Ureteric injury: a challenging condition to diagnose and manage. Nat Rev Urol. 2013;10:108-115. [PMID: 23318355 DOI: 10.1038/nrurol.2012.254]

When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement

Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice. They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes. As the incidence of complicated diverticular disease and colorectal malignancy increases, so too does the extent of fistulous connections between the gastrointestinal and urinary systems. These complex problems will be more common as a factor of an aging population with increased life expectancy. Diverticular disease is the most commonly encountered aetiology, accounting for up to 80% of cases, followed by colorectal malignancy in up to 20%. A high index of suspicion is required in order to make the diagnosis, with ever improving imaging techniques playing an important role in the diagnostic algorithm. Management strategies vary, with most surgeons now advocating for a single-stage approach to enterovesical fistulae, particularly in the elective setting. Concomitant bladder management techniques are also disputed. Traditionally, open techniques were the standard; however, increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management. Unfortunately, due to the relative rarity of these entities, no randomised studies have been performed to ascertain the most appropriate management strategy. Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer. With radiotherapy being a major contributing factor in the development of these complex fistulae, optimum surgical approach and exposure has changed accordingly to optimise their management. Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling, macerated tissues or associated co-morbidities. One may plan for definitive surgical intervention at a later stage. Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available. An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described. In low lying fistulae, a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts. According to recent literature, it offers a high success rate in complex cases.

Preservation of the mesureter to reduce urinary complications: analysis of data from the observational Leipzig School MMR study

OBJECTIVE

To evaluate the feasibility and effect of mesureteral preservation on urinary complications in the context of total mesometrial resection (TMMR), a surgical treatment for cervical cancer.

DESIGN

Retrospective cohort study with historic control.

SETTING

Single tertiary academic centre.

POPULATION

Women older than 18 with primary cervical cancer staged FIGO IB1-IIB enrolled in the prospective Leipzig School MMR study and underwent total mesometrial resection (TMMR) without adjuvant radiation.

METHOD

We retrospectively analysed 100 consecutive TMMR procedures which were performed for cancer of the uterine cervix and in which the mesureter was preserved (intervention group, 01/2014-06/2017). We compared this group with the previous 100 consecutive TMMRs, which were performed before the introduction of mesureteral preservation (control group, 09/2010-01/2014).

MAIN OUTCOME MEASURES

The occurrence of urological and specifically ureteral complications.

RESULTS

Mesureteral preservation was feasible and was associated with a significant decrease in ureteral complications (11% without mesureteral preservation versus 3% with mesureteral preservation, P = 0.049). Furthermore, we found a significant decrease in the number of postoperative percutaneous nephrostomies and re-operations (7% versus none, P = 0.014). There was also a trend towards a decrease in other urinary complications such as postoperative bladder atony and uretero-vaginal fistulas.

CONCLUSION

The mesureter constitutes a convenient dissection plane enabling the preservation of lateral ureteral blood supply during TMMR. In our study, maintenance of mesureteral integrity was associated with a significant reduction in ureteral complications. Mesureteral preservation might also be useful in other types of pelvic surgeries that carry a high risk of ureteral damage.

TWEETABLE ABSTRACT

Surgical preservation of the mesureter in cervical cancer patients was associated with a reduction in urinary complications.

Iatrogenic Ureteral Injury as a Complication of Posterior or Lateral Lumbar Spine Surgery: A Systematic Review of the Literature

OBJECTIVE

Iatrogenic ureteral injury associated with lumbar spine surgery is an uncommon but devastating complication with associated medicolegal implications.

METHODS

We performed a systematic review of the English language literature published between 1954 and 2019, accessed through 4 popular databases. We found 44 articles (28 case reports, 9 case-based reviews, 4 case series, 1 original article, 1 case illustration, and 1 pictorial) containing 46 cases of ureteral injuries after posterior or lateral lumbar spine surgery.

RESULTS

Except for 5 cases with insufficient data, 24 of the remaining 41 patients were female and 17 were male, with ages ranging from 16 years to 83 years. Excluding 4 cases without enough information, initial diagnoses of lumbar disc herniation (n = 33) or lumbar spinal stenosis (n = 4), spondylolisthesis (n = 3), degenerative disc disease (n = 1), and failed back surgery syndrome (n = 1) were reported from 18 countries; 54% of patients were from the United States, Japan, or Turkey. The interval from spinal surgery to restorative surgery ranged from <24 hours to 1 month to 1 year; in 48% of patients, it was >1 week, and 90% of patients recovered completely. Initial surgery was combined with vascular injury in 15% of patients.

CONCLUSIONS

Ureteral injury associated with lumbar spine surgery is overreported in developed or developing countries. It should be considered in the differential diagnosis of any patient who presents with symptoms of acute abdomen after lumbar spine surgery, and patients who underwent restorative surgery had a good prognosis.

The effects of rectal cancer surgery on the anatomical localisation of ureters - a prospective observational study

Introduction

Anatomical changes after surgery and fibrotic adhesions increase the organ laceration risk, including that of the ureter, in recurrent cases and secondary operations. The aim of this study was to investigate the changes in the anatomical localisations of the ureters via computed tomography urography in patients undergoing rectal cancer surgery.

Material and methods

The study involved prospectively collected data on the changes of ureteral location preoperatively and postoperatively in patients with operated rectal cancer. Distances (mm) of ureters determined midline in the computed tomography urogram phase.

Results

A total of 18 patients were included. The mean distances between the right (R₁) and left (L₁) ureters and the mid-vertebral line before the surgery were 30.9 ±5.4 mm and 34.5 ±9.9 mm, respectively. The postoperative distances between them (R₂ and L₂) were 26.4 ±9.1 mm and 29.5 ±9.9 mm, respectively. The R₂ measurement showed that 83.3% (15/18) of the right ureters had deviated medially, whereas 16.7% (3/18) of them had deviated laterally. The L₂ measurements showed that 88.8% (16/18) of the left ureters had deviated medially, whereas 11.2% (2/18) of them had deviated laterally. The differences between the preoperative and postoperative measurements of the right and left ureter positions were 4.5 ±9.2 mm and 4.9 ±4.6 mm, respectively, with the displacement in the left ureter being statistically significant (p ≤ 0.001).

Conclusions

Rectal cancer surgery causes medially deviated changes in the positions of the ureters.

Does Early Ureteroneocystostomy After Iatrogenic Ureteral Injury Jeopardize Outcome?

OBJECTIVE

To compare the outcomes of patients who underwent early repair (≤7 days) of iatrogenic ureteral injury with ureteroneocystostomy and compare them to those repaired in a delayed fashion (>7 days).

METHODS

A retrospective review of billing data between 2012 and 2018 identified patients who underwent ureteroneocystostomy for a benign ureteral disease. Inclusion criteria included all ureteral injuries related to a laparoscopic, robotic, or open surgical injury. Patients with ureteral injury related to radiation, stones, or reconstructive surgery were excluded. Patients undergoing reconstruction during the initial injury or within ≤7 days were designated as having undergone early repair, while the remaining were considered delayed repair. Demographics, as well as inpatient and postdischarge data were acquired, and statistical analysis was performed comparing the 2 groups.

RESULTS

Sixty-seven patients met inclusion criteria. Early repair was performed on 12 patients, while 55 underwent delayed repair. No significant difference in age, gender, Charlson Comorbidity Score, laterality, stricture location, or history of pelvic/abdominal radiation was noted. Inpatient complications were significantly higher in the immediate group (58 vs 18%, P =.004). Thirty- and 90-day complications were similar. Two patients in the delayed group and none in the immediate group demonstrated stricture recurrence (P =.710). A higher rate of Boari flap ureteral reconstruction was performed in the delayed cohort (P =.001).

CONCLUSION

In this cohort, there was no detectable difference in outcomes when comparing early and delayed ureteroneocystostomy for iatrogenic ureteral injuries.

Pelvic dimension as a predictor of ureteral injury in gynecological cancer surgeries

BACKGROUND

Ureteral injury is an intractable complication in gynecological cancer surgeries. Identifying risk factors can ensure safety of the ureters intraoperatively. A narrow pelvis is known to exert extra difficulties in pelvic surgeries. However, whether pelvic dimension can affect the risk of ureteral injury in gynecological cancer surgeries is poorly understood. We aimed to evaluate the association between pelvic dimension and the risk of ureteral injury during gynecological cancer surgeries.

METHODS

All patients who had undergone gynecological cancer surgeries were searched from January 2011 to July 2017. We included patients with ureteral injury who had available data of abdominal and pelvic computed tomography for measuring pelvic dimensions. Multivariate condition logistic analysis was used to identify the risk factors independently correlated with ureteral injury in gynecological cancer surgeries.

RESULTS

A total of 43 cases with 86 controls were included in this study. We discovered that a longer anteroposterior diameter of the mid-pelvis (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.01-1.13, P = 0.019) and a shorter transverse diameter of the mid-pelvis (OR 0.92, 95% CI 0.86-0.98, P = 0.013) were associated with ureteral injury in gynecological cancer surgeries. In laparoscopic analysis, a longer anteroposterior diameter of the mid-pelvis (OR 1.11, 95% CI 1.00-1.24, P = 0.041) was a risk factor for ureteral injury. In the analysis of open surgery, a longer transverse diameter of the mid-pelvis (OR 0.79, 95% CI 0.66-0.93, P = 0.006) was a protective factor for ureteral injury.

CONCLUSIONS

This study demonstrated that mid-pelvis dimensions were associated with ureteral injury, but the observed differences were too small. In addition, pelvic inlet dimensions did not appear to relate with ureteral injury. Thus, these pelvimetry measures could not be beneficial in assessing the risk of ureteral injury in gynecological cancer surgeries.

External-internal ureteral catheterization technique in treatment of ureteral injuries

Background/aim

It was aimed to describe the external-internal ureteral catheterization technique and evaluate its safety, efficacy, and reliability in iatrogenic and traumatic ureteral injuries.

Materials and methods

A retrospective review was performed on patients with iatrogenic and traumatic ureteral injury, treated using the external-internal ureteral catheterization technique between May 2012 and January 2018 in our hospital. A total of 14 patients were investigated with clinical, postoperative, and follow-up findings, as well as technical outcomes.

Results

The urology, gynecology, and general surgery departments referred patients for treatment at a rate of 57% (n = 8), 36% (n = 5), and 7% (n = 1), respectively. The causes were urological procedures for lithiasis (43%, n = 6), gynecological surgery (36%, n = 5), rectosigmoid surgery (7%, n = 1), penetrating injury (7%, n = 1), and partial nephrectomy (7%, n = 1). The most commonly affected segment was the distal third of the ureter, at a rate of 79% (n = 11). The mean duration of catheterization in all of the patients was 39 days. The overall technical success was 100% and no major complications occurred.

Conclusion

The external-internal ureteral catheterization technique in patients with ureteral injury is easy to apply and effective not only in reducing costs but also complications that may result from recurrent percutaneous interventions.

The sentinel stent? A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections

PURPOSE

'Prophylactic' ureteric stents potentially reduce rates, and facilitate intraoperative recognition, of iatrogenic ureteric injury (IUI) during colorectal resections. A lack of consensus surrounds the risk-benefit equation of this practice, and we aimed to assess the evidence base.

METHODS

A systematic review was performed according to PRISMA guidelines. MEDLINE, Scopus, EMBASE and Cochrane databases were searched using terms 'ureteric/ureteral/JJ/Double J stent' or 'ureteric/ureteral catheter' and 'colorectal/prophylactic/resection/diverticular disease/diverticulitis/iatrogenic injury'. Primary outcomes were rates of ureteric injuries and their intraoperative identification. Secondary outcomes included stent complication rates.

RESULTS

We identified 987 publications; 22 papers met the inclusion criteria. No randomised controlled trials were found. The total number of patients pooled for evaluation was 869,603 (102,370 with ureteric stents/catheters, 767,233 controls). The most frequent indications for prophylactic stents were diverticular disease (45.38%), neoplasia (33.45%) and inflammatory bowel disease (9.37%). Pooled results saw IUI in 1521/102,370 (1.49%) with, and in 1333/767,233 (0.17%) without, prophylactic ureteric stents. Intraoperative recognition of IUIs occurred in 10/16 injuries (62.5%) with prophylactic stents, versus 9/17 (52.94%) without stents (p = 0.579). The most serious complications of prophylactic stent use were ureteric injury (2/1716, 0.12%) and transient ureteric obstruction following stent removal (13/666, 1.95%).

CONCLUSIONS

Placement of prophylactic ureteric stents has a low complication rate. There is insufficient evidence to conclude that stents decrease ureteric injury or increase intraoperative detection of IUIs. Apparently higher rates of IUI in stented patients likely reflect use in higher risk resections. A prospective registry with harmonised data collection points and stratification of intraoperative risk is needed.

Factors in delay of diagnosis of gynecologic ureteral injuries at a rural academic hospital

INTRODUCTION AND HYPOTHESIS

Ureteral injuries are a source of morbidity, and delays in diagnosis can increase the risk for long-term sequelae. Our aim was to quantify and describe iatrogenic ureteral injuries in a rural tertiary care center. Our secondary goal was to evaluate the impact of delayed diagnosis of ureteral injury on patient outcomes and whether cystoscopy had any influence on these outcomes.

METHODS

A retrospective chart review was undertaken for ureteral injuries, identified by the ICD-9 code from 1997 to 2017 at West Virginia University (WVU) Hospital. Injuries were categorized by procedure, surgeon specialty, location (WVU versus community hospital), and intraoperative cystoscopy. A delay in diagnosis was defined as a ureteral injury sustained during surgery not diagnosed intraoperatively.

RESULTS

Forty-six patients were identified with iatrogenic ureteral injury at WVU. Twenty-seven occurred during gynecologic procedures (59%). Fourteen ureteral injuries were sustained at community hospitals and transferred to WVU for evaluation and treatment. Fifty percent of those had a known delay in diagnosis. The average delay in diagnosis for transferred patients was 6.5 days vs. 3.6 days for patients with ureteral injury sustained at WVU. Cystoscopy was only utilized in 37% (10/27) of gynecologic cases involving a ureteral injury. When cystoscopy was utilized, it was 80% (8/10) effective in helping to identify ureteral injury.

CONCLUSIONS

Within a rural population, approximately half of patients with ureteral injuries were transferred to a tertiary care center for evaluation and treatment. Transferred patients were more likely to have a delay to diagnosis than patients who had injuries sustained at WVU. The delayed diagnosis patients had comparatively worse outcomes. Gynecologic surgeons working in rural hospitals should be adequately trained to perform diagnostic cystoscopy.

[Management of ureteral injuries]

Ureteral injuries account for less than 3% of genitourinary injuries. Most of them are caused iatrogenically during abdominal surgery. The symptoms are often non-specific and do not aid in diagnosis. The later the injury is detected, the more often complications occur. Therefore, in such situations it is important to consider the possibility of ureteral injury and initiate further diagnostic steps as soon as possible. A variety of diagnostic tests are available. In addition to the direct inspection of the ureters and retrograde ureteropyelography, computed tomography (CT) urography is routinely used. Based on the time of diagnosis as well as the extent and the localization of the injury, the further procedure can be determined. For minor injuries, the insertion of a ureteral splint is usually the treatment of choice. In the case of higher grade damage, operative reconstruction by one of several possible surgical procedures is indicated.

An Isolated Ureteropelvic Junction Injury Following a Low-impact Mechanical Fall

OBJECTIVE

To describe the presentation of a rare isolated ureteropelvic junction injury resulting from a mechanical fall on ice.

MATERIALS AND METHODS

A 71-year-old previously healthy man presented to the emergency department at the University of Massachusetts Medical School 3 hours following falling on ice with complaints of gross hematuria and flank pain. Patient records were accessed via the institution's electronic medical records system between March 22, 2018 and April 22, 2018.

RESULTS

Abdominal imaging revealed urinary extravasation without evidence of accompanying injury to surrounding structures, confirming an isolated left ureteropelvic junction injury.

CONCLUSION

Isolated ureteral injury following low-impact blunt abdominal trauma is exceedingly rare. Furthermore, this patient's presentation challenges the accepted conventions for both mechanism of injury and accompanying clinical factors in ureteral trauma.

Near-infrared fluorescence laparoscopy of the ureter with three preclinical dyes in a pig model

Background

Ureteric injury is reported to occur in 1–7.6% of colorectal surgeries. To reduce the incidence of ureteral injury, it is essential to identify the ureters. The use of near-infrared fluorescence (NIRF) imaging with intravenously administered dyes might be of added value for ureteral visualization during laparoscopy. The aim of this study is to assess the performance of three preclinical dyes; IRDye^® 800BK, IRDye^® 800NOS and IRDye^® 800CW, for near-infrared fluorescence laparoscopy of the ureter in pigs.

Methods

In three female Dutch landrace pigs, the new dyes were evaluated. In each pig, 1 dye was tested using a 6-mg intravenous dose in a concentration of 1 mg/ml. Imaging was performed in fluorescence mode and white light mode with a laparoscopic imaging system. In order to further evaluate the dyes, an ex vivo imaging experiment was performed, in which 8 decreasing concentrations per dye, diluted in PBS, were evaluated in a transparent test tube with NIRF mode at a distance of 1, 5 and 10 cm from the laparoscope.

Results

All three dyes were effective in allowing the identification of the ureter with NIRF imaging. The ureter became fluorescent after 35, 45 and 10 min, respectively, for IRDye^® 800BK, IRDye^® 800NOS and IRDye^® 800CW with a maximum target-to-background ratio (TBR) of 2.14, 0.66 and 1.44, respectively. In the ex vivo imaging experiment, all three dyes produced a strong fluorescence signal at all concentrations and all distances evaluated.

Conclusions

Intravenous administration of the preclinical dyes IRDye^® 800CW, IRDye^® 800 BK and IRDye^® 800NOS facilitated successful identification of the anatomical course of the ureter in living pig models. The highest measured TBR occurred with the use of IRDye^® 800BK. Ex vivo, a correlation was observed between the fluorescence intensities of the signal with the concentration of the dye and with the distance to the object.

Upper Ureteric Stricture Secondary to Celiac Plexus Block Managed by Robotic Ureterocalicostomy

Introduction: Ureterocalicostomy is a well-established procedure of choice for recurrent pelviureteric junction (PUJ) obstruction refractory to endoscopic management, failed pyeloplasty, completely intrarenal pelvis, and iatrogenic upper ureteral stricture with significant peripelvic fibrosis. Robotic ureterocalicostomy is the procedure of choice in such scenarios where meticulous dissection and accurate anastomotic suturing is required.

Case Presentation: We report the case of an 18-year-old male, who underwent celiac plexus block for pain management of chronic calcific pancreatitis and presented with pain in the epigastric region and the right flank. A CT and subsequent nephrostogram revealed an upper ureteral defect (corrosive stricture) of ∼4 cm at the level of PUJ. Robotic ureterocalicostomy was performed. We discuss the clinical presentation, evaluation, and management along with literature review.

Conclusion: Iatrogenic ureteral strictures are not uncommon in urological practice, but an upper ureteral stricture secondary to celiac plexus block is a rarity. Adequate evaluation and timely intervention by reconstructive surgery, robotic ureterocalicostomy in this case, yield satisfactory results.

The incidence, causes, and management of lower urinary tract injury during total laparoscopic hysterectomy

OBJECTIVES

Determining the incidence and causes of lower urinary tract injury in patients undergoing total laparoscopic hysterectomy and examining the procedures applied for management.

METHODS

Patients who underwent total laparoscopic hysterectomy in a large referral center between 1 January 2015 and 31 October 2017 for benign gynecological reasons were included in the study. Patients who underwent laparoscopic supracervical hysterectomy, laparoscopy-assisted vaginal hysterectomy and robot-assisted laparoscopic hysterectomy were not included in this study. The hospital records of all patients included in the study were examined and the incidence, causes and management of lower urinary tract injuries were reviewed.

RESULTS

Total lower urinary tract injury rate was found as 2.01%, and these injuries were evaluated separately as bladder and ureter injuries. All the bladder injuries had occurred on the posterior wall of the bladder during vesicouterine dissection; six cases were intraoperatively detected and one case was detected on the first postoperative day. Most of ureteral injury cases were detected in the early postoperative period (75%). The rates of previous cesarean section and endometriosis were significantly higher in patients with injury to the bladder and ureter than in the control group (p<0,001). There was no significant difference between the patients with lower urinary tract injury and the control group regarding uterine weight, estimated blood loss, bilateral salpingo-oophorectomy, the presence and location of fibroids, and laparoscopic or vaginal closure of the vaginal cuff.

CONCLUSION

Laparoscopic hysterectomy may be a good option in appropriate patients, but in case of previous cesarean section and endometriosis cases, patients should be informed about the possible complications in detail before the operation and care should be taken during dissection.

Intraoperative Ureter Visualization Using a Novel Near-Infrared Fluorescent Dye

Ureters can be accidentally severed during pelvic surgeries, significantly prolonging the times in the operating room to allow for complete repair of damaged ureters and leading to significant morbidities associated with consequent ureter obstruction and possible kidney dysfunction. In an effort to prevent these complications, light-emitting stents and urine-excreted dyes have been introduced to illuminate the ureter during surgery. However, problems with mechanical insertion, ureter spasm, image contrast, and localized injection have limited interest in their clinical applications. We report here the synthesis and characterization of a new near-infrared (NIR) fluorescent dye (UreterGlow) that can be injected systemically but is excreted primarily through the renal system, allowing ureter imaging with an NIR fluorescence camera. Following intravenous injection of 0.1 mg/kg UreterGlow, we have monitored the flow of UreterGlow through the proximal, medial, and distal segments of the ureter. The timing of ureter visualization was calculated from the time of injection of the drug. The null hypothesis was that "Visualization of the ureter in pigs is possible 60 min after administration of UreterGlow using an NIR camera". UreterGlow displayed excitation and emission maxima of λ_ex = 800 nm and λ_em = 830 nm in phosphate buffered saline, pH 7.4, and could be imaged in the urinary tract in mice. Shortly after injection of UreterGlow into Yorkshire pigs, peristalsis of the ureter could be observed. The distal ureter could be visualized under NIR illumination after 60 min with constant fluorescence in all five pigs for >2 h. The same ureters could not be seen using visible light ( X², p = 0.0001). Because both excitation and emission of UreterGlow occurs at >30 nm longer wavelength than most tumor-imaging fluorescent dyes, it should be possible to distinguish ureter fluorescence from tumor fluorescence with this dye.

Contemporary management of ureteral strictures

Ureteral stricture disease is a luminal narrowing of the ureter leading to functional obstruction of the kidney. Treatment of strictures is mandatory to preserve and protect renal function. In recent times, the surgical management of ureteral strictures has evolved from open repair to include laparoscopic, robotic and interventional techniques. Prompt diagnosis and early first line intervention to limit obstructive complications remains the cornerstone of successful treatment. In this article, we discuss minimally invasive, endo-urological and open approaches to the repair of ureteral strictures. Open surgical repair and endoscopic techniques have traditionally been employed with varying degrees of success. The advent of laparoscopic and robotic approaches has reduced morbidity, improved cosmesis and shortened recovery time, with results that are beginning to mirror and in some cases surpass more traditional approaches.

Level of evidence: Not applicable for this multicentre audit.

Adult iatrogenic ureteral injury and stricture-incidence and treatment strategies

Iatrogenic ureteral injuries and strictures are relatively common complication of pelvic surgery and radiation treatment. Left untreated they are associated with severe short- and long-term complications such as urinoma, septic state, renal failure, and loss of a renal unit. Treatment depends on timing of diagnosis, as well as extent of injury, and ranges from simple endoscopic management to complex surgical reconstruction under usage of pedicled grafts. While recent advances in ureteral tissue engineering are promising the topic is still underreported. Historically a domain of open surgery, laparoscopic and robotic-assisted approaches have proven their feasibility in small case series, and are increasingly being utilized as means of reconstructive surgery. This review aims to give an outline of incidence and treatment of ureteral injuries and strictures in light of the latest advances.

Delayed Diagnosis of Ureteral Injury Following Penetrating Abdominal Trauma: A Case Report and Review of the Literature

BACKGROUND Ureteral injuries are considered to be uncommon in cases of trauma. The possibility of damage to the ureters may not be considered in the setting of acute trauma when life-threatening injuries take clinical management priority. A case of acute ureteral injury is described in a patient with acute penetrating gunshot abdominal injury that had a delay in diagnosis, with a review of the literature. CASE REPORT A 29-year-old woman presented to our hospital with a missed ureteral injury following a self-inflicted gunshot injury to the abdomen. She underwent abdominal computed tomography (CT) imaging and a retrograde pyelogram, which showed complete transection of the left upper ureter with contrast extravasation and the formation of a large urinoma. She underwent a percutaneous nephrostomy and drainage of the urinoma. An end-to-end ureteric anastomosis with excision of the intervening injured ureter, or ureteroureterostomy, was performed three weeks following the diagnosis. CONCLUSIONS Ureteral injuries following trauma are rare, but a delay in diagnosis can be associated with clinical morbidity. A high index of clinical suspicion is important for early identification of ureteral injury in cases of acute abdominal trauma.

Ileal Ureter Replacement Combined With Boari Flap-Psoas Hitch to Treat Full-Length Ureteral Defects: Technique and Initial Experience

OBJECTIVE

To evaluate the feasibility of ileal ureter replacement combined with Boari flap-psoas hitch procedure for the management of full-length ureteral defects (>20 cm).

METHODS

Three patients diagnosed with full-length ureteral defect were treated with our technique performed by a single surgeon between January 2015 to January 2016. All the patients had borderline renal function preoperatively. In each case, the ureteral reconstruction was performed by combining ileal ureter replacement with Boari flap-psoas hitch. Data on indications for surgery, intraoperative and postoperative outcomes, and changes in renal function were collected.

RESULTS

Surgery was performed successfully with an operation duration between 210 and 250 minutes. The mean estimated blood loss was 230 mL. The mean length of hospital stay was 11 days, and no major complications (grade ≥3) occurred. Postoperative follow-up showed radiological resolution of hydronephrosis and improved renal function in all 3 patients.

CONCLUSION

Ileal ureter replacement combined with Boari flap-psoas hitch is a feasible option for bridging full-length ureteral defects. This technique minimizes the length of ileal graft required as well as limitations concerning patient selection. Larger series with longer follow-up to confirm the value of the technique are warranted.

Laparoscopic ureteroureterostomy with an intraoperative retrograde ureteroscopy-assisted technique for distal ureteral injury secondary to gynecological surgery: a retrospective comparison with laparoscopic ureteroneocystostomy

OBJECTIVES

The aim of this study was to compare the operative and postoperative outcomes of laparoscopic ureteroureterostomy (LAP-UU) using a retrograde ureteroscopy-assisted technique with laparoscopic ureteroneocystostomy (LAP-UNC) in treating ureteral injury after gynecological surgery.

MATERIALS AND METHODS

The study analyzed 60 ureteral injury repairs performed between May 2010 and February 2016 in patients who underwent either LAP-UU using the retrograde ureteroscopy-assisted technique (n = 26) or LAP-UNC (n = 34). Demographic parameters, operative variables and perioperative outcomes were retrospectively analyzed. The chi-squared test, Fisher's exact test and Student's t test were used for statistical analyses.

RESULTS

Demographic and clinical data revealed no significant differences between patients in each group in terms of age, body mass index, length of obstruction, incidence of postoperative urinary leakage, incidence of urinary tract infection during hospitalization, oral antibiotics, mean hospital stay, incidence of recurrent obstruction, rate of conversion to open surgery and mean operative time. The LAP-UU group had significantly less estimated blood loss (85 ± 40 vs 120 ± 35 ml, p = .0006) and a significantly lower incidence of vesicoureteral reflux (grade I) on cystography (0/26 vs 6/34, p = .031) during a mean follow-up of 36.5 months (range 7-71 months).

CONCLUSIONS

Compared with LAP-UNC, LAP-UU is also a technically feasible and safe option for repairing distal ureteral injury secondary to gynecological surgery. The intraoperative retrograde ureteroscopy-assisted technique during LAP-UU contributes to precise localization of the lesion, reduces intraoperative bleeding, enables sufficient dissection of the intramural ureter and preserves its natural antireflux mechanism.

Hyperspectral interventional imaging for enhanced tissue visualization and discrimination combining band selection methods

PURPOSE

Hyperspectral imaging is an emerging technology recently introduced in medical applications inasmuch as it provides a powerful tool for noninvasive tissue characterization. In this context, a new system was designed to be easily integrated in the operating room in order to detect anatomical tissues hardly noticed by the surgeon's naked eye.

METHOD

Our LCTF-based spectral imaging system is operative over visible, near- and middle-infrared spectral ranges (400-1700 nm). It is dedicated to enhance critical biological tissues such as the ureter and the facial nerve. We aim to find the best three relevant bands to create a RGB image to display during the intervention with maximal contrast between the target tissue and its surroundings. A comparative study is carried out between band selection methods and band transformation methods. Combined band selection methods are proposed. All methods are compared using different evaluation criteria.

RESULTS

Experimental results show that the proposed combined band selection methods provide the best performance with rich information, high tissue separability and short computational time. These methods yield a significant discrimination between biological tissues.

CONCLUSION

We developed a hyperspectral imaging system in order to enhance some biological tissue visualization. The proposed methods provided an acceptable trade-off between the evaluation criteria especially in SWIR spectral band that outperforms the naked eye's capacities.

Simultaneous percutaneous nephrolithotomy and early endoscopic ureteric realignment for iatrogenic ureteropelvic junction avulsion during ureteroscopy

We present a case report of successful management of ureteropelvice junction avulsion during ureteroscopy successfully managed with simultaneous percutaneous nephrolithotomy and early endoscopic ureteral realignment.

Long-term Outcome of Ileal Ureteric Replacement With an Iliopsoas Muscle Tunnel Antirefluxing Technique for the Treatment of Long-segment Ureteric Strictures

OBJECTIVE

To investigate the long-term outcome of ileal ureteric replacement using a proximal antirefluxing technique for the treatment of long-segment ureteric strictures.

PATIENTS AND METHODS

Between January 1997 and December 2013, 41 patients with a long ureteral stricture or defect and 3 patients with unilateral mid-lower ureteral cancer (20 bilateral and 24 unilateral, 28 males and 16 females) were treated by ureteral substitution using a proximal antirefluxing technique. The distal part of the upper ureter (4 cm) was fixed between the psoas muscle and the ileal segment (the iliopsoas tunnel technique). The distal ileum was connected to the urinary bladder with an end-to-side anastomosis. A successful outcome was defined as the absence of major complications, worsening baseline renal function, metabolic derangements, or obstruction.

RESULTS

One patient with unilateral mid-lower ureteral cancer died 3 years postoperatively because of metastasis, and the remaining 43 patients were followed for 12-180 months (mean 69 months). Intravenous urography showed that the hydronephrosis improved significantly or disappeared after 6-12 months in 34 patients, with improvement in 9 patients. Cystography showed no evidence of ileoureteral reflux. Seven patients needed long-term oral alkalization to prevent hyperchloremic acidosis.

CONCLUSION

In our experience, outcomes following subtotal ureteric replacement are encouraging. The ileal ureter replacement by the proximal antirefluxing technique appears to be a reliable procedure for treating long-segment ureteral stricture and preservation of renal function.

Iatrogenic urinary tract injuries: etiology, diagnosis, and management

Iatrogenic injury to the urinary tract, including the kidneys, ureters, bladder, and urethra, is a potential complication of surgical procedures performed in or around the retroperitoneal abdominal space or pelvis. While both diagnostic and interventional radiologists often play a central and decisive role in the identification and initial management of a variety of iatrogenic injuries, discussions of these injuries are often directed toward specialists such as urologists, obstetricians, gynecologists, and general surgeons whose procedures are most often implicated in iatrogenic urinary tract injuries. Interventional radiologic procedures can also be a source of an iatrogenic urinary tract injury. This review describes the clinical presentation, risk factors, imaging findings, and management of iatrogenic renal vascular and urinary tract injuries, as well as the radiologist's role in the diagnosis, treatment, and cause of these injuries.

Postoperative ureteral leak treated using a silicone-covered nitinol stent

Ureteral fistula is a serious complication of abdomino-pelvic surgeries, often resulting in poor outcomes owing to lack of proper treatment. We report the case of a 49-year-old woman who underwent placement of a silicone-covered ureteral occlusion stent in her right ureter for the management of ureteral leakage after pelvic surgery. A ureterogram obtained 18 months following the stent placement confirmed that there was no stent migration or additional urine leakage. We propose that the silicone-covered ureteral occlusion stent is practical, fast, and safe for the management of ureteral leakage.

Automated Spectroscopic Tissue Classification in Colorectal Surgery

BACKGROUND

In colorectal surgery, detecting ureters and mesenteric arteries is of utmost importance to prevent iatrogenic injury and to facilitate intraoperative decision making. A tool enabling ureter- and artery-specific image enhancement within (and possibly through) surrounding adipose tissue would facilitate this need, especially during laparoscopy. To evaluate the potential of hyperspectral imaging in colorectal surgery, we explored spectral tissue signatures using single-spot diffuse reflectance spectroscopy (DRS). As hyperspectral cameras with silicon (Si) and indium gallium arsenide (InGaAs) sensor chips are becoming available, we investigated spectral distinctive features for both sensor ranges.

METHODS

In vivo wide-band (wavelength range 350-1830 nm) DRS was performed during open colorectal surgery. From the recorded spectra, 36 features were extracted at predefined wavelengths: 18 gradients and 18 amplitude differences. For classification of respectively ureter and artery in relation to surrounding adipose tissue, the best distinctive feature was selected using binary logistic regression for Si- and InGaAs-sensor spectral ranges separately. Classification performance was evaluated by leave-one-out cross-validation.

RESULTS

In 10 consecutive patients, 253 spectra were recorded on 53 tissue sites (including colon, adipose tissue, muscle, artery, vein, ureter). Classification of ureter versus adipose tissue revealed accuracy of 100% for both Si range and InGaAs range. Classification of artery versus surrounding adipose tissue revealed accuracies of 95% (Si) and 89% (InGaAs).

CONCLUSIONS

Intraoperative DRS showed that Si and InGaAs sensors are equally suited for automated classification of ureter versus surrounding adipose tissue. Si sensors seem better suited for classifying artery versus mesenteric adipose tissue. Progress toward hyperspectral imaging within this field is promising.

Robotic-assisted laparoscopic surgery: recent advances in urology

The aim of the present review is to summarize recent developments in the field of urologic robotic surgery. A nonsystematic literature review was performed to retrieve publications related to robotic surgery in urology and evidence-based critical analysis was conducted by focusing on the literature of the past 5 years. The use of the da Vinci Surgical System, a robotic surgical system, has been implemented for the entire spectrum of extirpative and reconstructive laparoscopic kidney procedures. The robotic approach can be applied for a range of adrenal indications as well as for ureteral diseases, including benign and malignant conditions affecting the proximal, mid, and distal ureter. Current evidence suggests that robotic prostatectomy is associated with less blood loss compared with the open surgery. Besides prostate cancer, robotics has been used for simple prostatectomy in patients with symptomatic benign prostatic hyperplasia. Recent studies suggest that minimally invasive radical cystectomy provides encouraging oncologic outcomes mirroring those reported for open surgery. In recent years, the evolution of robotic surgery has enabled urologic surgeons to perform urinary diversions intracorporeally. Robotic vasectomy reversal and several other robotic andrological applications are being explored. In summary, robotic-assisted surgery is an emerging and safe technology for most urologic operations. The acceptance of robotic prostatectomy during the past decade has paved the way for urologists to explore the entire spectrum of extirpative and reconstructive urologic procedures. Cost remains a significant issue that could be solved by wider dissemination of the technology.

Laparoscopic dissection of the intramural ureter to repair a complete transection of the distal ureter: Initial experience with a new minimally invasive technique that preserves the anatomy of the urinary tract

We report 2 patients with ureteral injury after a simple total laparoscopic hysterectomy for uterine myoma with a complete resection of the distal ureter. One patient had unilateral injury and the other 2 patients had bilateral injury. The surgical laparoscopic repair procedure was carried out 3 to 5 days after the injury. Surgery involved intramural dissection of the distal ureteral stump to expose at least 1 cm of the ureter, percutaneous ureteral stent placement, elimination of tension between the proximal ureter and the dissected distal stump, end-to-end anastomosis, and reinsertion of the distal ureter into the bladder muscle layer, which was previously dissected for the anastomosis.

Salpingo-ureteric fistula-A rare complication following laparoscopic surgery for colorectal cancer: A case report and literature review

INTRODUCTION

We report the management and outcome of the case of a 57-year old woman with adenocarcinoma of the rectum. Following neo-adjuvant chemo-radiotherapy and laparoscopic-assisted anterior resection of her tumour she developed a right salpingo-ureteric fistula.

PRESENTATION OF CASE

Three weeks following laparoscopic anterior resection of the tumour she presented with urinary frequency and incontinence. A ureteric stent was inserted and left in-situ for five months but the fistula did not heal. The patient underwent exploration and open repair of the salpingo-ureteric fistula which resolved her symptoms.

DISCUSSION

There have not been many reported cases in the literature of salpingo-ureteric fistulae but after initial trial of management with ureteric stents all eventually required open exploration and repair.

CONCLUSION

we advocate open repair of salpingo-ureteric fistulae as the definitive management following intra-operative injury.

Application of a new dye for near-infrared fluorescence laparoscopy of the ureters: demonstration in a pig model

BACKGROUND

Ureteral injury during laparoscopic colorectal surgery is a rare but serious complication with a reported incidence rate of 0.66%. The early detection and prevention of ureteral injury is clinically relevant and important. The successful use of preclinical near-infrared fluorophore CW800-CA for real-time intraoperative identification of the anatomical course of the ureters with the use of a laparoscopic fluorescence imaging system is reported.

METHODS

The usefulness of this new imaging technique was explored in two 35-kg pigs. Intravenous CW800-CA was administered 10 minutes before fluorescence imaging was conducted with the use of a commercially available laparoscopic fluorescence imaging system.

RESULTS

A dose of 1 mg/mL CW800-CA (bolus injection of 3 mL) provided clear delineation of the course of both ureters by using the fluorescence mode of the laparoscope. There were no adverse reactions to the injected dye.

CONCLUSION

Near-infrared fluorescence laparoscopy of the ureters, following intravenous CW800-CA administration, is easily applicable and provides real-time identification of the course of the ureters.