Transvaginal ureteroneocystostomy

Abstract

Ureteral injury is a known complication of gynecologic surgery with potential long-term sequelae. Traditional management of significant ureteral injury recognized at the time of transvaginal pelvic organ prolapse repair is a transabdominal re-implantation procedure using a transabdominal open or laparoscopic approach. We present a case describing a transvaginal approach for ureteroneocystostomy. During a transvaginal pelvic organ prolapse repair, a ureteral transection was noted. A transvaginal ureteroneocystostomy was performed. There was primary healing of the ureteroneocystostomy without sequelae during a 6-month follow-up period.

Keywords: Transvaginal; Ureteral injury; Ureteroneocystostomy.

Fig. 1

Transected ureter prepared for reimplantation. In this illustration, the transected right ureter is noted. The proximal ureter has been splayed approximately 1 cm at the 6 o'clock position and tagged with a 4-0 poliglecaprone 25 suture. This increases the diameter of the anastomosis. The distal transected ureter is ligated with a 2-0 polyglactin 910 suture. Cystoscopy has been performed to make sure no other defects are present. Through trans-illumination, an appropriate site for ureteral re-anastomosis is identified and marked with a 4-0 poliglecaprone 25 suture on the bladder muscularis. Transurethrally an M.D. Anderson clamp is used to create a 1 cm cystotomy as depicted.

Fig. 2

Ureteroneocystostomy performed with placement of a ureteral stent. A. The ureteroneocystostomy is initiated at the 6 o'clock position using the previously placed full-thickness 4-0 poliglecaprone 25 ureteral suture. Additional full-thickness 4-0 poliglecaprone 25 sutures are placed at 12, 2, 4, 8 and 10 o'clock in the cystotomy incision and tagged. It is important to place the sutures such that the knots are external. Of note, the M.D. Anderson clamp is used to gently open the cystotomy for proper suture placement. B. With the M.D. Anderson clamp in place the anastomosis is initiated at the 6, 4 and 8 o'clock positions. At this point, the distal end of a 0.035-inch ureteral guidewire is grasped with the M.D. Anderson clamp and brought through the urethra. The proximal flexible end of the guidewire is directed into the renal pelvis. C. The remaining full-thickness 4-0 poliglecaprone 25 sutures at 12, 2 and 10 o'clock are placed and tied. A 6 French double pigtail soft ureteral stent is then placed over the guidewire with the proximal end in the renal pelvis and the distal in the bladder. The guidewire is then removed. This illustration shows the anastomosis complete with the ureteral stent in place. The anastomosis is reinforced with four 4-0 poliglecaprone 25 sutures incorporating the serosa of the ureter and the bladder muscularis.

Fig. 3

CT urogram performed at approximately 2 weeks postoperatively noting no evidence of a urinary leak. A CT urogram is performed at approximately 2 weeks postoperatively and if there is no evidence of an anastomotic leak a voiding trial is initiated. The ureteral stent is then removed cystoscopically at approximately 4 weeks postoperatively. Imaging to evaluate for hydronephrosis is performed at 3 and 6 months postoperatively. This can generally be accomplished with renal ultrasound.