Retroperitoneal Laparoscopic Approach to Ureteral Primary and Reoperative Ureteral Reconstructive Surgery: A Case Series

Introduction

Dealing with intractable urinary problems resulting from a past operation, radiation therapy, or tumor enlargement is difficult. These patients often show several other problems, such as comorbidities, infection, or short life expectancy, and performance status might be poor. Minimally invasive surgery is needed to minimize the physical burden on patients when salvage surgery for intractable urinary tract problems is performed. We have performed minimally invasive salvage surgeries conducted based on retroperitoneal laparoscopic ureterolysis (RLU), and perceived the retroperitoneal laparoscopic approach to intractable urinary troubles as easier than the transperitoneal laparoscopic approach because of fewer adhesions in the retroperitoneal space despite severe intraperitoneal conditions. ^1,2 To examine the utility of salvage surgery based on RLU for intractable urinary tract problems, the indications and outcomes of the surgery were retrospectively researched.

Patients and Methods

Twenty-two patients underwent salvage surgeries based on RLU in our hospital between November 2002 and July 2017. All cases underwent RLU, in which the ureter was dissected with or without nephrolysis through a retroperitoneal laparoscopic approach, followed by various kinds of urinary tract reconstruction because the conventional transperitoneal approach seemed likely to encounter difficulties from strong intra-abdominal adhesions. All patients were followed by blood analysis and/or imaging (i.e., ultrasonography, computed tomography, and drip infusion pyelography). Clinical data including operative parameters, type of the urinary tract problem, primary diseases, chief complaints, history of radiation therapy, and/or intra-abdominal surgery were retrospectively obtained from hospital records. This retrospective study was approved by the institutional review board at Tohoku University Hospital.

Results

Twenty-three salvage surgeries based on RLU were performed in 22 patients (15 men, 7 women; Table 1). Median age was 61 years (interquartile range [IQR], 46–71 years). Median follow-up period after the operation was 8 months (IQR, 2–80 months). Operative parameters, types of urinary tract problems, primary diseases, and chief complaints are listed in Table 1 and Supplementary Table S1. Radiation therapy to the pelvic area had been performed for 9 patients (39%) and intra-abdominal surgeries had been performed for 19 patients (83%). Patients showed various urinary tract problems, that is, lower urinary tract dysfunction because of intrapelvic tumors or contracted bladder, middle or lower ureter troubles including ureter injury, stricture, or obstruction, refractory urinary fistulae caused by chemoradiation or intrapelvic infection, ureteroileal anastomotic stricture after ileal urinary tract diversion (three ileal conduits and one neobladder), and stomal stricture of cutaneous ureterostomy.

Retroperitoneal laparoscopic ureterolysis

At first, RLU was performed with the patient in the lateral or supine position. ^1,2 Representative port positions are shown in Figure 1. On the required side, retroperitoneal space was carefully dilated using a balloon dissection technique and the ureter without adhesions was found. The ureter was peeled off craniocaudally and transected at the level of common iliac artery, where adhesions were strong in most cases. Median time of ureterolysis was 45 minutes (IQR, 35–85 minutes).

OPEN IN VIEWER

FIG. 1.

Representative port positions. In all cases, the laparoscopic procedure was performed under a retroperitoneal approach. (a) Lateral position. (b) Supine position. Double circle: camera port; circle: 12-mm port; triangle: 5-mm port.

Discussion

Salvage surgery for intractable urinary problems is technically challenging because of severe tissue adhesions from past operations, radiation therapy, or tumor enlargement. Nevertheless, interventions need to be less invasive and show a higher success rate, because the patients often have several other problems such as comorbidities, infection, poor prognosis, or poor performance status. Traditionally, open salvage surgery has been chosen for such patients, but laparoscopic approaches have been developed because of the less invasive procedure. ^{3 –5} In cases with intra-abdominal adhesions, the retroperitoneal approach seems more feasible than the transperitoneal approach because fewer adhesions arise in the retroperitoneal space despite severe intra-abdominal conditions. We have introduced RLU as a basic procedure for urinary tract reconstructions. The retroperitoneal laparoscopic approach was a less invasive procedure that enabled us to constantly secure ureters of sufficient length to reconstruct the urinary tract. In all 23 procedures, RLU was effectively performed and followed by various kinds of urinary tract reconstructions tailored to the status of each patient. Our results indicate that RLU is useful as a basic procedure taking advantage of the retroperitoneal laparoscopic approach during salvage surgery for intractable urinary problems.

Various kinds of urinary tract reconstructions such as cutaneous ureterostomies, ureteroileal reanastomoses, ureterovesicostomies, and transureteroureterostomy with cutaneous ureterostomy had been described in this report. In cases of urinary rediversion, previous studies have reported that complications after urinary tract reconstructions using intestinal tract are common and reoperations are inescapably required at a certain percentage for a variety of reasons. ⁶ Fifty-four percent and 35.7% of patients required reoperations for urinary tract reconstructions using intestinal tract by Pahernik and colleagues and Liedberg and colleagues, respectively. ^6,7 In addition, Chang et al. reported that a history of radiation therapy should not serve as an absolute contraindication for salvage surgery, but attention must be paid to the use of ileum because of postoperative morbidity. ⁸ In our report, additional treatment was required in only two cases (8.7%). Although the short follow-up was a clear contributor to the small number of reoperations, we consider that another reason might be the small number of urinary tract reconstructions using intestinal tract, because most patients showed poor performance status or poor prognosis, resulting in the low frequency of additional treatment.

Ureteroileal anastomotic stricture is one of the major problems after radical cystectomy. ⁹ For patients with unilateral ureteroileal anastomotic stricture of the right side, ureteroileal reanastomosis is usually required for urinary tract reconstruction. Right RLU facilitates minimally invasive ureteroileal reanastomosis laparoscopically or through open mini-laparotomy. In cases of left-side or bilateral ureteroileal anastomotic stricture, however, ureteroileal reanastomosis is difficult to perform after RLU because access to the ileal conduit is not usually an easy procedure on the left side. Although several articles have recently reported effective ureteroileal anastomotic repairs using robotic surgical instruments, ^10,11 left-side repair remains an issue in the future because only few reports have described minimally invasive repair for left-side ureteroileal anastomotic troubles. Transureteroureterostomy, in which the left ureter is pulled from the left to the right retroperitoneal space through the retroperitoneal tunnel superior to the IMA, is one of a few minimally invasive salvage surgeries for left-side or bilateral ureteroileal anastomotic troubles. ² In our report, for those patients with bilateral ureteroileal anastomotic strictures or with refractory ileal conduit-perineum fistula, transureteroureterostomy followed by right-side cutaneous ureterostomy was performed.

Special attention should be paid to the indications for transureteroureterostomy. In the patient who underwent transureteroureterostomy with cutaneous ureterostomy for refractory ileal conduit-perineum fistula, anastomotic stricture occurred at the ureteroureterostomy and bilateral nephrostomies were required because of deterioration of renal function. Not so long ago, when transureteroureterostomy was performed in open surgery, an empirical statement was made that transureteroureterostomy did not work well if the recipient ureter was not dilated by obstruction of urine passage. Sufficient blood flow has been considered to correlate with effective transureteroureterostomy. ^{12 –14} Rainwater et al. reported that the ureter dilated by obstruction was favored in transureteroureterostomy because of the thickened ureteral wall and increased blood supply compared with the nondilated ureter. ¹⁴ Blanchard and coworkers verified that blood flow around the ureter was increased after blockage of the vessels at the ureterovesical junction in animal experiments. ¹⁵ In the case with renal function deterioration, the recipient and donor ureter are not dilated, and the blood supply might be insufficient. In each of the other three patients, in whom bilateral ureters were dilated by urinary obstruction, transureteroureterostomies proved effective.

This study showed various limitations. The most major limitation was the relatively short highly variable duration of follow-up (median follow-up, 8 months; IQR, 2–80 months). This study included patients with poor performance status and short life expectancy who were transferred to the hospice or died within a short period. Even in such cases, however, we were able to safely perform salvage surgery and no additional treatment was required in most cases. In addition, we did not use objective intraoperative methods for evaluating ureteral vascularity before anastomosis, such as near-infrared fluorescence imaging using indocyanine green, which has gained wide application in many fields of surgery for assessing blood supply. Despite the limitations seen in this investigation, retroperitoneal urinary tract reconstructions were effectively achieved in all cases and few additional treatments were required. Retroperitoneal salvage surgery based on RLU thus appears to offer an effective option in salvage surgery for intractable urinary tract problems.

Conclusions

To salvage intractable urinary tract problems, RLU is useful to avoid intra-abdominal adhesions and secure a sufficient ureteral length for anastomosis. Urinary tract reconstructions conducted based on RLU rescued patients from their intractable urinary tract problems. These salvage surgeries can also allow patients to achieve freedom from the nephrostomy catheter or nephroureteroconduit stent, even in patients with poor performance status and short life expectancy. Urinary tract reconstruction conducted based on RLU is minimally invasive and contributes to improved quality of life for patients.