URETERAL COMPLICATIONS FOLLOWING TYPE-3-4 RADICAL HYSTERECTOMY IN PATIENTS WITH LOCALLY ADVANCED CERVICAL-CANCER

In order to assess the incidence, and factors influencing the risk of ureteric complications in patients with stage IB-IIA>4 cm, IIB, II, II I cervical cancer who underwent type 3-4 radical hysterectomy followin g neoadjuvant chemotherapy, data from 157 consecutive patients were an alyzed. Among these, 90 patients entered a randomized study aimed to a ssess the efficacy of a ureteric stent in preventing ureteric complica tions. In these patients one ureter, randomly chosen, was stented befo re surgery, the surgeon being unaware of which. Ureteric dissection co nsisted in the isolation of the meter from the superficial and deep la yer of the vesico-uterine ligament and cutting of the ligament 1 cm fr om (type 3) or at bladder insertion (type 4). To prevent the distal me ter from being immersed in pelvic dead space, a protecting wall approx imating the stumps of the anterior and posterior parametria was perfor med. Ureteric fistula was observed in 11 (7%) patients of the whole se ries of 157 patients and stricture in three (2%) patients. The inciden ce of fistula declined from 13% of the first 31 patients to O% of the last 36 patients. Chi-square analysis showed that ureteric stenting, c umulative surgical experience expressed as date of surgery, age and th e construction of the protecting wall significantly affected the risk for fistula formation (P<0.05). Mild ureteric dilatation was observed in 53% of ureters not stented. Spontaneous resolution was observed in all patients at 6-12 months. Fistula was the most striking ureteric co mplication following type 3-4 radical hysterectomy. Increased skill of the operating team may explain the reduced frequency of ureteric dama ge over time, since this made it possible to actually respect the peri ureteric plexus which is the only vessel to the distal meter after cut ting the ureteric blood supply from the hypogastric artery. Although t he ability of a ureteric stent to prevent fistula formation was shown, stent-induced morbidity and the importance of surgical skill in preve nting ureteric damage suggest that routine stent utilization be avoide d.