Holmium Laser Endoureterotomy with the Lovaco Technique for the Treatment of Ureterointestinal Stenosis: Tips and Tricks

Ureterointestinal stenosis is a frequent complication after radical cystectomy, which in some series reaches 14% of cases. Some of the causes that have been related to this complication are the distal ureteral ischemia, the excessive tension of the ureterointestinal anastomosis, the junction of two different mucous membranes, or the leakage of urine around the anastomosis. Although it has been shown that success rates are better with open, laparoscopic or robotic surgery, today there are a number of endourological techniques that are useful in the treatment of this pathology. Some of the oldest and most used techniques are balloon dilatation or dilatation plus wire cutting. In the specific case of ureterointestinal stenosis, standard endoureterotomy has been described by anterograde access after percutaneous puncture of the kidney. In this work we present a retrograde access technique, which is different to standard procedure, it is the endoureterotomy with holmium laser after endoluminal invagination of the stenosis, as described by Lovaco.

This technique involves crossing a guide through the ureterointestinal stenosis, and introducing a dilation balloon into the ureter retrogradely, just in the proximal area of the stenosis. After inflating the balloon in the proximal area of the stenosis, it is pulled from the outside, producing an endoluminal invagination towards the segment of intestine, thus visualizing the stenotic segment that is to be incised. This intussusception allows a better view of the area to be cut, as well as improving safety, since the area to be incised is separated from the vascular and intestinal structures that can surround the stenotic area. Although the technique has been described with the use of different cutting instruments, such as the cold knife or Collins handle, in our video we show the surgery using a holmium laser, which improves visibility and precision in the cut.

The video also shows several tips and tricks to carry out this surgery, as well as the most difficult aspects. Although the success rate of our series is 80%, the sample size is small and follow-up time is short. Most published works on this and other techniques are from a single center, with few patients and with short follow-up periods, which is why the superiority of one technique over another can not be affirmed. However, we think that this surgery has some advantages with respect to standard endoureterotomy, such as greater safety, better visualization and control of the area to be incised, or not needing flexible material. Thus, in the video we describe this useful and reproducible technique, as another option for the treatment of ureterointestinal stenosis.

Written by: Jorge Panach-Navarrete MD, Lorena Valls-González MD, María Medina-González MD, José María Martínez-Jabaloyas MD PhD

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