Ureteral injury in gynecologic surgery is common and occurs in 1-2% of hysterectomies performed for benign conditions. Without cystoscopy, these injuries can escape immediate detection. The location and length of the injury and the time elapsed before detection play a role in surgical management. Regardless of the surgical approach selected, the repair must minimize tension to the anastomosis and maintain luminal patency and vascular integrity to the bladder and ureter. This video demonstrates surgical ureteral repairs using the DAVINCI-S robotic system by Intuitive Surgical. Three procedures are shown. A simple re-implant, a psoas hitch, and a boary flap. All procedures approximate those performed through traditional abdominal approaches. We begin with a simple ureteral re-implantation to the bladder, or ureteroneocystotomy, appropriate for injuries of the distal 3-4 cm of the ureter. This is a 38-year-old woman who sustained a 1.5 cm distal left ureteral injury at the time of hysterectomy. A nephrostomy tube has been in place since before this procedure. Attention is turned to the left pelvic sidewall where the peritoneum is entered and the ureter is identified at the level of the bifurcation of the common iliac vessels. Care is taken to minimize handling and disruption of the ureteral adventitia during dissection. A vessel loop is passed around the ureter and is used as a traction device. The dissection is continued to the level of the bladder. Next a WEC clip is applied to the ureter, which is then transected proximal to the injury. Here the bladder is visible to the right of the screen. A neocystotomy is then created. Visualization is facilitated with a suction irrigator device. The neocystotomy is marked at 4 points with 2-0 vigral suture. A 7th French 24-cm double-gene stent is gently guided into the proximal ureter. The posterior aspect of which is then spatulated for a length of 5-6 mm. The opposite end of the stent is then placed into the bladder. The bladder and ureter are then re-approximated with 3-0 vigral at the apex of the spatulation and with several 4-0 monocle sutures circumferentially. Sutures are placed in an out-to-in direction on the bladder and an in-to-out direction on the ureter. This technique will keep the knot external to the lumen of the ureter and bladder. The reanastomosis is then oversewn with 2-0 vigral suture using perivesical fat. We next describe the psoas hitch method utilized to minimize anastomotic tension at the time of ureteral re-implant when larger defects of the lower one-third of the ureter are encountered. We begin with a careful dissection of the left pelvic sidewall, exposing the psoas minor tendon. Care should be taken in this area to avoid injury to the genitofemoral nerve. If a clear psoas minor tendon is not visible, the psoas major muscle may be used. The bladder is then widely mobilized, beginning on the side contralateral to the injury. The retropubic dissection is developed down to the level of Cooper's ligament. The bladder is then retrograde filled with normal saline. It is then repositioned to take tension off the vesicle ureteral reanastomosis and the left dome is fixed to the psoas minor tendon using 2-2-0 vigral sutures. In our final case, we demonstrate the bowari flap technique. This procedure is useful when the ureteral length is insufficient to reach the bladder for reimplantation, even with a psoas hitch. This can occur if the injury involves 10-15 cm of the distal ureter. This is a 75-year-old woman with a recurrent right ureteral stricture sustained after multiple ureteroscopies. The right ureteral dissection begins distally in an area affected by significant inflammation. The ureter is approached anteriorly and posteriorly. A vessel loop is placed around the ureter. The ureter is transected just above the iliac vessels and the previously placed ureteral stent is removed. The bladder is then broadly mobilized from both sides. A psoas hitch is then performed. A 7 French 24 cm double J stent is passed into the proximal ureter, which is then spatulated. A wide 3-4 cm transverse incision is made with cautery on the anterior surface of the retrograde filled bladder. The incision is extended to the dome on each side to create the bowari flap. The other end of the stent is passed into the bladder. The ureter to bowari flap anastomosis is created with 4-0 monocryl on an RB needle over the stent. Again, stitches are placed outside in on the bowari flap and inside out on the ureter. The flap is tubularized and closed with 2-0 vicryl on an SH needle in a running fashion. The repair is then oversewn using perivesical fat with a 2-0 vicryl suture. This is a cystogram of the bladder postoperatively demonstrating the repaired bladder with the intact bowari flap. This video demonstrates three techniques used to repair ureteral injury. Although this surgical footage is from robotic surgeries, the same principles and techniques are used in open procedures.

surgical techniques

ureteral injuries

DAVINCI-S robotic system

ureteral re-implantation

psoas hitch