263Archivio Italiano di Urologia e Andrologia 2019; 91, 4 CASE REPORT Renal autotransplantation: A final option to preserve the kidney after an iatrogenic ureteral injury Napoleon Moulavasilis 1, Ioannis Katafigiotis 1, Dimitris Staios 3, Christos Nikolaidis 2, Spyridon Vernadakis 2, John Bokos 2, Ioannis Anastasiou 1 1 1st Department of Urology, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece; 2 Renal Transplant Unit, Laiko Hospital, Athens, Greece; 3 Urologist, Laiko Hospital, Athens, Greece. Background: Ureteral injuries are not very common and can occur after many surgical procedures. Kidney salvage is desirable. Renal autotransplanta- tion is a final option for some cases. In this case, we report an autotransplantation of the kidney after an iatrogenic injury of the ureter with totally extraperitoneal approach. Case report: A 41 years old female underwent left endoscopic ureterolithotomy with holmium laser for ureteral calculi. An iatrogenic ureteral injury, probably ureteral avulsion, occurred. After multiple interventions, she referred to us with a nephros- tomy tube. Imaging was performed and left renal autotrans- plantation was chosen as surgical management. The approach was totally extraperitoneal. No alteration of renal function or of urine outflow was observed during the follow up. Conclusions: The report supports the safety and efficacy of renal autotransplantation. KEY WORDS: Ureteral injury; Iatrogenic; Renal autotransplanta- tion; Totally extraperitoneal. Submitted 7 July 2019; Accepted 20 July 2019 Summary No conflict of interest declared. DOI: 10.4081/aiua.2019.4.263 INTRODUCTION Iatrogenic ureteral injuries are not a very common com- plication of urologic and non urologic surgery, but it can be quite challenging to correct them. Salvaging the kid- ney function and repairing the defect are of paramount importance. Treatment depends on the extent of the ureteral trauma and the site of the injury. Minor injuries can be treated endoscopically with ureteral stent place- ment, but can relapse. More serious injuries or relapses of minor injuries may require more complicated inter- ventions such as ureteral reimplantation with psoas hitch or Boari flap, or uretero-ureteral anastomosis. Even these more advanced techniques cannot treat the prox- imal ureter defects, due to short length of healthy ureter (1). Renal autotransplantation is a suitable option for such cases. The first case was performed by JD Hardy in 1963 to repair a ureteral injury, but its implementation is still limited. We present a case of an iatrogenic ureter- al injury with failed endoscopic management that result- ed in autotransplantation of the kidney. CASE REPORT/CASE PRESENTATION A 41 year old female was referred to us after a prolonged history of multiple interventions that resulted in the per- manent placement of nephrostomy tube for renal drainage. The initial intervention was endoscopic ureterolithotripsy with holmium YAG laser for an impacted ureteral calculi. After complete but strenuous stone fragmentation and removal of semirigid ureteroscope, a complete ureteral avulsion was realised. An immediate open intervention was decided and patient underwent ureteral anastomosis and ureteral stent placement. Patient’s post op course was uneventful and she was discharged five days later. Two months postoperatively the patient returned to the treating physicians because of abdominal pain and high fever of 38.5°C. Emergency imaging with a CT scan revealed a retroperitoneal abscess around the left kidney extending further to the psoas muscle. Patient underwent open drainage, recovered and was discharged again with a indwelling ureteral stent. Eight months later the patient had a relapse of fever and abdominal pain and CT scan again revealed a retroperitoneal urinoma, that was percu- taneously drained. Patient was discharged again after clin- ical improvement with an indwelling ureteral stent and a Foley catheter for bladder drainage. Seven days later, patient complained of abdominal pain, nausea and vomit- ing. An ultrasound reported fluid around the kidney extending to the psoas muscle. An attempt to replace the double J stent failed, a percutaneous nephrostomy was placed instead and an ureteral catheter was placed retro- gradely. Thereafter the patient was referred to our hospital. A treatment strategy was planned. Firstly, a computer tomography was performed. The report described that the ureteral catheter drained the retroperitoneal fluid. Treatment was given for 6 weeks according to antibiogram of fluid culture following antimicrobial treatment guide- lines. The exact site of the urinary tract injury and the extent of the ureteral trauma were investigated thereafter with antegrade pyelography and retrograde ureterography (Figure 1). An upper ureteral defect more than 15 cm in length was demonstrated. Moreover, magnetic resonance imaging (MRI) was performed. Autotransplantation was chosen as surgical management. It was performed almost 1 year after the initial intervention (endoscopic ureterolithotripsy with holmium laser). In supine position, previous incision was revised and the approach was totally extraperitoneal (Figure 2). The kid- ney was completely mobilized and was harvested with Katafigiotis_Stesura Seveso 10/01/20 08:56 Pagina 263 Archivio Italiano di Urologia e Andrologia 2019; 91, 4 N. Moulavasilis, I. Katafigiotis, D. Staios, C. Nikolaidis, S. Vernadakis, J. Bokos, I. Anastasiou 264 maximal artery and vein length. A healthy seg- ment of the upper ureter was mobilized. The renal vessels were anastomosed to the iliac vessels to reestablish renal perfusion and blood supply to the kid- ney was recovered with- in 40 minutes. The seg- ment of the proximal ureter was anastomosed to the bladder. No intra- operative complications occurred. Pigtail (double J stent) was left in the urinary tract for 4 weeks in order to provide safe urine flow from the transplant- ed kidney. Fifteen days after the autotransplantation the patient was discharged from our hospital with good state of the auto- transplanted kidney and urinary tract function. Ultrasound Doppler and DTPA were used to confirm good arterial and venous flow of the transplanted kidney (Fig ure 3). Thirty-two weeks after surgery, no signs of abnormalities of renal function or urine outflow were observed. DISCUSSION The management of major ureteral injury is always a challenge (2). It depends on the location and extent of the injury. Renal autotransplantation is considered a suit- able option for ureteral injuries especially when there is a major loss of ureteral length. Early recognition of the injury is very important because it is followed by mini- mally invasive procedure. Delayed recognition of injury requires treatment with extended procedures as well as high experience of the urologists. Repair of long defect of the ureter, especially of the proximal ureter, is a particu- larly difficult surgical challenge. There are no strict rec- ommendations on the treatment of long ureteral lesions. The treatment choice for every case is unique. The deci- sion for renal autotransplantation should be taken based on the extent and location of ureteral injury as well as patient preference and surgeon experience. CONCLUSIONS Iatrogenic ureteral injuries are relatively uncommon and the loss of a kidney is devastating. Renal autotransplan- tation in the setting of severe loss of ureteral length pro- vides an option as it preserves the renal function (3). This report supports the safety and efficacy of renal auto- transplantation. COMPLIANCE WITH ETHICAL STANDARDS Informed consent: Written informed consent was obtained from the patient for the publication of this Case Repost/any accompanying images. REFERENCES 1. Azhar B, Patel S, Chadha P, Hakim N. Indications for renal auto- transplant: an overview. Exp Clin Transplant. 2015; 13:109-14. 2. Benson MC, Ring KS, Olsson CA. Ureteral reconstruction and bypass: experience with ileal interposition, the Boari flap-psoas hitch and renal autotransplantation. J Urol. 1990; 143:20-3. 3. Shekarriz B, Lu H, Duh Q, et al. Laparoscopic nephrectomy and autotransplantation for severe iatrogenic ureteral injuries. Urology. 2001; 58:540-3. Figure 1. Antegrade pyelography. Figure 2. Extraperitoneal approach. Figure 3. DTPA. Correspondence Napoleon Moulavasilis, MD (Corresponding Author) napomoul@hotmail.com Ioannis Katafigiotis, MD katafigiotis.giannis@gmail.com Ioannis Anastasiou, MD ekati2@otenet.gr 1st Department of Urology, National and Kapodistrian University of Athens, Laiko Hospital Agiou Thoma str., Athens (Greece) Christos Nikolaidis, MD chr.nikolaidis@gmail.com Spyridon Vernadakis, MD svernadakis@yahoo.com John Bokos, MD johnbokos@gmail.com Renal Transplant Unit, Laiko Hospital, Athens (Greece) Dimitris Staios, MD dstaios@yahoo.com Urologist, Laiko Hospital, Athens (Greece) Katafigiotis_Stesura Seveso 10/01/20 08:56 Pagina 264