Transvaginal ureteroneocystostomy.

Our institutional policy specifies that case reports of individual patients or novel surgical approaches do not constitute a systematic investigation. Therefore, IRB approval is not required for the completion or publication of a case report.

A 76-year-old multiparous female with recurrent, symptomatic post-hysterectomy pelvic organ prolapse presented for surgical consultation. On examination, she was noted to have a grade 3 Baden-Walker lateral cystocele with apical prolapse. The decision was made to proceed with a transvaginal repair including anterior and posterior colporrhaphy in addition to a sacrospinous ligament vault suspension. At the beginning of the procedure, a suprapubic catheter was placed. With the initial posterior vaginal incision, an enterocele was identified and repaired preserving redundant peritoneum. The right sacrospinous ligament was identified and sutures placed for subsequent suspension. A midline anterior vaginal incision was made for repair of the cystocele. In the course of dissecting the endopelvic fascia from the anterior vaginal mucosa a right distal ureteral transection was noted. At this point, the decision was made to proceed with a transvaginal ureteroneocystostomy. As depicted in Fig. 1 , the proximal ureter was mobilized and a 1 cm incision made to increase the diameter of the anastomosis. The distal ureter was ligated. Cystoscopy was performed to rule out any other bladder related injury and to delineate an appropriate site for reimplantation which generally is superior and lateral to the affected ureteral orifice. Using a long, fine-tipped curved clamp placed transurethrally a cystotomy was performed. In Fig. 2 , the anastomosis was performed with interrupted 4-0 Poliglecaprone 25 sutures. Sutures were initially placed at 4, 6 and 8 o'clock. The previously transurethrally placed curved clamp was partially opened to better delineate the cystotomy incision ensuring a full thickness anastomosis. A flex-tip guidewire was positioned in the renal pelvis and the distal end brought through the urethra using the curved clamp. The anastomosis was completed with sutures at 10, 12 and 2 o'clock. An appropriate length 6 French double pigtail soft ureteral stent was properly positioned and the guidewire was removed. X-ray confirmed appropriate placement in the renal pelvis and bladder. Redundant posterior pelvic peritoneum was mobilized and sutured over the anastomosis isolating this from the vaginal incision line. The anterior vaginal mucosa was closed using an interrupted technique. The prolapse repair was completed including a right sacrospinous ligament suspension. Continuous bladder drainage was accomplished using the suprapubic catheter. Fig. 1 Transected ureter prepared for reimplantation . In this illustration, the transected right ureter is noted. The proximal ureter has been splayed approximately 1 cm at the 6 o'clock position and tagged with a 4-0 poliglecaprone 25 suture. This increases the diameter of the anastomosis. The distal transected ureter is ligated with a 2-0 polyglactin 910 suture. Cystoscopy has been performed to make sure no other defects are present. Through trans -illumination, an appropriate site for ureteral re-anastomosis is identified and marked with a 4-0 poliglecaprone 25 suture on the bladder muscularis. Transurethrally an M.D. Anderson clamp is used to create a 1 cm cystotomy as depicted. Fig. 1 Fig. 2 Ureteroneocystostomy performed with placement of a ureteral stent. A. The ureteroneocystostomy is initiated at the 6 o'clock position using the previously placed full-thickness 4-0 poliglecaprone 25 ureteral suture. Additional full-thickness 4-0 poliglecaprone 25 sutures are placed at 12, 2, 4, 8 and 10 o'clock in the cystotomy incision and tagged. It is important to place the sutures such that the knots are external. Of note, the M.D. Anderson clamp is used to gently open the cystotomy for proper suture placement. B. With the M.D. Anderson clamp in place the anastomosis is initiated at the 6, 4 and 8 o'clock positions. At this point, the distal end of a 0.035-inch ureteral guidewire is grasped with the M.D. Anderson clamp and brought through the urethra. The proximal flexible end of the guidewire is directed into the renal pelvis. C. The remaining full-thickness 4-0 poliglecaprone 25 sutures at 12, 2 and 10 o'clock are placed and tied. A 6 French double pigtail soft ureteral stent is then placed over the guidewire with the proximal end in the renal pelvis and the distal in the bladder. The guidewire is then removed. This illustration shows the anastomosis complete with the ureteral stent in place. The anastomosis is reinforced with four 4-0 poliglecaprone 25 sutures incorporating the serosa of the ureter and the bladder muscularis. Fig. 2 Transected ureter prepared for reimplantation . In this illustration, the transected right ureter is noted. The proximal ureter has been splayed approximately 1 cm at the 6 o'clock position and tagged with a 4-0 poliglecaprone 25 suture. This increases the diameter of the anastomosis. The distal transected ureter is ligated with a 2-0 polyglactin 910 suture. Cystoscopy has been performed to make sure no other defects are present. Through trans -illumination, an appropriate site for ureteral re-anastomosis is identified and marked with a 4-0 poliglecaprone 25 suture on the bladder muscularis. Transurethrally an M.D. Anderson clamp is used to create a 1 cm cystotomy as depicted. Ureteroneocystostomy performed with placement of a ureteral stent. A. The ureteroneocystostomy is initiated at the 6 o'clock position using the previously placed full-thickness 4-0 poliglecaprone 25 ureteral suture. Additional full-thickness 4-0 poliglecaprone 25 sutures are placed at 12, 2, 4, 8 and 10 o'clock in the cystotomy incision and tagged. It is important to place the sutures such that the knots are external. Of note, the M.D. Anderson clamp is used to gently open the cystotomy for proper suture placement. B. With the M.D. Anderson clamp in place the anastomosis is initiated at the 6, 4 and 8 o'clock positions. At this point, the distal end of a 0.035-inch ureteral guidewire is grasped with the M.D. Anderson clamp and brought through the urethra. The proximal flexible end of the guidewire is directed into the renal pelvis. C. The remaining full-thickness 4-0 poliglecaprone 25 sutures at 12, 2 and 10 o'clock are placed and tied. A 6 French double pigtail soft ureteral stent is then placed over the guidewire with the proximal end in the renal pelvis and the distal in the bladder. The guidewire is then removed. This illustration shows the anastomosis complete with the ureteral stent in place. The anastomosis is reinforced with four 4-0 poliglecaprone 25 sutures incorporating the serosa of the ureter and the bladder muscularis. At approximately 2 weeks postoperatively a CT urogram was performed with no evidence of a urinary leak ( Fig. 3 ). A voiding trial was performed successfully and the suprapubic catheter removed. The ureteral stent was also subsequently removed. Follow-up renal ultrasound and serum creatinine levels were obtained at 1, 3 and 6 months with no evidence of hydronephrosis. Fig. 3 CT urogram performed at approximately 2 weeks postoperatively noting no evidence of a urinary leak. A CT urogram is performed at approximately 2 weeks postoperatively and if there is no evidence of an anastomotic leak a voiding trial is initiated. The ureteral stent is then removed cystoscopically at approximately 4 weeks postoperatively. Imaging to evaluate for hydronephrosis is performed at 3 and 6 months postoperatively. This can generally be accomplished with renal ultrasound. Fig. 3 CT urogram performed at approximately 2 weeks postoperatively noting no evidence of a urinary leak. A CT urogram is performed at approximately 2 weeks postoperatively and if there is no evidence of an anastomotic leak a voiding trial is initiated. The ureteral stent is then removed cystoscopically at approximately 4 weeks postoperatively. Imaging to evaluate for hydronephrosis is performed at 3 and 6 months postoperatively. This can generally be accomplished with renal ultrasound.

LKB: Visualization, Validation, Writing – review & editing. CCM: Investigation, Writing – review & editing. SLL: Conceptualization, Resources, Writing – Original Draft, Supervision.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Consent for publication was obtained and remains on file in medical records.

In comparison to the traditional transabdominal re-implantation procedure, the above described approach allows the surgeon to maintain a transvaginal approach for management of a known complication of gynecologic surgery. In situations where the repair would otherwise be done via an open approach, this technique allows enhanced postoperative recovery and reduces hospital length of stay. The described surgical procedure can and should be considered when a ureteral re-implantation is needed for management of a ureteral injury during transvaginal gynecologic surgery.

Urinary tract injury is a known risk associated with gynecologic surgery. The bladder and pelvic ureters are normally millimeters away during dissection with normal anatomy. Any pelvic pathology that either potentially involves the urinary tract or distorts the normal anatomy increases the risk of surgical trauma. Malignant conditions are certainly risk factors but benign conditions such as uterine leiomyomata, tubo-ovarian abscess, severe endometriosis and complicated pelvic organ prolapse are also factors associated with an increased risk of urinary tract injury during surgery. Prophylactic ureteral stent placement has been evaluated for prevention of ureteral injuries at the time of pelvic organ prolapse surgery. While ureteral stents do not reduce the rate of injury, they may aid the surgeon in identification of the ureters, thus reducing ureteral injuries in select cases. Importantly, stents may aid surgeons in prompt identification of ureteral injury, enabling consideration for primary repair, thus preventing a delayed diagnosis of ureteral injury, which can be quite morbid for the patient. 4 When a ureteral injury is recognized and repaired at the time of the surgical procedure morbidity including potential loss of renal function, is dramatically reduced. Specific management at the time of recognition is dictated by the type and degree of ureteral injury as well as the skillset of the surgeon or consulting surgeon tasked with management of the injury. It is well established that significant ureteral compromise in close proximity of the bladder should be managed with a re-implantation procedure. Traditional repair involves direct ureteral re-implantation after adequate mobilization of the bladder in conjunction with a possible psoas muscle hitch or Boari flap to decrease tension on the anastomosis. 5 The success rate with ureteroneocystostomy approaches 100% with a minimal risk of subsequent ureteral stricture. Transvaginal surgical procedures complicated by significant ureteral compromise such as ureteral laceration or transection recognized at the time of surgery are traditionally managed with a transabdominal ureteral re-implantation via open or laparoscopic approaches. Transvaginal approach to repair of postoperative ureterovaginal fistulas has been previously described 6 thus transvaginal approach to ureteroneocystostomy for management of ureteral injury is certainly feasible. This case report describes in detail a successful transvaginal surgical technique for repair of ureteral transection recognized at the time of transvaginal repair for recurrent pelvic organ prolapse.

Urinary tract injury is a known risk associated with gynecologic surgery. The risk of ureteral injury associated with vaginal repair of pelvic organ prolapse has been reported to be as high as 10%. 1 , 2 , 3 Transvaginal surgical procedures complicated by significant ureteral injury such as vascular compromise, ureteral laceration or transection recognized at the time of surgery are traditionally managed with a transabdominal ureteral re-implantation via open or laparoscopic approaches. This report describes a transvaginal surgical technique for repair of a ureteral transection recognized at the time of transvaginal repair for recurrent pelvic organ prolapse.

None of the authors report any actual or potential conflicts of interest.