A systematic approach for successful repair of radiated and non-radiated ureteral injuries

Abstract

Background: Successful ureteral reconstruction is challenging, particularly in radiated fields. We characterize and directly compare surgical outcomes in modern cohorts of radiated and non-radiated patients undergoing ureteral reconstruction utilizing a systematic approach to pre-operative assessment. We hypothesize that radiated patients will undergo more complex ureteral reconstructions and experience higher rates of surgical failure and complications compared to nonradiated patients.

Methods: Consecutive cases of ureteral reconstruction for acquired ureteral injury performed by a single surgeon from 2010-2018 were retrospectively reviewed. Clinical data were collected including pre-operative bladder capacity, ureteral injury characteristics, and surgical technique. Ileal ureter and autotransplantation were classified as "complex" ureteral repairs, and surgical success was defined as freedom from surgical revision of the ureteral anastomosis and/or ureteral stenting.

Results: There were 47 ureteral reconstructions performed including 17 (36%) radiated patients. Radiated patients had lower pre-operative bladder capacity and were more likely to undergo complex repairs compared to non-radiated patients (35% vs. 7%, P=0.01). Overall surgical success was high (98%) and similar between radiated (94%) and non-radiated groups (100%) at median follow up of 30 months. Clavien grade 3-4 complications occurred in 18% of radiated and 10% of non-radiated patients (P=0.48).

Conclusions: Careful pre-operative evaluation and appropriate selection of surgical technique facilitates high and similar success of ureteral reconstruction in radiated and non-radiated patients. Complex ureteral repairs were more common in radiated patients, however the majority of radiated ureteral injuries (65%) were reconstructed without tissue transfer. Radiated patients had lower pre-operative bladder capacities, but similar surgical morbidity, renal function, and persistent urge incontinence compared to non-radiated patients.

Keywords: Disease; radiation injury; reconstructive surgical procedure; ureteral.

Figure 1

Our suggested approach to evaluation and management of ureteral injuries in both radiated and non-radiated patients. This approach centers on preoperative evaluation of the location of the injury, assessment of bothersome lower urinary tract symptoms at least four weeks after ureteral stent removal, and measurement of anatomic bladder capacity. We propose most radiated distal ureteral injuries with bladder capacity >300 mL can be reconstructed using ureteroneocystostomy techniques with psoas hitch and/or Boari flap. More proximal injuries and/or distal injuries in radiated patients with minimal bladder capacity or persistent incontinence should be considered for bowel interposition with ileal ureter, renal autotransplantation, or urinary diversion. PCN, percutaneous nephrostomy tube; LUTS, lower urinary tract symptoms.

Figure 2

Representative preoperative, post-operative, and follow-up imaging in three radiated patients. Patients 1 and 2 both developed left ureteral strictures following radiotherapy for cervical cancer. Pre-operative urodynamics revealed bladder capacities above 300 mL without bladder instability and both were managed successfully with a ureteral reimplant augmented with a psoas hitch. Patient 3 had bilateral ureteral strictures from cervical radiotherapy and a 200 mL bladder capacity. Urinary diversion was offered, but patient elected bilateral ileal ureter (here shown as a reverse-7 repair).