On the Right Track With the Urinary Tract?

INTRODUCTION: Congenital anomalies of the kidney and urinary tract account for 20–30% of all congenital anomalies detected prenatally, with vesicoureteral reflux (VUR) being one of the most prevalent. VUR affects 1–2% of children and often requires surgical intervention. This video discusses considerations for perioperative management of patients with a history of extravesical ureteral reimplantation undergoing gynecologic surgery. OBJECTIVE: The primary aim of this video is to highlight the anatomical challenges in subsequent gynecologic surgery that can be present in patients who underwent extravesical ureteral reimplantation for congenital VUR. We will also review the indications for and important surgical concepts regarding extravesical ureteral reimplantation. METHODS: We present a case of a 45-year-old nulligravida female with a past surgical history of laparoscopic extravesical ureteral reimplantation performed at 6 months of age. She was referred to our advanced gynecologic surgery center for evaluation of heavy menstrual bleeding and uterine fibroids. Preoperative evaluation included CT urogram, which revealed mild bilateral hydronephrosis and the ectopic course of the reimplanted ureter. RESULTS: This patient underwent a robot-assisted total laparoscopic hysterectomy and bilateral salpingectomy. Intraoperative findings confirmed the ectopic positioning of the left ureter, which was found traversing over her left round ligament, just lateral to the left cornua of an enlarged fibroid uterus. Careful dissection was performed to lateralize the left ureter out of the surgical field. At the conclusion of the hysterectomy, cystoscopy confirmed appropriate efflux from both ureters. CONCLUSIONS: This case highlights the importance of thorough preoperative assessment and anatomical knowledge when managing patients with a history of congenital ureteral anomalies undergoing gynecological surgery. An ectopic course of a reimplanted ureter necessitates meticulous intraoperative technique to avoid ureteral injury. Increased awareness among gynecologists about the potential anatomic changes associated with previous ureteral surgeries is crucial for optimizing patient care.