• Etiology
  • Most are secondary to unrecognized distal ureteral injuries sustained during gynecologic procedures
    • Abdominal or vaginal hysterectomy
    • Cesarean section
    • Anti-incontinence surgery
    • Other causes
      • Endoscopic instrumentation
      • Radiation therapy
      • Pelvic malignancy
      • Penetrating pelvic trauma
      • Other pelvic surgery (vascular, enteric, etc.).
    • Risk factors for ureteral injuries include a prior history of pelvic surgery, endometriosis, radiation therapy, and pelvic inflammatory disease.
    • Up to 12 percent of vesicovaginal fistulae may have an associated ureterovaginal fistula.
• Presentation
  • Clear drainage per vagina
  • Unilateral hydroureteronephrosis and flank pain secondary to partial ureteral obstruction.
    • Flank pain, nausea, fever, and clear vaginal drainage following pelvic surgery is very suggestive of ureteral injury.
• Evaluation
  • Intravenous urography.
    • A urogram may demonstrate partial obstruction, hydroureteronephrosis, and drainage into the vagina.
  • Cystoscopy and retrograde pyelography.
    • These are performed to evaluate for bladder injury and to visualize the distal ureteral segment if not well seen on the urogram.
    • An attempt at retrograde stenting is reasonable if the pyeloureterogram demonstrates ureteral continuity.
    • Prolonged internal diversion with ureteral stenting may result in resolution of the fistula.
  • CT/MRI.
    • Cross-sectional imaging can be useful to evaluate for pelvic malignancy when indicated or evaluate for an urinoma in patients with persistent fevers.
  • Cystogram or cystometrogram.
    • In cases where a long segment of distal ureter is involved and a Boari flap is being considered for reconstruction
    • Can also be useful to evaluate the bladder capacity and vesicoureteral reflux.
• Therapy
  • Percutaneous drainage and possible antegrade or retrograde stenting.
    • If high-grade partial obstruction exists in the setting of sepsis, percutaneous drainage and a course of antibiotic therapy is indicated prior to definitive repair
    • If retrograde stenting is unsuccessful but the pyeloureterogram shows continuity of the ureteral lumen, then an attempt at antegrade stenting can be made.
  • Surgery.
    • When stenting is unsuccessful, ureteral reimplantation (with or without psoas hitch) is performed.
    • Fistulas resulting from advanced pelvic malignancy may best be treated by urinary diversion.

References

Please log-in or register in order to submit comments.

Powered by AkoComment!