In this video, we present the management of delayed iatrogenic ureteral injuries following gynecologic surgery. Iatrogenic ureteral injuries are associated with urologic, gynecologic, and general surgery procedures. Most injuries are a consequence of gynecologic surgery. Reported rates of ureteral injuries following benign gynecologic surgery ranges from 0.3 to 1.5 percent. Recently, an analysis of a large prospective cohort of women undergoing hysterectomy demonstrated overall lower rates of ureteral injuries. These rates varied based on route of hysterectomy with laparoscopic and abdominal routes having a rate of 0.3 percent compared to a rate of 0.04 percent for the vaginal route. Unfortunately, despite increasing use of cystoscopy, most ureteral injuries are not recognized at the time of surgery. A recent systematic review evaluating urinary tract injuries in laparoscopic hysterectomy identified 157 ureteral injuries. Only 14 percent of these were diagnosed intraoperatively. There are three common locations for ureteral injuries in gynecologic surgery. These include the level of the infundibulopelvic ligament, the level of the uterine artery, and the level of the vaginal cuff. We illustrate the management of delayed iatrogenic ureteral injuries in a 45-year-old woman who underwent a robotic hysterectomy bilateral salpingo-oophorectomy for the indication of uterine fibroids. Two weeks following her initial surgery, she presented to the outside hospital emergency department with a complaint of severe blank pain. Common signs and symptoms of a delayed ureteral injury include abdominal or flank pain, leukocytosis, and fever. During her initial workup, a CT without contrast was obtained, demonstrating a dilated right renal pelvis as well as right hydronephrosis with an abrupt cutoff in the distal pelvis. In patients with a history and symptoms suggestive of a ureteral injury, we recommend initial evaluation with a CT urogram. CT urography is a diagnostic exam optimized for imaging the kidneys, ureters, and bladder. This test utilizes thin-section imaging and administration of IV contrast and images the renal system during the excretory phase. Based on her symptoms, recent surgery, and CT scan concerning her ureteral injury, a urologist recommended to conservatively manage her obstruction. Consequently, she underwent placement of percutaneous nephrostomy tube. Percutaneous nephrostomy tube placement is a valuable, minimally invasive procedure allowing for spontaneous recovery of an injured ureter. Lask et al. reported the spontaneous recovery of ureteral injuries in 20 patients with delayed ureteral injuries. She ultimately underwent anterograde intraluminal recannulation and stent placement. Minimally invasive anterograde stent placement is another conservative management option where a percutaneous nephrostomy route is created and the injured ureter is recannulated and eventually stented. Several small case series comment on the effectiveness of this procedure, specifically in gynecologic-related ureteral injury with high success rates. She was conservatively managed with a stent for three months. Four weeks following the removal of her stent, she underwent a LASIK renal scan to evaluate her kidney function. Nuclear renography is a nuclear medicine scan in which a radioisotope is injected to the venous system and a gamma camera tracks its filtration through the renal system. This test provides information on the function and drainage of the kidney. The curves generated in this report are the quantitative representation of the radioisotope tracer movement throughout the kidneys. The administration of LASIKs is particularly helpful in differentiating dilation from obstruction. Prompt clearance through the renal system rules out obstruction, whereas delayed clearance is indicative of obstruction. Our patient's left kidney demonstrates prompt clearance of the radioisotope, whereas her right kidney really does not respond to the administration of LASIKs, thus indicating a high-grade obstruction. Given her persistent high-grade obstruction, she was referred to our practice. We proceeded with retrograde pylography to determine the location of the ureteral injury. As suspected, her left renal collecting system appeared completely normal. When the retrograde pylogram was performed on the right, dye opacified the ureter approximately 1 centimeter proximal to the bladder, but with abrupt cutoff at this point, demonstrating a distal obstruction. Given the distal location of the iatrogenic ureteral injury, she was counseled to undergo a robotic ureteroneocystotomy. In the following surgical video, we outline the surgical steps of a robotic ureteroneocystotomy. Briefly, these steps include appropriate robotic port placement, dissection of the ureter, retropubic dissection and bladder mobilization, isolation and ligation of the ureter with spatulation, anastomosis of the ureter to bladder, placement of a double J stent, placement of psoas hitch if necessary, and inspection for a watertight seal. There are several surgical pearls to keep in mind when performing a robotic ureteroneocystotomy. We suggest that to successfully perform this procedure, one must take care not to disturb the amputation blood supply of the ureter, perform adequate retropubic dissection to mobilize the bladder, anastomose the ureter and bladder in a mucosa to mucosa fashion, insert the stent prior to completing the anastomosis, ensure a watertight closure, and if performing a psoas hitch, identify the genitofemoral nerve. We use a W port arrangement with a camera at the umbilicus, two robotic ports on the patient's left side, one on the patient's right side, with an additional assistant port on this side. It is helpful if there are at least 10 centimeters between each port. If the obstruction is suspected to be more proximal, the ports might have to be shifted upwards. We find it helpful to place a large acrylic dilator in the vagina to help develop the planes between the bladder and the vagina in aiding in dissection. Despite the location of injury, it is always easiest to identify the ureter at the bifurcation of the common iliac vessels. An adequate retropubic dissection is necessary to provide mobilization of the bladder for a tension-free anastomosis. It is important to be mindful of the location of the obturator nerve when performing this dissection. Once the ureter is isolated, it is helpful to place a vessel loop around it for manipulation. We place a single stay suture at the apex of the spatulated ureter to maintain orientation. Due to the high rates of congenital absence of the psoas tendon minor, we advocate direct visualization of the genitofemoral nerve by incising the peritoneum to avoid nerve injury. We place the most posterior anastomotic sutures first to allow for optimal visualization when completing the anastomosis. post-anastomosis. Post-operatively, we obtained a KUB to document appropriate stent placement. Correct stent placement is confirmed using bony landmarks. The vertebrae can be easily identified by locating T12. As highlighted in blue, the proximal coil of the double J stent is located at L2, the anatomic location of the right renal pelvis. Our patient was discharged home on post-operative day number one. Her transurethral catheter and right ureteral stent were removed in the office two and six weeks respectively following surgery. A Lasix renal scan demonstrated resolution of her obstruction.

delayed iatrogenic ureteral injuries

gynecologic surgery

ureteral injuries

laparoscopic hysterectomy

robotic ureteroneocystotomy