Interventional management of postoperative ureteric complications after pelvic surgery

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1 Interventional management of postoperative ureteric complications after pelvic surgery Poster No.: C-0169 Congress: ECR 2015 Type: Scientific Exhibit Authors: R. Tabashy, A. Hamed, S. El-Sebai; Cairo/EG Keywords: Interventional non-vascular, Urinary Tract / Bladder, Fluoroscopy, Technical aspects DOI: /ecr2015/C-0169 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 20

2 Aims and objectives Urinary leakage occurs in 4% of patients after urinary diversion. The most frequent site of leakage is the ureteral- reservoir anastomosis [1]. Ureteral stricture occurs more commonly at the Ureteroenteric anastomosis with frequency of 1% to 30% [2]. Ureteral and vesical injuries occur with 1% of major gynecologic procedures and cesarean section [3]. The prevalence of ureteral injuries is much higher following radical hysterectomy with lymph node dissection for pelvic malignancy than after hysterectomy for benign disease [4]. Our objective is to evaluate the role of different percutaneous intervention techniques and their feasibility in the management of the ureteric complications after pelvic surgery. Page 2 of 20

3 Methods and materials Twenty-five patients (13 males, 12 female) were included in the study. The age ranged from 38 to 74 years with mean age was 57 years. Eleven patients had cancer bladder, 6 patients had recto-sigmoid carcinoma, and 8 patients had gynecological malignancies (5 cancer cervix, 1 endometrial carcinoma, 1 vaginal peripheral neuroectodermal tumor, and 1 caner ovary). Bilateral nephrostomy was performed for 11 patients with complete uretero-diversion anastomotic failure and subsequent urine leak, high output through the abdominal drains, and burst abdomen. Unilateral nephrostomy was performed for 3 patients with unilateral complete ureteric dehiscence. Unilateral ureteric stenting was performed for three patients with partial ureteric injury. Eight patients were referred for management of obstructive uropathy 8 months and later after the surgery. Unilateral ureteric dilatation and nephrostomy was performed for 4 patients, and unilateral ureteric stenting was performed for the other 4 patients. All techniques performed in the interventional radiology unit under combined ultrasound and fluoroscopic guidance. Page 3 of 20

4 Images for this section: Fig. 1: 38-years-old female patient underwent radical hysterectomy for vaginal vault PNET. There was urinary leakage from the abdominal incision and from the vagina. Ultrasound and fluoroscopy guided right sided nephrostomy was done. Page 4 of 20

5 Fig. 2: Ureterography shows no evidence of urine leakage from the right side. Note that there is perirenal contrast leak during the pyelocalyceal targeting. Page 5 of 20

6 Fig. 3: Left pyelocalyceal system targeting by long 20G needle. Ureterography shows contrast leakage in the pelvis. Page 6 of 20

7 Fig. 4: Contrast leakage is noted to opacify the lower vagina and exit through the vulva (arrow). The urine leakage was subsided considerably after the bilateral nephrostomy with improvment of the abdominal wound and general condition. Page 7 of 20

8 Fig. 5: Ureterography 5 days later shows still there is still ureterovaginal fistulous connection from the left ureter only. The right nephrostomy tube was removed. Page 8 of 20

9 Fig. 6: The patient was re-explored and left ureteric re-implantaion was done. Postoperative Ureterography excluded urine leakage and the left nephrostomy tube was removed. Page 9 of 20

10 Results Thirty-six techniques were successfully completed in all patients with success rate 100%. No major complications were reported. Pelvicalyceal injury with perirenal urinoma occurred in 4 techniques (11%). All patients showed clinical improvement with decreased urine leak and conservative control of the burst abdomen. The obstruction was relieved in the 8 patients with obstructive uropathy, especially in 4 patients with a single functioning kidney. Page 10 of 20

11 Images for this section: Fig. 7: 39-years-old female patient underwent abdominal hysterectomy since 3 years for multiple fibroids. She presented by cervical stump cancer and underwent radical trachylectomy. During the surgery, the bladder and left ureter were injuried. The bladder injury was repaired, but the ureteric injury was not detected. After surgery, there was urine leakage from the vagina. IVP shows vaginal opacification by the leaked contrast medium. Page 11 of 20

12 Fig. 8: Ascending cystography shows no bladder urine leakage or fistula. Page 12 of 20

13 Fig. 9: CT shows contrast medium leakage in the pelvis (arrow) and in the vaginal vault (not Shown). Page 13 of 20

14 Fig. 10: Ultrasound guided left pyelocalyceal system targeting with 20G long needle (white arrow). The needle tip (black arrow) is seen in the renal pelvis. Page 14 of 20

15 Fig. 11: Left ureterography shows pelvic contrast medium leakage (arrow). Page 15 of 20

16 Fig. 12: Dilatation of the distal ureteric stenotic segment was done after failure to pass the Cobra angiographic catheter to the bladder. Page 16 of 20

17 Fig. 13: The double-j catheter is seen in situ at the end of the procedure. No nephrostomy tube was done. There was complete stoppage of the urine leakage immediately after the procedure. Page 17 of 20

18 Conclusion Postoperative ureteric complications after pelvic surgery can be managed safely by percutaneous intervention with high success rate. The techniques preclude further surgical intervention especially in patients with postoperative ureteric urinary leak. Page 18 of 20

19 Personal information Reda Tabashy, MD. Department of Diagnostic and Interventional Radiology. National Cancer Institute, Cairo University, Egypt. Page 19 of 20

20 References 1. Catalá V, Solá M, Samaniego J, Marti T, Huguet J, et al. CT findings in urinary diversion after radical cystectomy: post-surgical anatomy and complications. Radiographics 2009; 29: De Carli P, Mecali S, O'Sullivan D, et al. Ureteral anastomosis in the orthotopic ileal neobladder: comparison of 2 techniques. J Urol 1997; 157(2): Flores-Carreras O, Cabrera JR, Galeano PA, Torres FE. Fistulas of the urinary tract in gynecologic and obstetric surgery. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12: Paspulati RM, and Dalal TA. Imaging of complications following gynecologic surgery. Radiographics 2010; 30: Page 20 of 20

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