft

l;Ho1,o(:‘l

).4NlARY

I992

VOI,UME

XSNl?i.

NUMBER

material, close clinical and uroradiographic low-up is mandatory.

fol-

Department of Urology 1’0. Hex 33932 Shreveport, Louisiana 71130-3932 (DR. MATA) References 1. Bright TC, and Peters PC: Ureteral injurir\ secondary to operative procedures, Urology 9: 22 (19771. 2. Guerriero WC. and Devine CJ Jr: Urologic Injuries, Norwalk, CT, Appleton-Century-Crofts, 1984. p 54. G. Lorentzen JE, et al: Vascular graft infection: an anal!-sis of sixty-two graft infections in 2,411 consecutively implanted synthetic vascular grafts, Surgery 98: 82 (1985). 4. Yeager RA, McConnell DB, Sasaki TM, and Vetto KM: Aortic and peripheral prosthetic graft infection: differential management and causes of mortality, Am J Surg 150: 36 (1985). 5. Higgins CC: Ureteral injuries during surgery, JAMA 199: 118 (1967). 6. Schapira HE, rr ul: Iireteral injuries durinr: vascular surgery, j Urol 125: 293 (1981). 7. Selman SH, Hampel N. and Persky L: Ureteral injury: complication of partial excision of aortofemoral va:;cular prosthesis. J Urol 126: 817 (1981). 8. Zinman LM, Libertino JA, and Roth HA: Management of operative ureteral injury, Urology 12: 290 (1978). 9. Szilagyi DE, er ~1: A thirty-year survey of the reconstrrmtivc surgical treatment of aortoiliac occlusive disease. J Vast Srrrg 3: 421 (1986). 10. Sethia B, and Darke SG: Abdominal aortic aneurysm with retroperitoneal fibrosis and ureteric entrapment. Br J Surq 70: 434 (1983). 11. Fry DE, Milholen L, and Harbrecht PIi: latrogenic, ureteral injury, Arch Surg 118: 454 (1983). 12. Henry LG, and Bernhard VM: IJreteral pathology associated with aortic surgery: a report of three m1usuaI cases. Surgery 83: 464 (197X). 13. Ihse I, Arnesjo B, and Jonsson G: Surgical injuries of the ureter, Stand J Urol Nephrol 9: 39 (1975). 14. Dowling RA, Corriere JN, and Sandltr

Ureteral injury in abdominal vascular reconstructive surgery.

Iatrogenic ureteral injuries in vascular reconstructive surgery are rarely reported. We present a case of ureteral transection during repair of an aor...
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