Date: Tue, 10 Nov 2009 19:44:06 -0500 From: Kurian Thott Subject: Ureter repair laparoscopically

Recently involved in a case where the ureter was transected during a TLH, (at the level of uterine artery) it was discovered during cystoscopy after we finished the case (which I do after all cases) and after attempting to pass a stent and finding resistance, we went laparoscopically only to find the stent staring back at us. (after recovering from the vasovagal event) we had urology consulted. During the time we were waiting, I found the caudal end, opened it up, found urine and proceeded to pass the distal end stent into the caudal end, taking a few mm of the caudal end off to freshen the edge. I then started to repair the ureter laparoscopically. Two layer closer with 3-0.
It actually came together well, took about 20 mins. Urology arrived and I explained the repair, and they felt that a re-implant was the best way to go.
Stated that the stricture rate was 50%.I left it to their expertise and we performed an re-implant (open). I have done a literature search and could not
find any data that really supported either of our claims well. As I felt that it was a good end-to-end re-anastomosis maybe the primary repair would have
been a good option.
Does anyone have any experience out there with this? Any results published or anecdotal? The pt. had a 18 wk uterus with large fibroids (650g) extending to the side wall. Did well post-operatively and the re-implant working well.
Kurian Thott MD Women’s Health and Surgery Center Stafford, VA

First Response
Date: Wed, 11 Nov 2009 17:20:26 -0500 From: “Philippe R. Koninckx and Anastasia Ussia” Subject: Ureter repair laparoscopically
Laparoscopic ureter repair is a very important question for gynaecologists. We recently reviewed the literature (JMIG 2008) and reviewed our own data (Fertil steril, november 2009), predominantly following endometriosis surgery ( http://www.gynsurgery.org/topics/endometriosis-overview/surgical-therapy/#ureter ) .Taking all data together the following conclusions can be made
1. The literature contains asthonishing few data, as was confirmed here. A larger part of ureter surgery today therefore is based upon experience, authority, personal opinion and dogma’s.
2. What has changed, is evidence of the following
- blind stenting of a leak should be replaced by laparoscopically aided stenting and a stitch. Given the significant differences in outcome (50% versus 100% success) in both series, blind stenting today should no longer be performed.
- we retrieved 8 laparoscopic ureter reanastomoses and did 8 ourselves and all had an uneventful outcome. 16 is not a big series but it seems enough for us to conclude that laparoscopic reanastomosis should be considered the treatment of choice, leaving the ureter reimplantation as a secondary treatment when the first treatment fails .
- whether diagnosis and teatment is made during surgery or some days later does not affect outcome. This I think is medicolegally extremely important for us gynaecologists. In addition with these data we may suggest that if a repair has not to be done immediately, we do have the option to refer the patients a few days later to somebody who can do a laparoscopic repair/reanastomosis, thus avoiding the mutilating (boari flap) ureter reimplantation.

Second Response
Date: Sun, 22 Nov 2009 11:47:58 -0500
From: Philippe Koninckx and Anastasia Ussia
Subject: Ureter repair laparoscopically

Reading with interest the comments a word of caution seems appropriate since
there are to the best of my knowledge little data published permitting to
support one or another opinion about technique. If we only have opinions
based upon anecdotal experience I would suggest the following for our points
of discussion

1. Since strictures occur, it is wise to have an oblique suture (and or
spatulation) in order to decrease the risk of stricture

2. It is unclear whether suture should be water tight (6 sutures) or whether 4
are sufficient

3. It is unclear which type and diameter of suture should be used:
considering the size of the ureter a 4*o or 5*o seems to be a compromise

Philippe Koninckx and Anastasia Ussia

Disclosures : Licensor of patents to storz AG through the University of Leuven, Advisor to Covidien, Wyeth, TAP and Bayer. eSaturnus run by 2 sons

Philippe R. Koninckx and Anastasia Ussia
Uiversity of Leuven, Belgium and Gruppo Italo-Belga, Roma Italia