Laparoscopic Ureteral Reimplantation for a Distal Ureteral Injury Detected After Laparoscopic Radical Prostatectomy

Abstract

Distal ureteral injury is a rare complication of laparoscopic radical prostatectomy (LRP). The authors report such a case which was repaired successfully with an exclusively laparoscopic approach. They also describe the advantages of the flank position when performing this minimally invasive approach.

The Case: A 61-year-old Filipino male, with a PSA of 10 ng/cc, diagnosed with localized prostate cancer undergoes LRP, utilizing a posterior approach to the seminal vesicles. Intraoperatively, a large intravesical median lobe was noted which was dissected meticulously after the division of the bladder neck. The excision of the 60gm prostate was completed in the conventional manner followed by a urethrovesical anastomosis. Blood loss was minimal with no apparent intraoperative events. Histopathology confirmed prostate cancer, Gleason score (4+3) with negative margins. Postoperatively, he had progressively high pelvic drain output and noticeably a relatively low urethral catheter output. CT urogram done on POD 8 showed a distal left ureteral disruption with intraabdominal extravasation. The authors performed a laparoscopic left ureteroneocystostomy on POD 9. The patient did well after the repair. After removing the indwelling catheter on postoperative day 14, he was discharged in a good clinical condition. The ureteral stent was removed one month after the reimplantation. Follow-up CT urogram showed unobstructed flow through the reimplanted left ureter. Follow-up PSA at this time was 0.01ng/cc.

Conclusion. Ureteral injury following LRP is a devastating complication which may go undiagnosed intraoperatively. Prompt recognition, followed by a timely minimally invasive repair through a laparoscopic approach is needed to correct this problem.