U 51-godišnjega bolesnika učinjena je transuretralna resekcija urotelijalnoga karcinoma završnoga dijela lijevoga mokraćovoda. U sljedećoj fazi odstranjen je donji dio lijevoga mokraćovoda s pripadajućim dijelom mokraćnoga mjehura te je na toj strani postavljena perkutana nefrostoma. Radi postizanja boljega kapaciteta mokraćnoga mjehura, učinjena je transuretralna resekcija prostate i u
posljednjoj fazi učinjen je ”psoas hitch” postupak s ureteroneocistostomijom.In 51-year-old patient urothelial carcinoma of the terminal left ureter was resected transurethrally. In the next phase, a distal part of the left ureter with a ”cuff” of the bladder was removed, and ipsilateral percutaneous nephrostomy introduced. Better bladder capacity was achieved by transurethral resection of the prostate, and in the last phase left-sided ”psoas hitch” procedure with ureteroneocystostomy was performe

Bob Djavan

Michael Marberger

Silvio Altarac

Croatian

HRČAK - Portal of Croatian Scientific and Professional Journals

77Silvio Altarac and co-authors: “Psoas Hitch” ProcedureMed Vjesn 2005; 37(1-4): 77-78“Psoas Hitch” ProcedureSilvio Altarac1, Bob Djavan2, Michael Marberger2General Hospital Zabok, Croatia1, University Hospital Wienna, Austria2Professional PaperUDK 616.617-089Received: October 20, 2005In 51-year-old patient urothelial carcinoma of the terminal left ureter was resected transurethrally. In the next phase, a distal part ofthe left ureter with a ”cuff” of the bladder was removed, and ipsilateral percutaneous nephrostomy introduced. Better bladder capac-ity was achieved by transurethral resection of the prostate, and in the last phase left-sided ”psoas hitch” procedure with ureteroneo-cystostomy was performed..Key words: ”psoas hitch” procedure, ureteral tumorINTRODUCTIONWhen preparing a patient for open repair of a ureteral defect, thelocation and lengh of the defect should be carefully assessed. Astension on the anastomosis nearly always leads to stricture for-mation, only short defects should be managed by ureter-oureterostomy. Lower third ureteral defects are best managed byureteroneocystostomy with or without a psoas hitch or Boariflap. Preoperatively, the ureteral defect should be characterizedwith intravenous urography, retrograde ureteropyelography orantegrade nephrostomography. Further asessment such as anuclear medicine renogram to evaluate renal function andureteroscopy, ureteral barbotage or brushing to rule out carcino-ma should be individualized. CASE REPORTA 51-year-old man with uneventful medical history was present-ed with two days painless macroscopic hematuria. Digital rectalexamination showed enlarged and painless prostate. Creatininewas increased (1.6 mg/dl). A urine cytology, urine culture andPCR for TB was negative. Ultrasonography revealed left-sidedmoderate hydronephrosis, and CT scan showed tumor of the ter-minal left ureter. Transurethrally resected tumor of the left ure-tral ostium revealed transitional cell carcinoma. In the secondhospitalization the distal part of the left ureter with a "cuff" ofthe bladder have been removed by the open surgery. Resectedtissue was tumor-free. Left-sided percutaneous nephrostomywas performed to preserve the kidney function. Transurethralresection of prostate was done in the third hospitalizationbecause of a small capacity of the bladder and nocturia 5-6x.One month later urinary flow was improved with the maximalpeak flow of 21.1 ml/s. The patient was admitted to the hospitalfor the fourth time because of fever up to 38.9°C, and increasedvalues of serum leukocytes (20.0), C-reactive protein (26.9mg/dl) and creatinine (1.47 mg/dl). The creatinine was reducedto the normal level (1.12 mg/dl). He became afebril by thecourse of systemic antibiotics (Augmentin 2x2 g/day), and afterstabilisation of his overall condition, left-sided "psoas hitch"procedure with ureteroneocystostomy was performed. Intraoper-ative histopathology of the ureteric left stump excluded the pres-ence of the tumor. Postoperative period was burdened by a par-alytic ileus, but the patient recovered well and was discharged onday 12.DISCUSSIONThe psoas hitch is an effective means to bridge a defect of thelower third of the ureter (1). Indications include distal ureteralinjury, ureteral fistulas secondary to pelvic surgery, failedureteroneocystostomy and segmental resection of a distal ureter-al tumor, as in our case (2,3,4). A psoas hitch can also be used inconjunction with a transureteroureterostomy in more complicat-ed urinary tract reconstruction. A small, contracted bladder sizeand mobility  may not be present. Ureteral defects proximal tothe pelvic brim usually require more than a simple psoas hitchalone. Urodinamic studies may provide more informationsregarding detrusor capacity and compliance. Bladder outletobstruction or neurogenic dysfuntion should be treated preoper-atively.A Pfannenstiel or lower midline incision is usually employed.  Aurethral catheter is placed and 200 ml of sterile water instilledinto the bladder. The space of Retzius is developed and the blad-der mobilized by freeing its peritoneal attachment and dividingthe vas deferens or round ligament. With traction on the ipsilat-eral dome, the bladder should be able to reach superior to theiliac vessels. Additional mobility is gained by dividing the con-tralateral superior vesical artery. The affected ureter is identifiedas it crosses the iliac vessels and divided just proximal to the dis-eased segment. A fine stay suture is placed on the normal proxi-mal ureter and the ureter carefully mobilized. Manual displace-ment of the bladder toward the ipsilateral ureter may be facili-tated by an anterior cystotomy. Although a vertical or obliquecystotomy is generally used, a horizontal incision, which is thenclosed vertically in a Heineke-Mikulicz fashion, is advocated bysome.The ureter is delivered into the bladder at the superolateralaspect of the dome and the anastomosis performed, with or with-out a submucosal tunnel. The ipsilateral bladder dome is fixed tothe psoas minor tendion, if present, or the psoas major muscleusing several absorbable sutures. Care should be taken to avoidinjury to the genitofemoral nerve when placing these sutures.78Silvio Altarac and co-authors: “Psoas Hitch” ProcedureMed Vjesn 2005; 37(1-4): 77-78Alternatively, psoas fixation may be performed before ureteralreimplantation. A double-J stent generally is placed and bladderclosure performed with absorbable sutures.A psoas hich can provade ad additional 5 cm of length as com-pared with ureterocystotomy alone (table 1.). Its advantages overa Boari flap include simplicity, improved vascularity, easy ofendoscopic surveillance and minimal voiding difficulties. Thesuccess rate of ureteral reimplantation with a psoas hitch is over85% (5). The most common compliations are urinary fistula andureteral obstruction.       REFERENCES1. Turner-Warwick RT, Worth PHL. The psoas bladder-hitch procedure forthe replacement of the lower third of the ureter. Br J Urol. 1969;41:701-9.2. Prout GR Jr, Koontz WW Jr. Partial vesical immobilization: an impor-tant adjunct to ureteroneocystostomy. J Urol. 1970;103:147.3. Ehrlich RM, Melman A, Skinner DG. The use of vesico-psoas hitch inurologic surgery. J Urol.1978;119:322-5.4. Rodo Salas J, Martin Hortiguela E, Salarich de Arbell J. Psoas fixationof the bladder. An efficient aid in cases of repeat surgery of the uretero-vesical junction. Arch Esp Urol. 1991;44:125-9.5. Mathews R, Marshall FF. Versatility of the adult psoas hitch ureteralreimplantation. J Urol. 1997;158:2078-82.TABLE 1. Categorization of the usual length of ureteral defect that can be bridged with various surgical techniques for ureteral reconstructionTABLICA 1Kategorizacija uobièajene dužine uretralnog defekta koji se može premostiti razlièitim kirurškim tehnikama rekonstrukcije uretera”PSOAS HITCH” POSTUPAKSilvio Altarac1, Bob Djavan2, Michael Marberger2Opæa bolnica Zabok, Republika Hrvatska1, Sveuèilišna klinièka bolnica u Beèu, Republika Austrija2SAŽETAKU 51-godišnjega bolesnika uèinjena je transuretralna resekcija urotelijalnoga karcinoma završnoga dijela lijevoga mokraæovoda. Usljedeæoj fazi odstranjen je donji dio lijevoga mokraæovoda s pripadajuæim dijelom mokraænoga mjehura te je na toj strani postavlje-na perkutana nefrostoma. Radi postizanja boljega kapaciteta mokraænoga mjehura, uèinjena je transuretralna resekcija prostate i uposljednjoj fazi uèinjen je ”psoas hitch” postupak s ureteroneocistostomijom.Kljuène rijeèi: ”psoas hitch” postupak, tumor mokraæovoda

“Psoas Hitch” procedure

Abstract

Similar works

Full text

Available Versions

HRČAK - Portal of Croatian Scientific and Professional Journals

Hrčak - Portal of scientific journals of Croatia