ENDOPROSTHESIS PLACEMENT IN PATIENTS WITH PREVIOUS SURGERY FOR OVARIAN CANCER COMPLICATED BY UROPERITONEUM
ENDOPROSTHESIS PLACEMENT IN PATIENTS WITH PREVIOUS SURGERY FOR OVARIAN CANCER COMPLICATED BY UROPERITONEUM
Chiara Tudisca, Mario D’Amico, Giulio Clesceri, Francesco Paolo Tarantino, Mario Giuseppe Vallone
Surgery in ovarian cancer may be associated with several urinary tract complications. Ureteral injuries are complications of gynecologic oncology procedures and may increase morbidity and cause mortality. In consideration of the anatomical proximity between adnexal structures and ureters, complications affecting these anatomical structures, both intra-operatively and extra-operatively, are not uncommon and can increase the rate of morbidity and mortality in treated patients. The overall incidence of urinary tract injury in pelvic surgery is 0.33%. The most common type of urinary tract injury is bladder injury. Ureteral injury most commonly occurs proximally at the pelvic brim during ligation of the infundibulo-pelvic ligament and distally during ligation of the uterine artery during hysterectomy. A review of total laparoscopic hysterectomies found a 0.3% incidence of ureteral injury, with all injuries occurring at the distal ureter at the level of the uterine artery/uterosacral ligament. Up to 50% of cases of unilateral ureteral injury are asymptomatic postoperatively. If injury occurs, however, management depends on the location and mechanism of injury. This study aimed to determine how Interventional Radiology (IR) could be useful to allow rehabilitation of the ureter.
Among 50 patients referred to our hospital with a diagnosis of ovarian cancer and subjected to cytoreduction surgery, 5 of them, with an interval of 2-25 days from the operation, showed abdominal pain, fever, anuria, peritonitis, and/or even vaginal urinary leaking. On the contrast-enhanced CT examination was found an ureteral lesion with the presence of partially sacted urine collections and in some cases with complete dehiscence of the vaginal dome. These patients were treated with placement of a GORE® VIABAHN endoprosthesis, from the ureter lesion to its outlet in the bladder. In 3 of 5 patients the urologist advances a guidewire through the ureteral meatus and a intraperitoneal rendezvous procedure was attempted.
A CT scan with contrast of the complete abdomen was performed and ureteral lesion of the distal III was highlighted, as well as partially collections of urine (AXIAL VIEW)
A CT scan with contrast of the complete abdomen was performed and ureteral lesion of the distal III was highlighted, as well as partially collections of urine (SAGITTAL VIEW)
A stent-graft was placed from the middle proximal ureter to the bladder outlet. The procedure was completed by the placement of a Flexima nephrostomy 8 French.
Intra-procedural urographic checks, as well as remote CT checks at a month after the procedure, showed a correct exclusion of the ureteral fistula, as well as the absence of hydronephrosis or contrast medium extravasation in 100% of the patients. No post-procedural infectious and haemorrhagic complications.
CT scans done at 30 days from the procedure showed a correct exclusion of the ureteral fistula, absence of hydronephrosis or contrast medium extravasation. Collections are no longer appreciable.
Ureteral lesions are serious complications of onco-gynecological surgery. A salvage surgery is often unavoidable and alone may not be sufficient to definitively resolve the clinical picture. In these patients the placement of a endoprosthesis was decisive for the exclusion of the ureteral fistula. In these patients, radiologists play a pivotal role in both the diagnosis of the injury and tailoring of treatment. The conservative interventional radiological approach can represent the first choice for traumatic ureteral section treatment. A minimally invasive treatment of iatrogenic ureteral lesions after gynecological surgery was a safe, manageable, and effective option. However, further studies including a larger cohort of patients will be necessary to support these preliminary conclusions.