A systematic approach for successful repair of radiated and non-radiated ureteral injuries.

Background: Successful ureteral reconstruction is challenging, particularly in radiated fields. We characterize and directly compare surgical outcomes in modern cohorts of radiated and non-radiated patients undergoing ureteral reconstruction utilizing a systematic approach to pre-operative assessment. We hypothesize that radiated patients will undergo more complex ureteral reconstructions and experience higher rates of surgical failure and complications compared to nonradiated patients.

Methods: Consecutive cases of ureteral reconstruction for acquired ureteral injury performed by a single surgeon from 2010-2018 were retrospectively reviewed. Clinical data were collected including pre-operative bladder capacity, ureteral injury characteristics, and surgical technique. Ileal ureter and autotransplantation were classified as "complex" ureteral repairs, and surgical success was defined as freedom from surgical revision of the ureteral anastomosis and/or ureteral stenting.

Results: There were 47 ureteral reconstructions performed including 17 (36%) radiated patients. Radiated patients had lower pre-operative bladder capacity and were more likely to undergo complex repairs compared to non-radiated patients (35% vs. 7%, P=0.01). Overall surgical success was high (98%) and similar between radiated (94%) and non-radiated groups (100%) at median follow up of 30 months. Clavien grade 3-4 complications occurred in 18% of radiated and 10% of non-radiated patients (P=0.48).

Conclusions: Careful pre-operative evaluation and appropriate selection of surgical technique facilitates high and similar success of ureteral reconstruction in radiated and non-radiated patients. Complex ureteral repairs were more common in radiated patients, however the majority of radiated ureteral injuries (65%) were reconstructed without tissue transfer. Radiated patients had lower pre-operative bladder capacities, but similar surgical morbidity, renal function, and persistent urge incontinence compared to non-radiated patients.