Trends in ureteral surgery on an academic gynecologic oncology service.

OBJECTIVE: To describe the incidence, complications, and trends associated with ureteral surgeries on a gynecologic oncology service in the context of a fellowship training program over a 24-year period. METHODS: We conducted a retrospective cohort analysis of ureteral surgeries by gynecologic oncologists at either Moffitt Cancer Center or Tampa General Hospital from 1997 to 2020. Patient characteristics, predisposing factors, location and type of injury, repair method, postoperative management and complications were abstracted from the medical record. The recent cohort (2005-2020) was compared to our prior series (1997-2004). RESULTS: Eighty-eight cases were included. The average number of ureteral surgeries per year decreased from 5.75 (1997-2004) to 2.63 (2005-2020). Of 46 iatrogenic injuries, 45 were recognized and repaired intraoperatively. Ureteral transection was the most common type (85% [39 of 46]) and the distal 5 cm was the most common location of injury (63% [29 of 46]). Ureteroneocystostomy was the most common method of repair (83% [73 of 88]). Postoperative management, including stenting and imaging, has not changed significantly. Length of urinary catheter usage decreased in the recent cohort without associated complications. Five patients had major postoperative complications and 4 involved the urinary tract. Of those with follow-up, 96% (66 of 69) of ureteroneocystostomies and 75% (9 of 12) of ureteroureterostomies had radiologically normal urinary tracts. CONCLUSIONS: Ureteral surgery is necessary in the case of injury or involvement with invasive disease. There has been a decrease in number of procedures. Ureteroneocystostomy has remained the most common method of reconstruction for both injury and resection with acceptable postoperative complication rates.

Resolución endoscópica combinada de una estenosis yatrógena en una ureterosigmoidostomía / Combined endoscopic resolution of iatrogenic stricture in an ureterosigmoidostomy

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Toxina botulínica en el fracaso del cierre de derivaciones urinarias altas / Botulinum toxin in the failure of high urinary diversion closure

Introducción: El cierre de las derivaciones urinarias realizadas en la edad neonatal tiene un no despreciable porcentaje de fracasos en pacientes con patología vesical. Presentamos el uso de toxina botulínica como alternativa útil y mínimamente invasiva para el tratamiento en estos pacientes. Material y métodos: Presentamos dos pacientes monorrenos con valvas de uretra posterior (VUP) en los que fue necesario realizar ureterostomía por insuficiencia renal severa. En ambos pacientes fracasó el intento posterior de cierre de la derivación. Con 4 y 10 años de edad presentaban vejigas conocidas comúnmente como «vejigas secas», con baja capacidad (20 y 110ml), mala acomodación (1,5 y 3,1ml/ cm H2O) y altas presiones de apertura del detrusor. Se realizó punción en el detrusor de toxina botulínica-A 10 UI/ kg en una y dos ocasiones respectivamente previas al cierre de la derivación. Resultados: En ninguno de los pacientes hubo empeoramiento clínico ni ecográfico tras el cierre de la derivación, permaneciendo la función renal sin cambios respecto a la previa tras uno y 4 años de seguimiento, respectivamente. La videourodinámica al año de la intervención muestra una gran mejoría de la capacidad vesical (451 y 250ml), de la acomodación (20,4 y 81,9ml/ cm H2O) y de la presión de apertura del detrusor. Conclusiones: El cierre de las derivaciones urinarias altas tiene un porcentaje de fracasos elevado en niños con vejigas patológicas con presiones elevadas. La toxina botulínica puede ser útil como tratamiento vesical previo al cierre de la derivación, especialmente en pacientes monorrenos (AU)

Introduction: The closure of urinary diversions performed on newly born infants has a notable failure percentage in patients with bladder disease. We present the use of botulinum toxin as a useful and minimally invasive alternative to treat these patients. Material and methods: We present two patients with a single kidney and with posterior urethral valves (PUV), in whom it was necessary to perform a ureterostomy due to chronic kidney disease. In both patients, the subsequent attempt to close the diversion failed. Aged 4 and 10years respectively, they presented bladders commonly known as “dry bladders”, with a low capacity (20 and 110ml), bad adaptation (1.5 and 3.1ml/ cm H2O) and high opening detrusor pressure. A 10 UI/Kg botulinum toxin A puncture was applied in the detrusor on one and two occasions respectively, prior to the closure of the diversion. Results: Neither of the patients suffered clinical or ecographic worsening after the closure of the diversion and their kidney function continued without change with respect to the first diversion after one and four years of follow-up respectively. One year after the surgical procedure, video urodynamics showed a significant improvement in bladder capacity (451 and 250ml), in adaptation (20.4 and 81.9ml/cmH2O) and in the opening detrusor pressure. Conclusions: The closure of high urinary diversions has a high failure percentage in infants with pathological high-pressure bladders. Botulinum toxin may be useful as bladder treatment prior to closure of the diversion, especially in patients with a single kidney (AU)

Ureterocalicostomy: a contemporary experience.

OBJECTIVES: To report our contemporary experience with ureterocalicostomy to determine whether the indications or results have changed in modern practice. Ureterocalicostomy is a well-established treatment for patients with complicated ureteropelvic junction (UPJ) obstruction and other forms of proximal ureteral obstruction. Although both retrograde and antegrade endourologic interventions have become accepted forms of management, the success rates do not approach those of open or even laparoscopic interventions, potentially leading to a greater number of patients with treatment failure and the need for more complicated reconstruction. METHODS: Between July 1991 and February 2004, 11 patients (4 women and 7 men), aged 19 to 68 years (mean 38), underwent open surgical ureterocalicostomy. The indications for surgery were primary UPJ obstruction in 4, failed cutting balloon incision for UPJ obstruction in 3, proximal ureteral stricture after ureteroscopic stone removal in 2, and obliterated UPJ after percutaneous nephrolithotomy and failed antegrade endopyelotomy in 1 patient each. RESULTS: Hospitalization ranged from 4 to 7 days (mean 5.1). No patient experienced a significant perioperative complication. With follow-up ranging from 5 to 32 months (mean 10.1), relief of obstruction was evident in all patients as documented by intravenous urography or nuclear renography. Furthermore, differential function on the involved side improved from a mean of 54.6% preoperatively to 60.1% postoperatively (P <0.05). CONCLUSIONS: The spectrum of indications for ureterocalicostomy has changed, although excellent results can still be achieved. Although laparoscopic approaches are currently being evaluated, most patients currently undergoing this reconstructive procedure still require open operative intervention.