The objectives of this video are to describe the risk of ureteral obstruction during vaginal surgery for apical pelvic organ prolapse, to discuss cystoscopic techniques to evaluate for ureteral efflux, to review techniques for retrograde pylogram and ureteral stent placement, and to discuss management of a ureteral stent placed for known or suspected injury. The risk of ureteral obstruction is one of the most worrisome complications during transvaginal surgery, with rates as high as 11%. Cystoscopy can help identify ureteral obstruction or entrapment by the lack of ureteral efflux, and if identified, obstruction can often be relieved intraoperatively. Intraoperative cystoscopy is typically done with a 17 French cystoscope sheath and a 70 degree lens. Methods to evaluate for ureteral jets include simply using normal saline or D10 irrigation. Drugs to change the color of urine and facilitate visualization include methylene blue, phenazopyridine, or sodium fluorescein. At our institution, we inject 0.25 milliliters of a 10% preparation of sodium fluorescein mixed with 10 cc's of injectable saline five minutes before cystoscopy. As seen in this video, the drug changes the color of the urine to a bright yellow-green, which aids in visualization of the ureteral jets. If there is no concern for ureteral injury and jets are visualized bilaterally, the case can be completed without further intervention. If efflux is not visualized, it is important to remove all packing and retractors from the vagina, as these can distort the trigone and prevent the efflux of urine. In this video, the surgeon has a finger in the vagina at the time of cystoscopy, which demonstrates the effect of transvaginal objects such as packing or retractors on the trigone. After removing packing and retractors, the patient should be taken out of the Trendelenburg position, which allows gravity to aid in ureteral drainage. The surgeon must be patient, as it can take up to 20 minutes to see efflux. If jets are not visualized within five minutes, we give a bolus of IV fluids and five milligrams of IV furosemide, unless it is medically contraindicated. If there is still no efflux visible, or if there is any concern for ureteral obstruction, the suspension sutures on the side of concern should be removed in a stepwise fashion, with the most distal suture first. Because the pelvic ureter runs more medial, lower in the pelvis, it is more likely to be injured by the more distal sutures. Occasionally, patients will have a solitary kidney. In these cases, there will not be any efflux from the orifice on a side lacking a renal unit. If available, preoperative imaging should be reviewed to look for the absence of either kidney. If there is a question about the presence of bilateral kidneys, an on-the-table intravenous pylogram can be performed by injecting two milligrams per kilogram of IV contrast and taking a plain film 10 minutes later. The first step in evaluation of a possible ureteral injury is a retrograde pylogram. This allows the surgeon to look for obvious obstruction, discontinuity, contrast extravasation, or medial deviation of the distal ureter. A retrograde pylogram can be done on an OR table if a C-arm is available. With the patient in lithotomy, a Eurobag drape can be used to help collect cystoscopy fluid. The drape can be connected to suction tubing so that fluid does not weigh down the bag. The C-arm should be covered with a sterile drape to ensure it does not contaminate the field. This Mayo stand has all of the basic instruments needed for cystoscopy and retrograde pylogram, including 17 and 22 French cystoscope sheaths, a 30 and 70 degree lens, a laparoscopic camera and light cord, cystoscopy tubing, contrast, and a 10cc syringe. A nipple is needed to place on the back of the cystoscope and prevent leakage of fluid when passing wires and catheters. The retrograde pylogram itself can be done with either a cone-tip catheter or a wire and open-ended catheter. When planning for retrograde pylogram, a cystoscope sheath of at least 20 French should be used, as anything smaller will not accommodate the catheters. It is important to confirm proper patient positioning and obtain a scout image prior to starting. When using a fluoroscopy table, the entire ureter can be imaged with a single film. Comparatively, when using a C-arm, it is difficult to visualize the entire ureter in one image. Initially, the C-arm should capture the distal ureter. It can then be rotated, and subsequent image is taken to inspect the ureter to the level of the ureteropelvic junction in a piecemeal fashion. In order to perform a retrograde pylogram using a cone-tip catheter, the lower lock on the catheter must be advanced to the end, and a 10cc syringe that has been pre-filled with contrast can be connected. The catheter is then placed through the cystoscope and flushed of any air bubbles. The tip is used to intubate the ureteral orifice, and a retrograde pylogram is shot while injecting 5-8cc of contrast. The benefit of a cone-tip catheter is that the wider diameter at the base of the cone helps seclude the ureteral orifice, thus forcing contrast into the collecting system and preventing it from spilling back into the bladder. If a cone-tip catheter is not available, a retrograde pylogram can be done using a wire and an open-ended catheter. The wire is loaded into the open-ended catheter and fed through the cystoscope. The wire is then advanced to intubate the ureteral orifice before advancing the catheter to avoid raising a flap of tissue. Once the wire is advanced sufficiently, the open-ended catheter is placed over the wire, the wire is removed, and contrast is injected while retrograde pylogram images are taken. There are various types of guide wires available to help pass open-ended ureteral catheters and stents. These wires are classified by size, tip design, surface coating, and shaft rigidity. The standard Benson wire is acceptable for most cases and should always be inserted with the floppy end first. Hydrophilic wires can help with a difficult or tight ureteral orifice as they are the most atraumatic. Completely hydrophilic wires must be flushed prior to use. A hybrid wire, such as a sensor wire, is an excellent option. It has a hydrophilic tip to help with atraumatic negotiation, but an uncoated body to prevent slippage. A stent should be placed if there is any extravasation of contrast on a retrograde pylogram or other concern for damage or obstruction. A ureteral stent functions to maintain ureteral continuity, prevent extravasation of urine which may cause fistula or urinoma, and bypass obstruction. Stenting precludes the need for an external bag from a percutaneous nephrostomy tube and in the case of severe injury, make subsequent repair with a ureteral re-implant easier. The length of the ureter can be determined using a combination of fluoroscopic and cystoscopic guidance. As seen in this video, the length of the ureter is measured by advancing a ureteral catheter over a wire that is in the renal pelvis. Each mark is one centimeter apart. Fluoroscopy can confirm when the tip of the catheter is at the level of the uretero-pelvic junction. The corresponding measurement of the ureteral catheter at the orifice determines the proper stent length. The double J stent comes in a package with a radial peak pusher and a dangler attached to the stent. When placing a stent for concern of ureteral injury, the dangler should always be removed. As seen here, the stent of proper size is placed over a wire that has been advanced to the renal pelvis. Once the stent is within the cystoscope, a pusher is used to advance the stent until the distal marking is at the ureteral orifice. Fluoroscopic guidance is used to confirm the proximal end of the stent has reached the pelvis. The wire is then removed and fluoroscopy is used to confirm a good proximal curl. The distal curl can be visualized through the cystoscope. If the stent is difficult to place, some helpful tricks are to use a hydrophilic stent or dip the stent in mineral oil. If trouble is encountered passing the stent, one option is to replace your initial wire with a stiffer wire through the ureteral catheter. Another option is to use a stent with a smaller diameter. Stenting without fluoroscopy is never recommended. Without fluoroscopy, it is impossible to confirm correct positioning and it is easy to straighten out a kink in the ureter that should not be missed. If fluoroscopy is not available, the patient should be moved to a table that is equipped with fluoroscopy or, as a last resort, interventional radiology can place an antigrade stent. Common complications from a stent include flank pain, hematuria, urinary urgency and frequency, and pyuria. It is important to note that a urinalysis from a patient with an indwelling stent is expected to have white blood cells and positive leukocyte esterase, which should not be mistaken for a urinary tract infection in the absence of other symptoms. An often feared complication of a stent that has been left in place too long is stent encrustation. This is a dramatic example of a woman with bilateral stents in place that was lost to follow-up. These stents led to the formation of bilateral staghorn calculi, which highlights the importance of close follow-up any time a stent is left in place. When inserted for concern of injury, ureteral stents should remain in place for at least six weeks to allow time for the ureter to heal. These stents should always be removed under anesthesia with a simultaneous retrograde pylogram to ensure ureteral patency and evaluate for structure formation or contrast extravasation. If the retrograde pylogram appears normal at six weeks, the stent can be removed. If the injury is not healed by six weeks, ureteral reconstruction can be undertaken. Patients should be followed with a renal ultrasound in 6 to 12 months to assure there is no hydronephrosis, which may indicate delayed structure formation. If there is any concern for obstruction, a renal scan can be done to evaluate renal drainage. In conclusion, there is a significant rate of ureteral obstruction during transvaginal surgery for pelvic organ prolapse. Evaluation of ureteral efflux intraoperatively allows for identification of injury and prevents long-term complications. Suspension sutures should be removed starting distally if there is concern for ureteral obstruction. Urology should be consulted if there is any concern for ureteral injury. Retrograde pylogram is the first step in evaluation of the ureter. Ureteral stenting without fluoroscopy is never recommended. A ureteral stent should be left in place for six weeks if there has been any injury to the ureter.

ureteral obstruction

vaginal surgery

apical pelvic organ prolapse

cystoscopy

retrograde pylogram