Expanded Experience with Laparoscopic Nephrectomy and Autotransplantation for Severe Ureteral Injury

Abstract

Complex injuries of the upper ureter with significant loss of length are difficult to manage. Traditional options include nephrectomy, bowel interposition and autotransplantation. The advent of laparoscopic donor nephrectomy has created a new option when preservation of functioning renal parenchyma is desirable. We update our experience with severe iatrogenic ureteral injuries requiring laparoscopic nephrectomy and autotransplantation. Seven patients with severe ureteral injuries were referred for definitive management. In all cases preoperative evaluation demonstrated comparable split renal function and anatomy not amenable to routine reconstruction. Transperitoneal laparoscopic nephrectomy and autotransplantation to the ipsilateral pelvis were attempted. Of the patients 5 had a history of nephrolithiasis with intervention resulting in the ureteral injury and 5 underwent prior endoscopic or open management of the defects. All cases were associated with dense perinephric and perihilar fibrosis. Operative and warm ischemic times averaged 508 and 5 minutes, respectively. After ex vivo graft preparation, ureteral and vessel length and quality were adequate for transplantation in 6 cases. In the other patient the renal pelvis was not amenable for reconstruction. Urinary drainage consisted of ureteroneocystostomy in 2 cases and ipsilateral ureteroureterostomy in 4. There were no intraoperative complications and all grafts functioned immediately. Hospitalization averaged 6.4 days. At a mean followup of 17 months imaging studies demonstrated functioning renal autographs with a mean decrease in serum creatinine of 5%. Laparoscopic nephrectomy in conjunction with autotransplantation is a viable option for severe proximal ureteral loss. Acceptable perioperative morbidity and excellent graft function were obtained in all cases when the kidney was transplanted. Close cooperation with a transplant team is crucial to coordinate graft harvest, ensure appropriate organ preparation and select the optimal urinary anastomosis.