The ureter is my friend

Posted 12 years ago by Andreas Hackethal

Our gynaecological anatomy puts a heavy focus on the female reproductive organs. Though, most of the genital tract is developed out of the Mullerian duct and comprises mostly a vagina, a uterus and a pair of ovaries and tubes only, the retroperitoneal anatomy of the pelvis extends our anatomical and surgical field drastically. As a matter of fact, two additional organ systems terminate their course within the pelvis, the bowel and the ureters and bladder.

Previously, this blog touched on the issue of dealing with ureter complications and how we, as Gynaecologists can actively deal with them. In fact, 28 out of the first 60 recent publications on pubmed, using the search term „ureter gynecology“ deal with gynaecological complications to the ureter. Another 12 focus on the management of ureteric endometriosis and only 3 papers are on ureters in the context of cancer. 

Our training, our specialty, our daily work as Gynaecologists is associated with the imperative anxiety to harm the ureter. WE FEAR THE URETER!

Well, lets take it to another level and not talk about fear and complication avoidance. But rather about friendship and managing the relationship with our friend, the ureter, in a positive way.

I am one of the gynaecological oncology trainees at the QLD Centre for Gynaecological Cancer (QCGC). We recently reviewed 21 intended distal ureter resections at QCGC. Of the 21 ureters, three were re-anastomosed and 18 re-implanted into the bladder, requiring another 3 Boari flaps and 11 Psoas hitch procedures. Hospital data were analyzed from 2006 to 2012 and the surgical management and patients’ postoperative courses were evaluated. Within the time period, seventeen ureter resections were performed to achieve a complete cytoreduction for cancer and four to achieve a complete excision of extensive endometriosis. Strikingly, more than 75% of patients were diagnosed with hydronephrosis prior to surgery. No postoperative ureteric leaks, fistulas or abscesses occurred as to our knowledge. The most common complications were urinary tract infections, which resolved with antibiotic treatment. Though the intended surgery to the distal ureter performed by a gynaecologist is not common, the study raises awareness of an important feature of infiltrative disease:

INFILTRATIVE DISEASE DOES NOT STOP AT THE ORGANS OF YOUR SPECIALISATION

Within this series 18 procedures were performed by a gynaecological oncologist alone and three with the assistance of a urologist. Should gynaecologists operate on the ureter herself or hand over care to a urologist?

There are more than two answers to the question:

First, the surgical perspective: Anastomising or reimplanting a ureter is feasible and safe and not so much a myth. Like any other surgical procedure, it requires certain steps to be followed in a systematic way. Having healthy and vascularised ureter ends (may need trimming), insertion of a ureteric stent followed by 3-0 monofilament sutures and maybe even an additional covering omental flap is all it needs. 

Many of us would have performed refertilising surgery to anastomise the Fallopian tubes and this is a very similar procedure to ureter anastomosis.

Secondly, the political perspective: Anyone who is not certified in urology should involve a urologist for reconstructive surgery of the urinary tract. However, involving a urologist can also mean, that you ask the urologist to supervise and guide you. Like us, the urologist would always have the patient’s safety as a primary concern in mind. Many colleagues may be happy to give you a hand, especially, if you have an ongoing relationship and they know of your thorough and meticulous clinical management.  

WE SHALL KEEP IN MIND: The most important factor is the patients SAFETY. However, also adequate surgical resection is of outmost importance for patients’ prognosis in ovarian cancer and endometriosis, as examples.

So, what can be done about our ureter anxiety?

My second year training as a registrar for O&G was at the Justus-Liebig University Clinic in Giessen, Germany in 2004. During the following seven years (there is no mandatory rotation in Germany), I was trained mainly by the director of this clinic, Prof. Dr. Dr. Hans-Rudolf Tinneberg, an outstanding person, a supporting and diligent teacher and excellent surgeon. He is an ideal role model for picking up on how to cope with surgical situations beyond only performing demanding and planned procedures.

From a surgical perspective, endoscopy and endometriosis were our daily bread and butter, as the clinic was the only tertiary endometriosis centre in the middle of Germany. Whatever case you can imagine, it was likely to happen in Giessen. Opening of the retroperitoneum with dissection of vital structures, in particular the ureters were daily business. 

As Gynaecologists we know, the key to adequate cancer surgery and deep infiltrating endometriosis surgery is the radical excision of affected tissue.

One of Prof. Tinnebergs key repetitions turned into a mantra during difficult surgeries:

„The ureter is our friend“.

Remembering the efficient, respectful but fearless dissection of the ureter, pushing it away from affected tissue, I understand that the implications of the ureter being a friend are:

1. You want to look after your friend and know where s/he is
2. You want to comfort your friend and not traumatize or damage it
3. You want to follow your friend and walk with him, whatever distance is required
4. You want to make sure, that your friend is well and happy
5. YOU DO NOT want to be AFRAID to do all the above because YOU may cause harm to your friend

I start out every case with opening the retroperitoneum and saying: THE URETER IS MY FRIEND. 

I think we need to get trained to manage neighboring organs within the pelvis during our specialty training. I like to involve my friendly urology colleagues, as often as necessary.

What about you?

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