ureteral injuries: damage control to reconstruction · • tag ureter – nonabsorbable suture •...
TRANSCRIPT
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Ureteral Injuries:
Damage Control to Reconstruction
E. Charles Osterberg, MD
Assistant Professor of Surgery (Urology)
Dell Medical School
Chief of Urology and Genitourinary Reconstruction at DSMC
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Disclosures
• None
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Outline
• Case presentation
• Damage Control
• Iatrogenic Injury
• Ureteral Reconstruction
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Outline
• Case presentation
• Damage Control
• Iatrogenic Injury
• Ureteral Reconstruction
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Case
• 33 yo M o/w healthy GSW to RLQ
• GCS 12
• VS on arrival: 37.7,134, 88/46, 95% on NRB
• CXR WNL
• Taken to OR for Exlap
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Case
• Injuries
– Right Common Iliac artery transection
– Right mid ureteral transection
– Right colon injury
– Psoas hematoma
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Right ureter transection
Right Common Iliac Artery Shunt
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OR
• Bypass R-CIA
• Ureter tied off
• Bowel reconstruction
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Case Questions
• When to reconstruct?
• How to reconstruct?
– Length of defect ~2-3 cm
– Bladder capacity = 400mL
– Location = iliac crossing
• Optimal drainage until reconstruction?
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Outline
• Case presentation
• Damage Control
• Iatrogenic Injury
• Ureteral Reconstruction
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Damage Control for Ureteral Injury
• Identification – Contusion
• Ureteral J Stenting
– Transection • Tag ureter – nonabsorbable suture
• If transection Diversion – Clip and place delayed Nephrostomy (w/in 24 hours)
– Ureterostomy to skin as stoma
– Stent to Skin
Azimuddin et al. J Trauma. 1997
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Damage Control for Ureteral Injury
– Ureterostomy to skin as stoma
– 5 French Ureteral stent tunnel to skin
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Damage Control for Ureteral Injury
• Next 24 hours:
– Imaging: CT Urogram (delay images) to stage contralateral ureter / kidney
– Maximal urinary diversion: stent + Foley catheter
– Thoughtful multidisciplinary discussion on timing of ureteral reconstruction
Morey et al. Urotrauma AUA Guidelines. JUrol. 2014
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Outline
• Case presentation
• Damage Control
• Iatrogenic Injury
• Ureteral Reconstruction
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Incidence
• Gynecologic surgery: 0.5% – 7%
• Colonrectal Surgery 0.3% - 5.7%
• Urology 1%-5%
Brandes et al Consensus on Genitourinary Trauma. BJU Int 2004; 94, 277-289
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Occurrence
• Most ureteral injuries occur during ‘routine’
and ‘uncomplicated’ surgery on patients
with no identifiable risk factors
• Approximately 2/3 are missed initially
High index of suspicion is required
Brandes et al Consensus on Genitourinary Trauma. BJU Int 2004; 94, 277-289
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• Distal 1/3rd is most common iatrogenic location of injury
• GYN:
• At uterine vessels which pass in mesometrium / cardinal ligament
• At pelvic brim posterior to IP Ligament (ovarian vessels)
• Colorectal:
• Lateral rectal attachments
Common Locations of Injury
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Early Recognition and Evaluation
• Isolate and visually inspect e.g. contusion
• Indigo Carmine leak test
• Retrograde pyelogram
• Stent placement
Zinman et al. Surgical management of Urologic Trauma and Iatrogenic Injuries. Surg Clin North Am. 2016
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Delayed Recognition and Timing of Repair
• > 7d since injury longer operative time
• No difference in outcomes, re-stricture
rates
• Timing of Repair
– Patient stability
– Appropriate diagnostic work up
Ahn et al. Urology 2001.
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Injury Types and Treatment • Transection
– Partial (< ½ diameter): primary closure over stent
– Complete (>½ diameter): reconstruction
• Suture ligation – Release of suture and stenting
• Crush Injury – Highly variable: stent reconstruction
• Devascularization – Delayed urine leak / Stricture
– Stent + Omental flap vs. reconstruction
Brandes et al Consensus on Genitourinary Trauma. BJU Int 2004; 94, 277-289
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Prevention
Osterberg et al. Feasibility and Safety of Robotic Distal Ureterectomy. J EndoUrol. 2013
• Anticipation
• Hemostasis
• Preoperative Ureteral Stenting
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Outline
• Case presentation
• Damage Control
• Iatrogenic Injury
• Ureteral Reconstruction
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• Location
• Length
• Tension-free
Principles of Reconstruction
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• <1cm defect; mid ureter
• Devascularized segment removed
• Wrap with omentum
• 90% success rate
• 10% urine leak
• 5% stenosis
Primary Ureteroureterostomy
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• Abdomen = medial
• Spatulate laterally
• Pelvis = lateral
• Spatulate medially
Blood Supply to Ureter
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• Distal ureter divided
• Mobilization of healthy ureter
• Reimplant at dome
• Non-refluxing vs. Refluxing
• 95% success rate
• 5% urine leak
• 2% stenosis
Ureteral Reimplant (Ureteroneocystotomy)
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• Superior contralateral
pedicle ligated
• Ipsilateral fixation of
bladder to psoas with
vertical non absorable
suture
• Uretero-neocystotomy
• 95% success rate
Psoas Hitch + Reimplant
Stein et al. Psoas Hitch and Boari Flap Ureteroneocystotomy BJU Int 2013.
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• Perform Psoas Hitch
• U- shaped flap 4:1 ratio to
width ureter
• Reimplantation and
tubularization
• 95% success rate
Boari Flap
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• Large defect
• Bowel prep necessary (not rec in
trauma setting)
• Cr < 2.5
• 20cm TI approx 20cm prox to IC
valve
• Sigmoid may be used for L ureter
• Isoperistaltic
• Hypercholermic metabolic acidosis
• Success 81%
Ileal Ureter
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• Solitary kidney, complete avulsion
• Pyelovesicostomy
• Renal vein CIV
• Renal artery IIA, EIA, or CIA
Auto-Transplantation
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• Secondary option for distal ½ ureteral injury with small bladder capacity
• 1.5cm ureterotomy is made then end-to-side anastomosis
• Above IMA
• Contraindicated for pt with kidney stones
Trans – Uretero-Ureterostomy
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• Location
• Length
• Tension-free
Principles of Reconstruction
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•Objective: long term follow up of renal
preservation by type of repair: psoas hitch, boari
flaps, primary U-U
•Retrospective review: N = 100 (1986-2012) – 24
UNC, 58 Psoas hitch, 18 Boari flap
•Median f/u: 48 mos (12-250)
Wenske et al. Urology. 2013.
Any type of repair better for Kidney function?
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•No sig difference in type
of repair vs. GFR
•Incr age and baseline
GFR predictive of
postoperative GFR
decline
•3% ureteral leakage
•2% stricture
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Author N Procedure F/U Outcomes
Patil et al
Urology 2008
12 UNC+Psoas hitch (robotic) 15 mo Mild hydro 2 mos
Gozen et al
WJU 2010
24 10 UNC + Psoas hitch, 9
boari flap, 5 LG reimplant
(open)
20 mo 95% success, 1 major
complication
Castillo et al
Jurol 2005
9 Boari flap (lap) 17 mo No evidence of stricture on
IVP
Simmons et al
Urology 2007
46 UU, UNC, Boari flap (lap +
open)
43 mo 98% ureteral patency, no diff
in technique
Modi et al
Urology 2008
6 UNC (lap) 12mo No evidence of stricture on
IVP
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Back to Case
• When to reconstruct?
– Deferred for 6 mo
– Prolonged hospital course
• Optimal drainage until reconstruction?
– R PCN tube
• How to reconstruct?
– Concern about PTFE graft infection
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Back to Case • 6 month f/u
• Robotic transureteroureterostomy – Avoid dissection around graft
– Avoid concern about ureteral fistula
– R PCN capped then removed on POD#3
• Stent for 6 wks
• Lasix Renogram – no obstruction
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– True long term re-stricture rate by location,
technique, etiology
– Novel allografts (ie. Buccal, Appediceal
interposition)
– Tissue engineering
– Ureteral Matrix
Future Directions in Ureteral Reconstruction
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• Damage control > Reconstruction
• Type of ureteral repair is dictated by location, nature, and extent of
injury
• Principles of repair: tension free anastomosis, preservation of
adventitia, spatulate contralateral to blood supply, water tight,
stenting
• Timing of repair dictated by patient stability – outcomes unaffected
• Type of ureteral reimplantation technique is not significantly
associated w/ leak, renal function, or re-stricturing
• BE CREATIVE
Conclusions
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Thank You
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Questions?