Uretero-Vesical Reimplantation Techniques According to Nesbit and Leadbetter Politano: Indications, Surgical Techniques and Results in Two Teaching Hospitals of Cameroon ()
1. Introduction
Iatrogenic damage to the pelvic ureter, although of varied origins, is a surgical complication quite common in our environment. Their occurrence can lead to serious complications in the upper urinary tract notably uretero-hydronephrosis, upper urinary tract infections, renal parenchyma atrophy and renal failure in cases where ureteral lesions were bilateral [1]. The Gold standard for the management of this pathology in industrialized countries is via laparoscopic or robotic surgery. In our context, open surgery remains relevant because of our limited technical platform [2]. Uretero-vesical reimplantation is a surgical intervention which consists of creating a bridge, either at the level of the natural ureterovesical junction, or by creating a totally new junction [2]. Epidemiological data in the literature of iatrogenic damage to the ureter tells us that the overall prevalence of such lesions to the lower ureter is 75% compared to all other locations. In the USA, we note that a frequency of 1% to 2% has been found in the population [3]. In Europe, a prevalence of 0.4% to 1.8% was recorded in several studies [4]. Adama et al. had a prevalence of 4.8% at POINT G Hospital in Bamako, Mali [5]. Similarly, in Congo, Otiobanda et al. found a prevalence of 1% after gynecologic surgeries. In Cameroon, a prevalence of 1.8 cases/year was reported by Fouda et al. at the Yaoundé Central Hospital [6]. Our results, therefore aim to update the data already existing in the local and international literature on the indications and results of these surgical techniques according to Nesbit and Leadbetter Politano in two of our university teaching hospitals. We focused on these two techniques because they are the techniques best mastered by the urologist in this setting
2. Methodology
We conducted an observational longitudinal study with both retrospective and prospective data collection in the urology departments of the YCH and that of the DLH. The retrospective phase was conducted between January 2012 and December 2022 and the prospective phase between January 2023 and July 2023. Sampling was consecutive and exhaustive. Inclusion criteria was: patient files of both sexes with documented pathologies of the pelvic ureter and/or the ureterovesical junction that had benefited from ureterovesical reimplantation surgery according to the two surgical techniques cited above in one of these two study hospitals. The variables examined were the sociodemographic characteristics (age, sex, frequency),clinical data (history, side of the affected ureter, symptoms), paraclinical data before surgery (urea, creatinine, ultrasound scan of the urinary tree, urine microscopy and culture, renal scintigraphy, intravenous urography, and CT urogram), the surgical technique and documented results were studied (surgical indication, approach, type of reimplantation that was carried out, type of sutures that were used, intraoperative incidents, duration of surgery, estimated blood loss). Exclusion criteria involved files with incomplete data and patients who did not give consent. Figure 1 illustrates the recruitment and exclusion of files across both hospitals.
The procedure was done after clearance from an anaesthetic team. All were done under general anaesthesia. Gibson incitions were mostly used, dissection down abdominal wall layers and concomitant haemostasis was done with diathermy. The bladder was identified, stay sutures placed in the bladder wall and a cystostomy done in between, exposing both ureteral meatii. The ureter was identified and the diseased segment cut at its upper margin. Spatulation was done. A submucosal tunnel was made in to out. The spatulated ureteral end was canalised with a double J stent then brought in via this new tunnel. A wide anastomosis to the bladder was then done with polyglactin 910 3/0. Bladder closure was then done with polyglactin 910 2/0 in two layers. Drains were systematically put into Retizus space and brought out via separate stab incisions. All patients had post op antibiotic cover and analgesic regimen was a function of individual tolerance to incitional site pain. The Retzius space drain was removed when its collection ceased. Removal of the ureteral stent was done at 7 weeks post op and an ultrasound scan was systematically done. Absence of ureterohydronephrosis was our marker of surgical success. Patient follow up was for 48 months.
All this data was entered and analyzed using the Epi-Info software version 3.5.4 on Windows. On an ethical level, we obtained authorization from the local committee and informed consent was obtained from all patients included in this study.
Figure 1. Patient flow chart.
3. Results
3.1. Sociodemographic and Clinical Data
Over the last ten years, 27 usable patient files of patients who had benefited from ureterovesical reimplantation according to Nesbit or Leadbetter Politano in the two study hospitals were found, with a frequency of 2.7 cases/per year and a sex ratio of 4.4 in favor of women. The average age was 42.5 ± 7.54 years with extremes ranging from 8 to 77 years. Specifically, the average age of men was 40.5 ± 20.5 years with extremes ranging from 8 to 77 years, while that of women was 43.25 ± 7.25 years with extremes ranging from 30 to 63 years. The oldest age group represented was the 40 to 50year age group. Delay to consultation in this study was on average 30 (7 - 150) days with extremes ranging from 1 day to 6 years (Figure 2).
Figure 2. Distribution according to presenting symptoms.
3.2. Medical and Surgical Past Histories
Urinary tract infections were recurrent in 51.9% of patients and 63% had undergone a hysterectomy. We equally recorded 3.7% of patients who had ligated pelvic ureters secondary to laparoscopic varicocelectomies (Table 1).
Table 1. Distribution of patients according to their history (N = 27).
Variables |
Number |
Frequency |
Medical |
|
|
Recent UTI |
14 |
51.9% |
Lithiasis |
3 |
11.1% |
Renal colic |
14 |
51.9% |
Recurrent fever |
13 |
48.1% |
Surgical |
|
|
C section |
3 |
11.1% |
Hysterectomy |
17 |
63% |
Laparoscopic varicocelectomy |
1 |
3.7% |
3.3. Clinical Presentation
Chronic low back pain was found in 12 (44.4%) of our patients. Continuous intravaginal urine leakage was found in 10 (37.0%) patients and was associated with urinary tract infections in 5 patients (Table 2).
Table 2. Patient spread according to surgical indication (N17).
Variables |
Number |
Frequency |
Chronic pain |
12 |
44.4 |
UTI |
5 |
18.5 |
Persistent urine leakage |
10 |
37 |
3.4. Paraclinical Examinations
The vast majority of our patients, a percentage of 85.2 had an ultrasound scan of the urinary tract. A CT urogram was performed in 44.4% of patients. Grade III uretero-hydronephrosis was found in 56.5% of patients and grade IV in 21.7%. The damage to the ureter concerned the right side in 51.5% of patients and the left in 33.3% (Figure 3).
3.5. Time to Management and Types of Lesions Discovered
Once the diagnosis was made, the time to surgical treatment was an average of 90 (14 - 150) days with extremes ranging from 1 day to 6 years. Iatrogenic injury was the most represented lesion 20 (74.1%), 63% was secondary to hysterectomy and 11.1% due to C section. The initial intraoperative lesion found was ligation of the pelvic ureter with suture material in 13 (48.1%) patients. Furthermore, we had 14.7% of our patients in whom ureteral stones were found in the intramural part of the pelvic ureter. Ureterocele, primary vesicoureteral reflux and punctal diverticulum were found with a frequency of 3.7% each (Table 3).
Figure 3. Distribution according paraclinical investigations.
Table 3. Distribution of patients according to lesions of the ureterovesical junction bladder found (N = 27).
Variable |
Number |
Frequency |
Ureterocele |
1 |
3.7 |
VUR |
1 |
3.7 |
Meatal calculi |
4 |
14.8 |
Iatrogenic injury |
20 |
74.1 |
Ureteral meatus diverticulum |
1 |
3.7 |
3.6. Surgical Technique
We noticed in this study by using patient files that, several surgical techniques had been used. However, the technique of direct ureterovesical reimplantation according to Nesbit had been the most regular, in 55.6% of patients, followed by that of Leadbetter Politano seen in 14,8% of cases (Figure 4).
Figure 4. Distribution according to surgical techniques.
3.7. Type of Suture Material
The type of sutures used for the ureterovesical anastomosis had been specified in the operative reports of only 17 patients. These were resorbable polyglactin910 sizes 3/0, 4/0 or 5/0 all with round bodied needles. Braided sutures were used in 12 patients (44.5%) and monofilaments in 5 (18.5%) (Table 4).
Table 4. Distribution of patients according to the types of threads used (N = 27).
Variable |
Number |
Frequency |
Monofilament |
5 |
18.5 |
Braided |
12 |
44.5 |
No information |
10 |
37 |
3.8. Bleeding and Types of Drainage
Intraoperative bleeding around the point of fibrosis was the most common complication. Average blood loss was estimated at 145 ± 55 ml per intervention with extremes ranging from 80 to 500 ml. 33.3% of patients required whole blood transfusions. A ureteral stent across the anastomotic area was systematically placed in all patients (100%). This was externalized through a counter skin incision in 12 (44.4%) patients. For the internal stents, the DJ stent was the most used type, used in 15 (55.6%) patients (Table 5).
Table 5. Distribution of data according to drainage and bleeding operative (N = 27).
Variable |
Number |
Frequency |
Stents |
|
|
External drainage |
12 |
44.4 |
Internal drainage |
15 |
55.6 |
Type of stent |
|
|
Ureteral stent |
0 |
0 |
DJ stent |
15 |
55.6 |
Paediatric NG tube |
12 |
44.4 |
Intraoperative com [plications] |
|
|
None |
11 |
40.7 |
Bleeding |
16 |
59.3 |
Blood loss in cc |
|
|
<100 cc |
7 |
25.9 |
100 – 200 cc |
12 |
44.4 |
>200 cc |
8 |
29.6 |
3.9. Duration of the Surgical Procedure
The average duration of interventions was 172.5 ± 7.5 min with extremes ranging from 90 to 300 min (Table 6).
Table 6. Distribution of data according to the duration of the intervention surgery and blood loss (N = 27).
Variables |
Number |
Frequency |
Operation time (mins) |
|
|
<60 |
0 |
0 |
60 - 120 |
2 |
7.4 |
120 - 180 |
5 |
18.5 |
>180 |
20 |
74.1 |
3.10. Duration of Keeping the Ureteral Stent and Postoperative Surgical Site Infection
The trans-vesico-parietal ureterostomy was removed on the 12th day (8 - 14).
Post operation and the double J stent removed on the 49th (42 - 180) day. Removal of the drainage tube in the space of Retzius was done on the 9th post operation day (6.7 - 13) with extremes ranging from 5 to 17 days and that of the urinary catheter was made at the 10.5th (8 - 15) day with extremes ranging from 2 to 32 days. The postoperative period was unremarkable in 15 patients. 12 developed surgical site infections, 7 (25.9%) of whom benefitted from appropriate wound care. Unfortunately, one death was recorded in this study, it occurred on post operation day 21 in a context of chemical peritonitis.
3.11. Duration of Hospitalization and Reassessment of Patients
The hospital stay was an average of 15 (13 - 19) days with extremes ranging from 7 to 30 days. After an average follow-up of 48 (34.5 - 85.5) months, 26 patients were re-evaluated and none presented clinical signs of a failed anastomosis. Serum creatinine was normal in all patients, urine microscopy and culture was negative in 23 (88.5%) patients. Sterile pyuria was noted in 3 (11.5%) other patients. Control ultrasound scanning was the only paraclinical examination requested in the postoperative period for all 26 patients. No case of uretero-hydronephrosis was seen post op. The clinical success rate of the surgery was therefore evaluated at 96.29%.
4. Discussion
4.1. Sociodemographic and Clinical Data
All age groups were represented in our study, the age group the most represented was that from 40 - 50 years. Our figures show that this Intervention is mainly practiced on adult subjects, with a female predominance and sex ratio of 4.4. This contradicts the series by Jellal et al. in Togo which reported an equal sex distribution [7].
4.2. Medical and Surgical History
Hysterectomy was the most common surgical past history in our study population with a percentage of 63%, followed by cesarean section with 11.1%. Fouda et al. at the YCH reported that 94% of patients who had undergone a hysterectomy complicated by a ureteral injury benefited from Uretero-vesical reimplantation surgery [6]. The techniques of hysterectomy should therefore be revisited or further mastered in future to reduce the incidents of these ureteral accidents
4.3. Clinical Presentation
Low back pain was the most frequent reason for consultation, seen in 59.3% of the cases. Chronicity of this pain was the indication for surgery in 44.4% of our patients. This indication was same in the study by Adama and al in Mali and that of Amri et al in Morocco [5] [8]. Recurrent urinary tract infection was found in 5 patients and persistent intravaginal urine leak in 40.7% of cases of patients who had a history of gynecologic surgery. This figure is higher than that of Amri et al. who had a value of just 20%. These symptoms were found in similar proportions by Amri et al. in Morocco [8] and by Adama Seydou et al. in Mali [5].
4.4. Paraclinical Examinations
The majority of our patients (85.2%) had an ultrasound scan of the urinary tract. This is the first-line examination mentioned in the diagnosis of ureteral lesions. IVU was only performed in 25.9% here, explained by the fact that IVU has gradually lost in value over the years with the advent of CT scanning. CT Urogram was performed in 44.4% of the cases. None had done renal scintigraphy. Renal differential function was therefore assessed based on the excretory phases of the CT urogram and/or IVU. We equally relied on the thickness of the renal parenchyma. The realities of our third world study settings did not permit us have renal scintigraphy done for direct renal function assessment. Any future study on this subject with use renal scintigraphy will definitely be of better quality.
A uretero-hydronephrosis grade 3 or 4 was present in 85.2% of patients. This result is comparable to that of Amri et al. who found 87% of uretero-hydronephrosis on ultrasound in his study population [8].
4.5. The Types of Lesions Discovered and Treatment Times
Iatrogenic injury was the most prevalent lesion, seen in 20 (74.1%) patients ,63% of which were secondary to hysterectomy and 11.1% to cesarean section. The initial intraoperative lesion found was ligation of the pelvic ureter, found in 13 (48.1%) patients. In the studies of Gambachidze et al. and those of Amri et al., both reported iatrogenic lesions to the pelvic ureter (section, ligation, perforation, devascularization) of gynecological origin in 54% of cases and approximately 25% of these lesions were secondary to hysterectomy. These lesions either caused an obstruction in more than two thirds the time, an immediate or a late fistula [7] [8]. Amri et al. in a study in Morocco reported stenosis of the pelvic ureter in 45.83% of cases and 25% of these were secondary to urogenital tuberculosis. Ureterovaginal fistulas was equally reported in 20.83% of cases in the same study [8]. Adama et al. in their study in Mali found stenosis of the pelvic ureter in 75.56% of cases and the etiology here had been parasitic (urogenital schistosomiasis) in 69.48% of cases.
Furthermore, we found 14.7% of patients with lithiasis in the intramural part of the pelvic ureter. Ureterocele, primary vesicoureteral reflux and punctal diverticulum were equally found with a frequency of 3.7% for each. These results are similar to those of Adama et al. in Mali, who had same position lithiasis in 17.78%, ureterocele and primary vesicoureteral reflux each in 4.17% of cases [5]. The intraoperative lesions here are similarly encountered in other studies across the globe. This gives further value to our study and to its potential to be exploited by the scientific community across the world.
4.6. Surgical Technique
The Nesbit direct ureterovesical reimplantation technique without an anti-reflux system was the most used in 55.6% of cases followed by that of Leadbetter Politano, in 14.8% of cases. This is contrary to standard literature information where the most used techniques are those of Leadbetter Politano, Lich Gregoir and Cohen [8]. Although this is contrary to standard literature, the techniques is mastered by surgeons here and still guarantees good results post op.
4.7. Type of Suture Threads
The type of suture material most used was Polyglactin 910 with sizes 3/0, 4/0 or 5/0. Braided suture was used in 12 patients and monofilament suture No. 4/0 in 5 patients. This is contrary to standard literature where resorbable monofilament suture is the recommended material to perform ureteral reimplantations.
4.8. Bleeding and Types of Drainage
Intraoperative bleeding around the fibrosis site was the intraoperative incident the most recorded, in 16 (59.3%) patients. Gambachidze et al. in a review of the literature published blood loss which varied from 163 to 610 ml in open surgery, 86 to 466 ml in laparoscopic surgery and from 44 to 104 ml in robot-assisted laparoscopy. These are contrary to the result of our study where the mean estimated blood loss was 145 ± 55 ml with extremes ranging from 80 to 500 ml. 33.3% of patients in this study received whole blood transfusions intraoperatively or during the immediate postoperative period. A ureteral stent, across the anastomotic site was systematically used in all patients (100%). This stent was exteriorized via a separate stab incision in 12 patients (44.4%), and an internal DJ stent used 55.6% of the time.
4.9. Duration of the Surgical Procedure
The average duration of these surgical interventions varies depending on the approach. Here It was 172.5 ± 7.5 minutes with extremes ranging from 90 to 300 mins. This time is close to that reported by Gambachidze et al. in a review of the literature where it varied between 176 and 235 minutes in open surgery, from 118 to 228 minutes in laparoscopic surgery and finally from 162.5 to 262.5 minutes in robot-assisted laparoscopic surgery [9]. In case of repeat surgery, estimated blood loss will depend on the experience of the surgeon and also on the degree of inflammatory fibrosis around the lesion.
4.10. Duration of Keeping the Ureteral Stent and Postoperative SSI
Removal of the DJ probe via endoscopy was carried out on average on the 49th (42 - 180) post-operative day. Other series offer removal around the 42nd day, a deadline close to ours [5] [7] [8]. We extended this time by a week further out of extra caution. Removal of the transurethral urine catheter was done on 10.5 (8 - 15) days post-operation, that of the drain located in the Retzius space on the 9th day (6.7 - 13) post-operation and from the external drain on the 12th (8 - 14) post-operative day.
4.11. Duration of Hospitalization and Reassessment of Patients
The postoperative course was unremarkable in 15 patients. Twelve patients had postoperative complications. Surgical site infections were found in 7 (25.9%). These complications were found in several other series [5] [7] and classified grade I according to the Clavien-Dindo system, therefore not requiring surgical interventions. Adama et al. in Mali found the same grade of complications [5]. Surgical site infections are quite common, nonetheless we should be relentless in our efforts to control them in future.
5. Conclusion
The indications for ureterovesical reimplantation surgery are reached in the face of discomfort secondary to continuous urinary incontinence or with recurrent urinary tract infections most often complicating an iatrogenic lesion to the pelvic portion of the ureter or due to pathology of the ureterovesical junction. The open reimplantation techniques recorded in this study proved to have a low rate of complications with fairly satisfactory results seen post operatively.
6. Study Limitations
This study was carried out in just two of the numerous urology units across Cameroon. Therefore, the data accrued here might not reflect the true post operative picture of this intervention nation wide.
The surgical procedures were carried out by different surgeons. Hence success or failure was highly surgeon dependent.