# The Management of Bilateral Ureteric Injury following  Radical Hysterectomy

Authors: Matthew B. K. Shaw; Mark Tomes; David A. Rix; Trevor J. Dorkin; Lakkur N. S. Murthy; Robert S. Pickard
Journal: Advances in Urology
 (2008)

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## Abstract

Iatrogenic ureteric injury is a well-recognised complication of radical hysterectomy. Bilateral ureteric injuries are rare, but do pose a considerable reconstructive challenge. We searched a prospectively acquired departmental database of ureteric injuries to identify patients with bilateral ureteric injury following radical hysterectomy. Five patients suffered bilateral ureteric injury over a 6-year period. Initial placement of ureteric stents was attempted in all patients. Stents were placed retrogradely into 6 ureters and antegradely into 2 ureters. In 1 patient ureteric stents could not be placed and they underwent primary ureteric reimplantation. In the 4 patients in which stents were placed, 2 were managed with stents alone, 1 required ureteric reimplantation for a persistent ureterovaginal fistula, and 1 developed a recurrent stricture. No patient managed by ureteric stenting suffered deterioration in serum creatinine. We feel that ureteric stenting, when possible, offers a safe primary management of bilateral ureteric injury at radical hysterectomy.


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## Body

## 1. Introduction

Iatrogenic ureteric injury is a well-recognised complication of radical
hysterectomy occurring in 5–30% of cases
[1, 2]. Bilateral injuries are rare,
being documented as isolated case reports but do present a considerable
reconstructive challenge [3, 4].The management of ureteric injury presenting during and following
radical gynaecological surgery has been frequently discussed in the literature
although the evidence base for such management is restricted to expert opinion,
with reports of long-term outcome lacking [5–8]. Injuries recognised during the initial
surgery are generally straightforward to treat involving immediate open repair
over a ureteric stent. The management of injuries presenting in the
postoperative period generally with ureterovaginal fistula formation has
evolved over the past decade changing from a predominantly open approach to
endourological retrograde or antegrade stent placement [7, 9]. In addition to the ureteric injury it must
not be forgotten that pelvic surgery such as radical hysterectomy can affect
lower urinary tract function, typically by injury to the pelvic nerves,
resulting in a proportion of women experiencing long-term bladder dysfunction
[10].Issues surrounding the management of bilateral ureteric injury are more
complex and are less considered in the literature despite the challenging
reconstructive problem that they present.
The standard methods of surgical management used for unilateral injury
may need to be modified or used in combination for cases of bilateral injury
and close observation is needed to minimise further loss of renal function and
to avoid uro-sepsis.In view of the rarity of bilateral ureteric injury and the lack of
literature outlining the management of such cases, we conducted a chart review
of 5 women who attending our tertiary referral urology department for treatment
to illustrate the salient points of diagnosis and management of these complex
injuries.


## 2. Materials and Methods

A retrospective analysis of a prospectively acquired departmental
database of ureteric injuries was performed for the years 1999 to 2005. Five patients with bilateral ureteric injury
occurring during radical hysterectomy were identified. The case notes and imaging of the five
patients were comprehensively reviewed.All patients underwent imaging immediately following referral in the
form of intravenous urography (IVU) followed by retrograde
ureteropyelography. Surgical operation
notes and inpatient stays were all reviewed.
Follow up information reviewed included outpatient consultation, IVU,
isotope renography, retrograde studies, and cystometry.Patients were included in the study if the injury to the ureters was
bilateral and occurred at the time of radical hysterectomy for malignant
cervical pathology. Patients were excluded if they had undergone preoperative
chemotherapy or radiotherapy or if the injury only became apparent after the
subsequent use of these treatment modalities; this was in order to standardise
the aetiology of the ureteric injury.


## 3. Results

### 3.1. Presentation

Five patients referred with bilateral ureteric injury following radical
hysterectomy for cervical cancer were identified from the database. The median age (range) at the time of
hysterectomy was 42 (38–84) years. In four cases the main presenting symptom was
that of a vaginal urinary leak whilst the fifth patient presented with anuria
associated with acute renal failure on biochemical assessment. The median time
(range) from hysterectomy to discovery of the ureteric injury was 21 (12–58) days.
Follow-up was available for a median (range) of 26 (21–88) months. The
findings and their progress are summarised in Table1.Table 1
Details of diagnosis, management, and outcome of patients with bilateral ureteric injury.
Abbreviations: IVU (intravenous urogram), CT scan (computed tomogram).
Patient
Presenting symptom
Initial imaging
Ureterovaginal fistula
Antegrade/retrograde stent
Healed with stent alone
Long-term outcome
1
Vaginal discharge
IVU
Yes, 1 ureter
Retrograde, both ureters
Recurrent right stricture, reimplanted
Normal creatinine, detrusor overactivity
2
Vaginal discharge
IVU
Yes, 2 ureters
Retrograde + antegrade
Yes
Normal creatinine, endoscopic dilatation stricture
3
Anuria & acute renal failure
Ultrasound & CT scan
No
Unable to stent, therefore reimplantation
—
Elevated creatinine, detrusor overactivity
4
Vaginal discharge
IVU
Yes, 2 ureters
Retrograde + antegrade
Persistent leak, therefore reimplantation
Normal creatinine, low-pressure voiding
5
Vaginal discharge
IVU
Yes, 1 ureter
Retrograde, both ureters
Yes
Normal creatinine, hydroureter (1)The diagnosis of ureteric injury was made by intravenous urography and
biochemical analysis of the vaginal effluent in the four patients presenting
with a vaginal urine leak. The anuric
patient was initially investigated by noncontrast CT urography after an
ultrasound examination had suggested upper urinary tract dilatation. CT
confirmed bilateral hydroureteronephrosis down to the pelvic ureter with a
large pelvic fluid collection believed to be a urinoma.After initial radiological imaging suggesting ureteric injury (see Figure1), all went on to have cystoscopy and bilateral retrograde ureteropyelography
performed. All 10 ureters demonstrated
stenotic defects in the distal pelvic segment on initial contrast injection.
Further contrast injection supplemented by methylene blue leak test showed that
4 women had ureterovaginal fistulae arising from 6 of the 8 ureters with the
remaining 2 ureters have stenoses without leakage. In the final patient, both ureters were
draining into a pelvic urinoma. This same patient was also found to have an
associated vesicovaginal fistula at the time of repeat cystoscopy.Figure 1
Intravenous urogram showing bilateral ureterovaginal fistula and significant
quantities of gas within both ureters.


### 3.2. Management

The initial management option attempted in all 5 cases was retrograde
placement of a ureteric stent. If this was unsuccessful, the procedure was
repeated using an antegrade approach via a percutaneous nephrostomy. Using
these methods, four patients were initially managed by ureteric stenting alone;
6 ureters using a retrograde approach and 2 ureters using an antegrade
approach. The remaining patient could not be stented either in an antegrade or
retrograde fashion due to an inability to negotiate the strictured portion of
the ureter and therefore primary open repair by bilateral ureteroneocystotomy
with a unilateral psoas hitch was performed.


### 3.3. Follow-up

Of the 4 patients initially managed with ureteric stents, 3 patients
demonstrated complete bilateral ureteric healing, with no stricture formation
on retrograde ureteropyelography and therefore had stents removed at 8, 16, and
24 weeks, respectively. In the remaining
stented patient, the ureterovaginal fistula persisted and open
ureteroneocystotomy with closure of the fistula was performed 22 weeks after
initial stent insertion.Of the 3 women initially managed by endourological methods alone, one
has, since developed a stricture at the site of the original injury requiring
balloon dilatation and ureteric stent insertion. This stricture, however,
persisted and a subsequent ureteroneocystotomy was performed. Imaging by means
of IVU and renography at a median 18 months shows only one of the 6 ureteric
units to be minimally dilated in these women.
This patient has decided not to pursue further invasive management.The technique used for the two patients who required early open
reconstruction was to pass the freed left ureter under the sigmoid mesocolon
and then perform separate reimplantation of both ureters into a right psoas
bladder hitch. The ureters were implanted through a short detrusor tunnel and
bladder mucosa groove without special precaution to prevent reflux. On
follow-up, the patient
showed neither evidence of reflux nor of obstruction.Four of the 5 patients currently have normal serum creatinine. The remaining patient, who underwent
immediate open reconstruction, presently has a stable elevation of her
creatinine at 177μmol/L; this has not changed significantly over
48 months of follow-up.Cystometry (CMG) was performed on four of the five patients. In two of
the patients the indication was symptomatic urge incontinence when no such
symptoms existed prior to the ureteric injury and detrusor overactivity was
present in both. In the two other patients symptomatic voiding difficulties
prompted the CMG studies; one study suggested low pressure voiding, with
voiding to empty and the other study was normal.


## 3.1. Presentation

Five patients referred with bilateral ureteric injury following radical
hysterectomy for cervical cancer were identified from the database. The median age (range) at the time of
hysterectomy was 42 (38–84) years. In four cases the main presenting symptom was
that of a vaginal urinary leak whilst the fifth patient presented with anuria
associated with acute renal failure on biochemical assessment. The median time
(range) from hysterectomy to discovery of the ureteric injury was 21 (12–58) days.
Follow-up was available for a median (range) of 26 (21–88) months. The
findings and their progress are summarised in Table1.Table 1
Details of diagnosis, management, and outcome of patients with bilateral ureteric injury.
Abbreviations: IVU (intravenous urogram), CT scan (computed tomogram).
Patient
Presenting symptom
Initial imaging
Ureterovaginal fistula
Antegrade/retrograde stent
Healed with stent alone
Long-term outcome
1
Vaginal discharge
IVU
Yes, 1 ureter
Retrograde, both ureters
Recurrent right stricture, reimplanted
Normal creatinine, detrusor overactivity
2
Vaginal discharge
IVU
Yes, 2 ureters
Retrograde + antegrade
Yes
Normal creatinine, endoscopic dilatation stricture
3
Anuria & acute renal failure
Ultrasound & CT scan
No
Unable to stent, therefore reimplantation
—
Elevated creatinine, detrusor overactivity
4
Vaginal discharge
IVU
Yes, 2 ureters
Retrograde + antegrade
Persistent leak, therefore reimplantation
Normal creatinine, low-pressure voiding
5
Vaginal discharge
IVU
Yes, 1 ureter
Retrograde, both ureters
Yes
Normal creatinine, hydroureter (1)The diagnosis of ureteric injury was made by intravenous urography and
biochemical analysis of the vaginal effluent in the four patients presenting
with a vaginal urine leak. The anuric
patient was initially investigated by noncontrast CT urography after an
ultrasound examination had suggested upper urinary tract dilatation. CT
confirmed bilateral hydroureteronephrosis down to the pelvic ureter with a
large pelvic fluid collection believed to be a urinoma.After initial radiological imaging suggesting ureteric injury (see Figure1), all went on to have cystoscopy and bilateral retrograde ureteropyelography
performed. All 10 ureters demonstrated
stenotic defects in the distal pelvic segment on initial contrast injection.
Further contrast injection supplemented by methylene blue leak test showed that
4 women had ureterovaginal fistulae arising from 6 of the 8 ureters with the
remaining 2 ureters have stenoses without leakage. In the final patient, both ureters were
draining into a pelvic urinoma. This same patient was also found to have an
associated vesicovaginal fistula at the time of repeat cystoscopy.Figure 1
Intravenous urogram showing bilateral ureterovaginal fistula and significant
quantities of gas within both ureters.


## 3.2. Management

The initial management option attempted in all 5 cases was retrograde
placement of a ureteric stent. If this was unsuccessful, the procedure was
repeated using an antegrade approach via a percutaneous nephrostomy. Using
these methods, four patients were initially managed by ureteric stenting alone;
6 ureters using a retrograde approach and 2 ureters using an antegrade
approach. The remaining patient could not be stented either in an antegrade or
retrograde fashion due to an inability to negotiate the strictured portion of
the ureter and therefore primary open repair by bilateral ureteroneocystotomy
with a unilateral psoas hitch was performed.


## 3.3. Follow-up

Of the 4 patients initially managed with ureteric stents, 3 patients
demonstrated complete bilateral ureteric healing, with no stricture formation
on retrograde ureteropyelography and therefore had stents removed at 8, 16, and
24 weeks, respectively. In the remaining
stented patient, the ureterovaginal fistula persisted and open
ureteroneocystotomy with closure of the fistula was performed 22 weeks after
initial stent insertion.Of the 3 women initially managed by endourological methods alone, one
has, since developed a stricture at the site of the original injury requiring
balloon dilatation and ureteric stent insertion. This stricture, however,
persisted and a subsequent ureteroneocystotomy was performed. Imaging by means
of IVU and renography at a median 18 months shows only one of the 6 ureteric
units to be minimally dilated in these women.
This patient has decided not to pursue further invasive management.The technique used for the two patients who required early open
reconstruction was to pass the freed left ureter under the sigmoid mesocolon
and then perform separate reimplantation of both ureters into a right psoas
bladder hitch. The ureters were implanted through a short detrusor tunnel and
bladder mucosa groove without special precaution to prevent reflux. On
follow-up, the patient
showed neither evidence of reflux nor of obstruction.Four of the 5 patients currently have normal serum creatinine. The remaining patient, who underwent
immediate open reconstruction, presently has a stable elevation of her
creatinine at 177μmol/L; this has not changed significantly over
48 months of follow-up.Cystometry (CMG) was performed on four of the five patients. In two of
the patients the indication was symptomatic urge incontinence when no such
symptoms existed prior to the ureteric injury and detrusor overactivity was
present in both. In the two other patients symptomatic voiding difficulties
prompted the CMG studies; one study suggested low pressure voiding, with
voiding to empty and the other study was normal.


## 4. Discussion

This series of 5 cases demonstrates that primary management by stenting
can safely be accomplished for most (80%) women with bilateral ureteric injury
following radical hysterectomy.  This
approach has the advantage of stabilising the situation, protecting renal
function, and drying up the vaginal leakage, whilst the patient recovers from
the primary surgery. The potential
disadvantage exists however of needlessly delaying definitive open repair. Stenting was all that was needed for 2 of the
cases with 2 women requiring delayed open repair. Despite this endourological success,
vigilance is required to detect silent ureteric stenosis in the longer term,
which may threaten remaining renal function [11]. Open surgery can therefore be reserved for
the case where stenting fails or for later management of persistent distal
ureteric strictures. Open repair in these cases is hampered by the difficulty
in performing bilateral bladder reconfiguration by psoas hitch or Boari
flap. We overcame this hurdle by
swinging the mobilised left ureter to the right iliac fossa allowing separate
implantation of both injured ureters into the same bladder flap.Current surgical management of cervical carcinoma mandates wide excision
of the local disease and completes
removal of the draining lymphatics [12]. Despite the ureters being identified
and protected during the dissection, it is easy to severely compromise the
blood supply, leaving a devascularised segment which then stenoses and ruptures
in the immediate postoperative period. This mechanism of injury explains the delayed presentation and the
universal finding of a stenosed distal segment in our series. This is in line with published results which
suggest that between 5% and 30% of women undergoing radical hysterectomy suffer
a ureteric injury [1] and of these, 85% involve the distal ureter
[5]. Despite improving surgical
technique and increased awareness of the risks of ureteric injury, it is likely
to be a problem that will continue to challenge the urological surgeon. Management of these patients is often taxing
requiring a range of technical skills and is hampered by the lack of clear
evidence supporting one particular treatment modality and the medicolegal
pressures that surround patients with iatrogenic injury.Conventional management of ureteric injury presenting in the
postoperative period has been by open surgery, particularly when faced with ureterovaginal fistula [13]. With more recent developments in endourological
techniques and equipment, the use of ureteric stenting as a primary manoeuvre
is amassing an increasing volume of supportive evidence. Support for the use of
ureteric stents is provided by Selzman and Spirnak, who reviewed the management of
ureterovaginal fistulas treated at their institution over 20-year period
[7]. Seven patients whose stents were
successfully placed and left in situ for a long enough time period to allow
fistula closure all showed complete healing. One patient developed a stricture
that required further endourological intervention. Giberti et al. also
produced excellent early results from the successful stenting of ureteric
injuries, however, three of their cases went on to have open reconstruction
[5]. The use of ureteroscopy in assisting stent placement has been shown to be
successful even in the face of previously failed attempts [14]. In a series of
patients with 10 injured ureters, Tsai et al. report the combined use of a
ureteroscope and a fluoroscopically guided antegrade snare to place a ureteric
stent [15]. In this study, six required
no further intervention, and three required balloon dilatation for subsequent
stricture formation. In one case (10%)
balloon dilation was unsuccessful and open ureteric reimplantation was
required.An obvious area of concern in bilateral ureteric injury is the
preservation of renal function over both the short- and long-terms. In respect of this, the evidence comparing
open reconstruction and endourological methods is scant. Indeed some studies deem bilateral injury an
indication to exclude these patients from endourological treatment and proceed
directly to open reconstruction [6], however in our study no patient
had a rise in plasma creatinine from the time subsequent to stent placement.In our study, we demonstrate that initial endourological management
offers a safe, minimally invasive option in patients with bilateral ureteric
injury. The placement of ureteric stents
allows recovery from a large and traumatic procedure. In many cases, ureteric stenting offers a
definitive treatment and avoids further extensive and challenging procedures.



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