When the Ureter Takes a Detour: Navigating a Total Laparoscopic Hysterectomy After a Psoas Hitch

INTRODUCTION: Ureteral reconstruction techniques such as the psoas hitch are utilized to address distal ureteral injuries or strictures, often secondary to previous surgeries, trauma, or malignancies. Correct identification and management of these complex cases are essential to preserve urinary function and minimize complications when undergoing pelvic surgery after a psoas hitch has been performed. This case presents a detailed account of a 41-year-old woman with a history of duplicated right ureters and recurrent UTIs with subsequent ureteral strictures requiring a right psoas hitch, now undergoing total laparoscopic hysterectomy. OBJECTIVE: To demonstrate methods to employ and perform a safe and effective hysterectomy in a patient with a prior right-sided psoas hitch and ureteral duplication, while preserving ureteral integrity and avoiding intraoperative injury. This case emphasizes the importance of preoperative planning, intraoperative techniques, and intraoperative urological collaboration to optimize surgical outcomes. METHODS: Preoperative evaluation included multidisciplinary planning with urology, including cystoscopy with ureteral catheter placement on the right side affected by ureteral duplication prior to hysterectomy. Precise intraoperative techniques were used including careful dissection around the bladder and vascular structures, taking care to preserve the previous psoas hitch and avoid disturbing bladder adhesions that would otherwise be taken down to restore anatomy. Pedicles were successfully and sequentially ligated with energy devices by employing bladder retraction, and uterine removal was accomplished via vaginal route. Post-removal, cystoscopy assessed ureteral patency, with final ureteral catheter removal confirming bilateral normal function. RESULTS: A total laparoscopic hysterectomy in a patient with a prior psoas hitch was completed without intraoperative complications. Although ureteral visualization was challenging due to the altered anatomy, intraoperative ureteral stenting aided in helping identify areas where there was no evidence of ureteral stents. Preservation of the psoas hitch adhesions was maintained, avoiding tension on the ureter and preventing injury. Postoperative cystoscopy confirmed ureteral function. The patient experienced an uneventful recovery and was discharged without complications. CONCLUSIONS: In cases with a history of psoas hitch and complex ureteral anatomy, preparedness involving urology consultation and preoperative planning is critical. Preoperative cystoscopy and ureteral stenting are valuable for baseline assessment and intraoperative guidance. Caution should be exercised to preserve existing adhesions related to the psoas hitch that would otherwise be taken down in efforts to restore anatomy, as disturbing these structures may jeopardize ureteral integrity and function. Meticulous surgical technique, multidisciplinary collaboration, and intraoperative assessment are instrumental in ensuring safe operative outcomes in complex hysterectomies with prior ureteral reconstruction.