Management of postoperatively detected iatrogenic lower ureteral injury: should ureteroureterostomy really be abandoned?

OBJECTIVES

To reevaluate the role of ureteroureterostomy in the management of postoperatively detected iatrogenic lower ureteral injury. Despite the advantages of preserving the integrity of bladder and the natural antireflux mechanism, open end-to-end ureteroureterostomy is rarely performed today for treatment of lower ureteral injury diagnosed postoperatively.

METHODS

A retrospective analysis was performed of 9 patients (all women, mean age 49.2 years) who had received end-to-end ureteroureterostomy from 1998 to 2002 for postoperatively detected iatrogenic lower ureteral injuries sustained during gynecologic or general surgery.

RESULTS

All patients had the intact distal ureteral stumps identified by retrograde pyelography before undergoing ureteroureterostomy. Open end-to-end ureteroureterostomies with double-J catheter stenting were performed as soon as the diagnosis had been made (interval from injury to repair 10 days to 21 weeks). The mean length of the eventually resected segments of the injured lower ureter was 2.7 cm, and the mean distance between the distal margin of the injured ureteral segment and the ureterovesical junction measured intraoperatively was 2.9 cm. Renal mobilization was required in 1 patient. In 1 patient who had a bilateral ureteral injury, ureteroureterostomy was performed on only one side, with a psoas hitch on the contralateral side. In all cases, the initially observed hydronephrosis and fistula disappeared after surgery, and no complications were observed during a mean follow-up of 33.7 months (range 6 to 55).

CONCLUSIONS

Ureteroureterostomy may still be considered a realistic treatment option in the case of postoperatively detected iatrogenic lower ureteral injuries with distal ureteral stumps preserved and identified on retrograde pyelography.