Ureteral injuries in colorectal surgery: an analysis of trends, outcomes, and risk factors over a 10-year period in the United States

Iatrogenic ureteral injuries: a case series analysis with an emphasis on the predictors of late ureteral strictures and unfavorable outcome in different surgical specialties

INTRODUCTION AND HYPOTHESIS

We aimed to report the demographics and management of iatrogenic ureteral injuries (IUIs) with different surgical specialties. Moreover, our goal was to analyze the predictors of late ureteral strictures and secondary intervention after primary surgical management, and the final effect on the kidney.

METHODS

A retrospective study, between 2006 and 2019, enrolled all patients undergoing urological, abdominal, and pelvic surgeries performed through open, laparoscopic, or endoscopic means. If IUIs were discovered intraoperatively, they were managed either by internal stent or surgical intervention following the standard procedure. For IUIs discovered postoperatively, either percutaneous nephrostomy (PCN) or double J (DJ) ureteral stents were inserted for later endoscopic or surgical management. The final outcomes were divided into two groups: patients with successful primary outcomes and those who required secondary intervention later. All predictors were compared between the two groups.

RESULTS

Forty-eight patients were reviewed: 23 out of 48 (48%) from obstetrics and gynecology (ob/gyn) involving the lower ureter primarily with overall favorable outcomes (82%), 15 (31%) colorectal, and 10 (21%) urology with serious injuries affecting men in the upper ureter. The primary management included open surgery in 12 patients, and drainage (PCN or DJ) in 36 patients. Restoration of ureteral anatomy and kidney function was achieved in all, but 18 cases required a secondary correction, either endoscopically or surgically. Both early and late discovery resulted in the same outcome. On bivariate analysis, only the side of the injury (left side, p = 0.03), and the specialty (colorectal cancer surgeries, p = 0.01) were predictors for late ureteral strictures, and both sustained their significance in multivariate regression analysis.

CONCLUSION

Iatrogenic ureteral injuries associated with ob/gyn surgeries involve the lower ureter, primarily with overall favorable outcomes (82%). Serious ureteroscopic IUIs affect men in the upper ureter with greater frequency. IUIs on the left side and colorectal cancer surgeries are the predictors for late strictures and secondary interventions.

Surgical Management of Recurrent Uncomplicated Diverticulitis

Sigmoid diverticulitis represents a most common gastroenterological diagnosis in the western world. There has been a significant change in the management of recurrent uncomplicated diverticulitis in the last 10 to 15 years. The absolute number of previous episodes is not used as criteria to recommend surgery anymore. Young age is no longer considered to be an indication for more aggressive surgical treatment. It is accepted that subsequent episodes of diverticulitis are not significantly worse than the first episode. Laparoscopic surgery is now the standard of care for elective surgery for diverticulitis where expertise is available. There is a consensus that decision to perform sigmoid colectomy should be individualized, after careful risk benefit assessment.

Complicated Diverticular Disease

The modern management of colonic diverticular disease involves grouping patients into uncomplicated or complicated diverticulitis, after which the correct treatment paradigm is instituted. Recent controversies suggest overlap in management strategies between these two groups. While most reports still support surgical intervention for the treatment of complicated diverticular disease, more data are forthcoming suggesting complicated diverticulitis does not merit surgical resection in all scenarios. Given the significant risk for complication in surgery for diverticulitis, careful attention should be paid to patient and procedure selection. Here, we define complicated diverticulitis, discuss options for surgical intervention, and explain strategies for avoiding operative pitfalls that result in early and late postoperative complications.

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.

Incidence and Clinical Outcomes of Gonadal Artery Injury during Colorectal Surgery in Male Patients

BACKGROUND

Gonadal artery is susceptible to accidental injury due to their anatomical proximity to the colon and rectum. There are few literature reviews focusing on this injury during colorectal surgery. We conduct a retrospective study to evaluate the incidence and the clinical significance of these injuries in terms of testicular size and testicular enhancement on the contrast CT scan.

METHODS

Patients' characteristic data included age, body mass index (BMI), diagnosis, operation type, cause of gonadal artery injury, side of injury, level of injury, method of vessel ligation, and follow-up period. We measured the testicular sizes before and after gonadal artery injury and measured the enhancement level by recording the mean attenuation value on the injury side and non-injury side of the testis on the CT scan.

RESULTS

The incidence of gonadal artery injury was 3.61% and 15 male patients with this injury were enrolled. There were 5 patients with iatrogenic injury and 10 patients with non-iatrogenic injury due to advanced tumor or inflammation. No patients had any complaints of testicular discomforts or atrophy after the surgery. The testicular sizes before and after the surgery showed no significant difference (p = 0.877). The mean attenuation values of the injury side and non-injury side of the testis also showed no significant difference (p = 0.79).

CONCLUSIONS

Gonadal artery injury during colorectal surgery is not a rare complication. To prevent this injury, knowledge of the anatomy and staying in the proper plane of dissection are the key points. In patients with gonadal artery injury during colorectal surgery, sacrifice of the gonadal artery is safe without clinical significance in terms of testicular size and testicular enhancement on the contrast CT scan.

Ureterocolic fistula detected by mercaptoacetyltriglycine (MAG-3) diuretic renography including single photon emission CT and low-dose CT (SPECT-CT)

We describe the case of a 60-year-old man with a ureterocolic fistula following laparoscopic sigmoid resection. The fistulous tract between the left ureter and sigmoid colon was detected by mercaptoacetyltriglycine diuretic renography including single photon emission CT with low-dose CT. Ureteroneocystostomy was successfully performed.

Routine prophylactic ureteral stenting before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Safety and usefulness from a single-center experience

OBJECTIVE

There are very few evidences about safety and usefulness of routine prophylactic ureteral stenting (PUS) before cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

MATERIAL AND METHODS

An analysis of prospectively collected data about patients who underwent CRS and HIPEC for different sites of primary disease was carried out focusing on ureteral complications.

RESULTS

A total of 138 patients who underwent CRS and HIPEC between December 2010 and June 2017 were considered. All patients underwent PUS before CRS and HIPEC. Of them, 91 (66.4%) patients received pelvic peritonectomy, 49 (35.8%) pelvic lymphadenectomy, 31 (22.6%) left hemicolectomy, 44 (32.4%) right hemicolectomy, 46 (33.6%) rectal resection, 56 (40.9%) hysteroannessiectomy, and 39 (28.5%) appendectomy. There was one (0.7%) postoperative ureteral fistula. The cumulative risk of ureteral stent-related major complications was 4.3% (two patients (1.4%) had protracted gross hematuria, two patients (1.4%) had urinary sepsis, and three patients (2.9%) developed hydronephrosis after a period from removing ureteral stents and required restenting. Morbidity due to ureteral stenting was associated with a longer length of stay (LOS) (p=0.053). A total of 52 patients (44.1%) developed renal dysfunction according to the RIFLE (Risk, Injury, Failure, Loss of kidney function, End-stage kidney-disease) criteria: 19.5% were in risk class, 10.2% in acute renal injury class, and 14.4% in acute renal failure class.

CONCLUSION

PUS could be a useful tool for reducing iatrogenic ureteral injury, but it is associated with a non-negligible morbidity, which implies longer LOS. A more accurate patient selection for PUS is necessary.

Robotic pelvic dissection as surgical treatment of complicated diverticulitis in elective settings: a comparative study with fully laparoscopic procedure

BACKGROUND

Recently, minimally invasive treatment of complicated sigmoid diverticulitis is becoming a valid alternative to standard procedures. Robotic approach may be useful to allow more precise dissection in arduous pelvic dissection as in complicated diverticulitis. The aim of this study is to investigate effectiveness, potential benefits and short-term outcomes of robotic-assisted laparoscopic surgical resection, compared with fully laparoscopic resection in complicated diverticulitis.

METHODS

Between January 2009 and December 2017, 156 consecutive patients with history of complicated diverticular disease were referred to our Department of General, Mininvasive and Robotic Surgery. All patients underwent elective colonic resections performed by the same colorectal surgeon and followed a perioperative ERAS program. Demographic and clinical features, surgical data, postoperative data, 30-day morbidity and mortality, VAS for surgeon's compliance were evaluated.

RESULTS

One hundred and fifty-six consecutive patients underwent elective colonic resection: 92 fully laparoscopic (FL) colorectal resections and 64 procedures with robotic hybrid approach (RHA). Conversion rate was none in the RHA group versus 6.5% in the FL group, because of poor vision due to bowel distension, inflammatory pseudotumor and peritoneal adhesions. No 30-day mortality was observed. Mean operative time was 167.5 ± 54.4 min (80-420) in the FL group and 172.5 ± 55.64 min (110-325) in the RHA group (p 0.079), mean intraoperative blood loss was 144.6 ± 40.6 ml (40-200) with the FL technique and 138.4 ± 28.3 ml (20-185) with the RHA (p 0.295). Mean hospital stay for FL was 5 ± 4.1 days (range 3-45) and 5 ± 2.7 days (range 3-20) for RHA (p 0.974). Overall postoperative morbidity rate was 21.6% in the FL group and 12.3% in the RHA (p 0.067). Major postoperative morbidity (Clavien-Dindo 3 and 4) represented 13% and 4.6%, respectively (p 0.091). VAS for surgeon's compliance revealed a better performance in the robotic arm (p 0.059).

CONCLUSIONS

This preliminary study highlights the potential benefits of robotic-assisted laparoscopy in colorectal resections for complicated diverticular disease in terms of surgical efficacy, postoperative morbidity and better surgeon's compliance.

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.

Urological Injuries during Colorectal Surgery

The proximity of the colon and rectum to the organs of the urologic system virtually ensures that iatrogenic urologic injuries become a distinct possibility during complex colorectal surgical procedures. An intimate knowledge of urogenital anatomy as well as strategies for identification and repair of potential injuries is of paramount importance. Attention is mandated when operating within the narrow confines of the pelvis, as this is where these structures are most at risk. The ureters are at highest risk of injury, followed by the bladder and urethra. The nature of these injuries encompasses both functional and mechanical morbidities. Patient factors, including prior pelvic surgery, radiation, inflammatory bowel disease, infectious processes, and urogenital abnormalities all increase the risk of injury. As colorectal surgeons encounter an increasing number of patients with the above risk factors, it is important to be familiar with the various urologic injury patterns, their diagnosis, and appropriate management.

Iatrogenic ureteral injuries and their prevention in colorectal surgery: results from a nationwide survey

AIM

Iatrogenic ureteral injury (IUI) occurs rarely during colorectal surgery but is associated with significant mortality, morbidity and medicolegal issues. Few cases are reported, and recommendations regarding prevention are lacking. The aim of this study is to describe the current state of practice regarding IUI and its prevention among general surgeons in Switzerland.

METHOD

All Swiss general surgeons who are members of either the Swiss Association of Laparoscopic and Thoracoscopic Surgery or the Swiss Surgical Society were invited to participate in an anonymous online survey. Demographics, surgical practice, rate of IUI and methods used to prevent IUI were investigated.

RESULTS

All participants were board-certified general surgeons, 63.4% were certified visceral surgeons and 17.9% were certified colorectal surgeons. The mean level of experience in colorectal surgery was 15.6 ± 9.2 years. Formal ureter identification was considered mandatory during sigmoid or rectal surgery by 83.7% of participants, and 31.7% considered identification of the right ureter during right colectomy to be mandatory. In total, 61.8% of the participants and 78.4% of surgeons with more than 20 years of experience had encountered at least one IUI. Prophylactic ureteral stenting was considered useful in complex procedures by 93.5% of participants, and 56.9% had used stents at least once in the past 12 months. Noninvasive techniques for identifying ureters would be considered in regular daily practice by 54.5% of the participants.

CONCLUSION

Most general surgeons experience IUI. Ureter identification is widely integrated in colorectal procedures. Prophylactic stenting is widely used for difficult cases. Noninvasive methods to improve ureter identification are now needed.

Ureteral Injury During Colorectal Surgery: Two Case Reports and a Literature Review

Iatrogenic ureteral injury (IUI) is a dreaded complication of abdominopelvic surgery. Although rare, it is associated with severe consequences. This complication most commonly occurs during gynecological procedures but may also occur during colorectal surgeries. We present two cases of IUI in patients in whom the ureteric stents were electively placed. The first case was a 71-year-old male with no significant medical history. The patient underwent an elective laparoscopic sigmoidectomy for complicated diverticulitis. During the procedure, a proximal IUI occurred, and was recognized and repaired. The second case occurred in a 68-year-old male with a history of multiple complicated abdominal surgeries. The patient underwent a second redo low anterior resection for a long preanastomotic stricture. The IUI occurred in the right fibrosed presacral plane, approximately 3 cm proximal to the bladder. The ureter was reimplanted to the bladder during the same procedure. We will also present a literature review of IUI, including the risk factors, intraoperative prevention, and repair options.

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.

Ureteral stents increase risk of postoperative acute kidney injury following colorectal surgery

BACKGROUND

Ureteral stents are commonly placed before colorectal resection to assist in identification of ureters and prevent injury. Acute kidney injury (AKI) is a common cause of morbidity and increased cost following colorectal surgery. Although previously associated with reflex anuria, prophylactic stents have not been found to increase AKI. We sought to determine the impact of ureteral stents on the incidence of AKI following colorectal surgery.

METHODS

All patients undergoing colon or rectal resection at a single institution between 2005 and 2015 were reviewed using American College of Surgeons National Surgical Quality Improvement Program dataset. AKI was defined as a rise in serum creatinine to ≥ 1.5 times the preoperative value. Univariate and multivariate regression analyses were performed to identify independent predictors of AKI.

RESULTS

2910 patients underwent colorectal resection. Prophylactic ureteral stents were placed in 129 patients (4.6%). Postoperative AKI occurred in 335 (11.5%) patients during their hospitalization. The stent group demonstrated increased AKI incidence (32.6% vs. 10.5%; p < 0.0001) with bilateral having a higher rate than unilateral stents. Hospital costs were higher in the stent group ($23,629 vs. $16,091; p < 0.0001), and patients with bilateral stents had the highest costs. Multivariable logistic regression identified predictors of AKI after colorectal surgery including age, procedure duration, and ureteral stent placement.

CONCLUSIONS

Prophylactic ureteral stents independently increased AKI risk when placed prior to colorectal surgery. These data demonstrate increased morbidity and hospital costs related to usage of stents in colorectal surgery, indicating that placement should be limited to patients with highest potential benefit.

Cathelicidin LL37 Promotes Epithelial and Smooth-Muscle-Like Differentiation of Adipose-Derived Stem Cells through the Wnt/β-Catenin and NF-κB Pathways

Ureter reconstruction is a difficult procedure in urology. Adipose-derived stem cells (ADSCs), along with multipotency and self-renewal capacity, are a preferred choice for tissue engineering-based ureteral reconstruction. We explored the synergic role of cathelicidin LL37 (LL37) in epithelial and smooth-muscle-like differentiation. ADSCs were separated from adipose tissues of mouse and characterized by flow cytometry. The ADSCs were then stably transfected with pGC-FU-GFP (pGC) or pGC containing full-length LL37 (pGC-LL37), respectively. Cell viability and apoptosis were respectively estimated in the stably transfected cells and non-transfected cells. Then, qRT-PCR and Western blot analysis were used for determinations of epithelial marker expressions after induction by all-trans retinoic acid as well as smooth-muscle-like marker expressions after induction by transforming growth factor-β1. Then, possibly involved signaling pathways and extracellular expression of LL37 were detected. Cell viability and apoptosis were not changed after LL37 overexpression. Expression levels of epithelial and smooth-muscle-like markers were significantly upregulated by LL37 overexpression. Moreover, expressions of key kinases involved in the Wnt/β-catenin pathway as well as epithelial marker were upregulated by the LL37 overexpression, while it was reversed by Wnt/β-catenin inhibitor. Likewise, expressions of key kinases involved in the nuclear factor κB (NF-κB) pathway as well as smooth-muscle-like markers were upregulated by LL37 overexpression, which was reversed by NF-κB inhibitor. LL37 was found in the culture medium. LL37, which could be released into the medium, had no impact on cell proliferation and apoptosis of ADSCs. However, LL37 promoted epithelial and smooth-muscle-like differentiation through activating the Wnt/β-catenin and NF-κB pathways, respectively.

Prophylactic Ureteral Catheters for Colectomy: A National Surgical Quality Improvement Program-Based Analysis

BACKGROUND

Despite improvement in technique and technology, using prophylactic ureteral catheters to avoid iatrogenic ureteral injury during colectomy remains controversial.

OBJECTIVE

The aim of this study was to evaluate outcomes and costs attributable to prophylactic ureteral catheters with colectomy.

DESIGN

This was a retrospective study.

SETTINGS

The study was conducted at a single tertiary care center.

PATIENTS

The colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2014 was queried.

MAIN OUTCOME MEASURES

The primary end point was the rate of 30-day ureteral injury after colectomy. Univariate and multivariate analyses determined factors associated with ureteral injury and urinary tract infection in patients undergoing colectomy.

RESULTS

A total of 51,125 patients were identified with a mean age of 60.9 ± 14.9 years and a BMI of 28.4 ± 6.7 k/m; 4.90% (n = 2486) of colectomies were performed with prophylactic catheters, and 333 ureteral injuries (0.65%) were identified. Prophylactic ureteral catheters were most commonly used for diverticular disease (42.2%; n = 1048), with injury occurring most often during colectomy for diverticular disease (36.0%; n = 120). Univariate analysis of outcomes demonstrated higher rates of ileus, wound infection, urinary tract infection, urinary tract infection as reason for readmission, superficial site infection, and 30-day readmission in patients with prophylactic ureteral catheter placement. On multivariate analysis, prophylactic ureteral catheter placement was associated with a lower rate of ureteral injury (OR = 0.45 (95% CI, 0.25-0.81)).

LIMITATIONS

This was a retrospective study using a clinical data set.

CONCLUSIONS

Here, prophylactic ureteral catheters were used in 4.9% of colectomies and most commonly for diverticulitis. On multivariate analysis, prophylactic catheter placement was associated with a lower rate of ureteral injury. Additional research is needed to delineate patient populations most likely to benefit from prophylactic ureteral stent placement. See Video Abstract at http://links.lww.com/DCR/A482.

Trends of ureteral stent usage in surgery for diverticulitis

BACKGROUND

Many believe that the use of ureteral stents in colorectal surgery for diverticulitis aids prevention and easier identification of ureteral injuries; others argue that the added time, cost, and risks of stent placement negate potential benefits. Even among providers who use stents, selective use is common. Among unclear consensus, it remains unknown if the use of stents is growing.

MATERIALS

Patients in the National Inpatient Sample who underwent a partial colectomy or anterior rectal excision for diverticulitis between 2000 and 2013 were included (n = 811,071). Trends in ureteral stent use, multivariate logistic regression of factors influencing stent placement, and linear regression of length of stay (LOS) and costs associated with stent use were examined.

RESULTS

Usage of ureteral stents increased from 6.66% in 2000 to 16.30% in 2013 (P < 0.0001). Rates of stent usage were higher with laparoscopic surgery (19.31% versus 12.31% open, P < 0.0001). Regression demonstrated patients in the Northeast (Midwest odds ratio (OR) 0.49 [0.37-0.66] P < 0.0001, South OR 0.60 [0.45-0.80] P = 0.0004, West OR 0.30 [0.22-0.41], P < 0.0001), and those whose admission was elective (OR 2.37 [2.08-2.69], P < 0.0001) were more likely to receive stents. Stent use was associated with an increased LOS (0.55 days, P < 0.0001) and cost ($1,983, P < 0.0001).

CONCLUSIONS

The use of ureteral stents in surgery for diverticulitis has steadily increased since 2000, despite the lack of consensus of their overall benefit. Stent usage is associated with laparoscopic surgery and varies widely among regions of the country. Further studies are required to truly understand the risk-benefit ratio of ureteral stenting and to determine if its increased use is warranted.

Incidence of Iatrogenic Ureteral Injury During Open and Laparoscopic Colorectal Surgery: A Single Center Experience and Review of the Literature

INTRODUCTION

Iatrogenic ureteral injury is a rare but potentially devastating complication of colorectal surgery. We evaluated the incidence and management of iatrogenic ureteral injuries in colorectal surgery during the transition phase from open to laparoscopic surgery.

MATERIALS AND METHODS

We conducted a retrospective single center study. All patients who underwent colorectal surgery between 2004 and 2014 were evaluated by collecting data of electronic patient charts. Both acute and elective procedures were included.

RESULTS

A total of 3302 colorectal procedures were performed in the study period. Of these, 2817 operations were performed open and 484 laparoscopically. A total of 23 iatrogenic ureteral injuries were identified, of which 5 were found during laparoscopic surgery. The cumulative incidence of ureteral injuries was 0.6% for open procedures and 1.0% for laparoscopic procedures.

CONCLUSIONS

Ureteral injury is a rare complication of colorectal surgery. The incidence might rise with the increasing use of laparoscopy.

The Impact of Minimally Invasive Surgery on Major Iatrogenic Ureteral Injury and Subsequent Ureteral Repair During Hysterectomy: A National Analysis of Risk Factors and Outcomes

OBJECTIVE

To identify risk factors for ureteral injury during hysterectomy and to assess outcomes of concurrent minimally invasive vs converted to open repairs.

METHODS

We queried the American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2013 to identify abdominal hysterectomy (AH), minimally invasive hysterectomy (MIH), or vaginal hysterectomy. Ureteral injury was identified based on intraoperative or delayed management. Multivariate logistic regression was performed to assess the effect of hysterectomy approach on risk of ureteral injury while controlling for covariates. For patients with ureteral injury during MIH, we compared 30-day outcomes following minimally invasive vs converted open repairs.

RESULTS

There were 302 iatrogenic ureteral injuries from 96,538 hysterectomies, with 0.18%, 0.48%, and 0.04% from AH, MIH, and vaginal hysterectomy, respectively. Patients who underwent MIH were younger and had decreased comorbidities compared to patients who underwent AH (all P < .001). MIH resulted in lower overall complications (6.6% vs 14.8%, P < .001) but higher ureteral injury rate (0.48% vs 0.18%, P < .001) compared to AH. On multivariate analysis, the minimally invasive approach was associated with increased risk of ureteral injury (odds ratio 4.2, P < .001). Patients undergoing minimally invasive ureteral repairs (89%) during MIH had shorter operating room time and length of stay but similar overall perioperative complications compared to those with converted open repairs (11%).

CONCLUSION

Using a large national series, we show that the minimally invasive approach for hysterectomy is an independent risk factor for iatrogenic ureteral injuries. During MIH, concurrent minimally invasive ureteral repairs resulted in comparable 30-day outcomes compared to converted to open repairs.

Role of Minimally Invasive Surgery in the Reoperative Abdomen or Pelvis

Laparoscopy has become widely accepted as the preferred surgical approach in the management of benign and malignant colorectal diseases. Once considered a relative contraindication in patients with prior abdominal surgery (PAS), as surgeons have continued to gain expertise in advanced laparoscopy, minimally invasive approaches have been increasingly incorporated in the reoperative abdomen and pelvis. Although earlier studies have described conversion rates, most contemporary series evaluating the impact of PAS in laparoscopic colorectal resection have reported equivalent conversion and morbidity rates between reoperative and non-reoperative cases, and series evaluating the impact of laparoscopy in reoperative cases have demonstrated improved short-term outcomes with laparoscopy. The data overall highlight the importance of case selection, careful preoperative preparation and planning, and the critical role of surgeons' expertise in advanced laparoscopic techniques. Challenges to the widespread adoption of minimally invasive techniques in reoperative colorectal cases include the longer learning curve and longer operative time. However, with the steady increase in adoption of minimally invasive techniques worldwide, minimally invasive surgery (MIS) is likely to continue to be applied in the management of increasingly complex reoperative colorectal cases in an effort to improve patient outcomes. In the hands of experienced MIS surgeons and in carefully selected cases, laparoscopy is both safe and efficacious for reoperative procedures in the abdomen and pelvis, with measurable short-term benefits.

Genitourinary Considerations in Reoperative and Complex Colorectal Surgery

Genitourinary structures are at risk of injury during colorectal surgery. The incidence of injury is low; however, the risk is higher in cases involving severe inflammatory or infectious processes, locally advanced or recurrent cancer, previous radiation, and reoperation. Consideration of the anatomical relationship between the genitourinary system, and the colon and rectum is crucial to avoid injuries. Intraoperative diagnostic techniques such as intravenous pyelogram (IVP), fluoroscopic cystogram, or retrograde urethrogram can aid in identifying suspected injuries. Early recognition and repair of injuries decrease the morbidity of an injury. Repair of injuries depends on the location and extent of the injury. Simple injuries may be repaired primarily, while complex injuries may require more advanced repairs such as a flap reconstruction.

Ureteral injury after laparoscopic versus open colectomy

Background and Objectives:

Ureteral injury is an infrequent but potentially lethal complication of colectomy. We aimed to determine the incidence of intraoperative ureteral injury after laparoscopic and open colectomy and to determine the independent morbidity and mortality rates associated with ureteral injury.

Methods:

We analyzed data from the National Surgical Quality Improvement Program for the years 2005–2010. All patients undergoing colectomy for benign, neoplastic, or inflammatory conditions were selected. Patients undergoing laparoscopic colectomy versus open colectomy were matched on disease severity and clinical and demographic characteristics. Multivariate logistic regression analyses and coarsened exact matching were used to determine the independent difference in the incidence of ureteral injury between the 2 groups. Multivariate models were also used to determine the independent association between postoperative complications associated with ureteral injury.

Results:

Of a total of 94 526 colectomies, 33 092 (35%) were completed laparoscopically. Ureteral injury occurred in a total of 585 patients (0.6%). The crude incidence in the open group was higher than that in the laparoscopic group (0.66% versus 0.53%, P = .016). CEM produced 14 630 matching pairs. Matched analysis showed the likelihood of ureteral injury after laparoscopic colectomy to be 30% less than after open colectomy (odds ratio, 0.70; 95% confidence interval, 0.51–0.96). Patients with ureteral injury were independently more likely to have septic complications and have longer lengths of hospital stay than those without ureteral injury.

Conclusion:

Laparoscopic colectomy is associated with a lower incidence of intraoperative ureteral injury when compared with open procedures. Ureteral injury leads to significant postoperative morbidity even if identified and repaired during the colectomy.

Analyzing clinical outcomes in laparoscopic right vs. left colectomy in colon cancer patients using the NSQIP database

INTRODUCTION

Optimization of surgical outcomes after colectomy continues to be actively studied, but most studies group right-sided and left-sided colectomies together. The aim of our study was to determine whether the complication rate differs between right-sided and left-sided colectomies for cancer.

METHODS

We identified patients who underwent laparoscopic colectomy for colon cancer between 2005 and 2010 in the American College of Surgeons National Surgical Quality Improvement Program database and stratified cases by right and left side. The two groups were matched using propensity score matching for demographics, previous abdominal surgery, pre-operative chemotherapy and radiotherapy, and preoperative laboratory data. Outcome measures were: 30-day mortality and morbidity.

RESULTS

We identified 2512 patients who underwent elective laparoscopic colectomy for right-sided or left-sided colon cancer. The two groups were similar in demographics, and pre-operative characteristics. There was no difference in overall morbidity (15% vs. 17.7%; p value < 0.08) or 30-day mortality (1.5% vs. 1.5%; p value < 0.9) between the two groups. Sub-analysis revealed higher surgical site infection rates (9% vs. 6%; p value < 0.04), higher incidence of ureteral injury (0.6% vs. 0.4%; p value < 0.04), higher conversion rate to open colectomy (51% vs. 30%; p value < 0.01) and a longer hospital length of stay (10.5 ± 4 vs. 7.1 ± 1.3 days; p value < 0.02) in patients undergoing laparoscopic left colectomy.

CONCLUSION

Our study highlights the difference in complications between right-sided and left-sided colectomies for cancer. Further research on outcomes after colectomy should incorporate right vs. left side colon resection as a potential pre-operative risk factor.

Outcomes of Iatrogenic Genitourinary Injuries During Colorectal Surgery

OBJECTIVE

To describe, categorize, and determine the outcomes of repairs of genitourinary (GU) injuries that occur during colorectal surgery. Presently, little is known regarding these injuries or the long-term outcomes of their repair.

METHODS

We performed a retrospective review of patients undergoing colorectal surgery between 2003 and 2013 who experienced iatrogenic GU injuries requiring surgical repair. GU repair failures were defined as development of urine leak, urinary fistula, or anastomotic stricture requiring secondary GU intervention. Possible risk factors associated with repair failures were examined and included age, American Society of Anesthesiology score, comorbidities, type of colorectal surgery, radiation, and chemotherapy.

RESULTS

Of 42,570 colorectal surgeries performed, 75 GU injuries were identified (0.18%). Mean age was 57.5 years (range, 22-91), and median follow-up was 19.5 months (range, 1-128). Fifty-nine (59/75, 79%) patients required a single GU repair whereas 16 of 75 (21%) patients experienced repair failure requiring additional GU intervention. The most common GU injuries were cystotomy (26/75, 35%), incomplete ureteral transection (22/75, 29%), complete proximal and distal ureteral injuries (13/75, 17%; 11/75, 15%), urethral injury (2/75, 3%), and injury to a pre-existing ileal conduit (1/75, 1). Twenty-seven patients (36%) had prior radiation and 35 patients (47%) had prior chemotherapy. Preoperative radiation and chemotherapy were both associated with failure of the GU repair (P = .003; P = .013). Delayed repair of the GU injury was also associated with repair failure (P = .001).

CONCLUSION

Iatrogenic GU injuries during colorectal surgery are rare, affecting only 0.18% of colorectal procedures. Preoperative external beam radiation therapy/chemotherapy and delayed GU repair are associated with worse outcomes of repairs of these injuries.

Management of Complications Following Emergency and Elective Surgery for Diverticulitis

BACKGROUND

The clinical spectrum of sigmoid diverticulitis (SD) varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications. Sigmoid colectomy with restoration of continuity has been the prevailing modality for treating acute and recurrent SD, and is often performed as a laparoscopy-assisted procedure. For elective sigmoid colectomy, the postoperative morbidity rate is 15-20% whereas morbidity rates reach up to 30% in patients who undergo emergency surgery for perforated SD. Some of the more common and serious surgical complications after sigmoid colectomy are anastomotic leaks and peritonitis, wound infections, small bowel obstruction, postoperative bleeding, and injuries to the urinary tract structures. Regarding the management of complications, it makes no difference whether the complication is a result of an emergency or an elective procedure.

METHODS

The present work gives an overview of the management of complications in the surgical treatment of SD based on the current literature.

RESULTS

To achieve successful management, early diagnosis is mandatory in cases of deviation from the normal postoperative course. If diagnostic procedures fail to deliver a correlate for the clinical situation of the patient, re-laparotomy or re-laparoscopy still remain among the most important diagnostic and/or therapeutic principles in visceral surgery when a patient's clinical status deteriorates.

CONCLUSION

The ability to recognize and successfully manage complications is a crucial part of the surgical treatment of diverticular disease and should be mastered by any surgeon qualified in this field.

Techniques in total mesorectal excision surgery

Advances in the surgical management of rectal cancer have placed the quality of total mesorectal excision (TME) as the major predictor in overall survival. A standardized TME technique along with quality increases the percentage of patients undergoing a complete TME. Quality measurements of TME will place increasing demands on surgeons maintaining competence with present and future techniques. These efforts will improve the outcome of the rectal cancer patients.

[Intraoperative complications of the lower gastrointestinal tract : Prevention, recognition and therapy]

Every surgical intervention is associated with the risk of intraoperative complications. These occur in approximately 2-12% of patients but significantly influence the postoperative outcome, overall complication and mortality rates. This article presents the treatment of typical intraoperative complications during surgery of the lower gastrointestinal tract with a focus on the prevention and identification of risk factors. Especially changes in the regular anatomy caused by previous surgery, inflammation, tumors and emergency situations carry the risk of iatrogenic injuries to the bowels, spleen, ureter and blood vessels. These risk factors must be considered when choosing a surgical procedure, a surgical approach or an appropriate surgeon. The early detection of complications with a definitive restoration is the essential step for a successful treatment without long-term sequelae. Every delay in therapy is associated with an increased morbidity and mortality and should be avoided.

Intraoperative complications have a negative impact on postoperative outcomes after rectal cancer surgery

PURPOSE

The impact of intraoperative complications on the postoperative outcome in rectal cancer surgery is only poorly studied in literature. Thus, the aim of the present study was to assess the frequency of intraoperative complications during rectal resections for malignancies and its influence on the short term outcome.

MATERIAL AND METHODS

We analyzed 605 consecutive patients, who had operations for rectal cancer at a single institution between 1995 and 2010. Retrospective data from the surgical procedure and postoperative course were obtained from the institutional colorectal database and individual chart reviews. Intraoperative complications were recorded and its influence on postoperative course was investigated.

RESULTS

Intraoperative complications occurred in 66 (10.9%) patients, with injury to the spleen (n = 35 of 66, 53%) being the most frequent complication. Patients with intraoperative complications had a significant longer hospital stay (median: 13 days, range 7-92) compared to patients without complications (median: 12 days, range 2-135; p = 0.0102). In addition, intraoperative complications showed a tendency towards an increased risk for postoperative surgical complications (p = 0.0536), whereas no impact on postoperative medical complications could be found (p = 0.8043). Pulmonary disorders were the only predictive marker for intraoperative complications (p = 0.0247) by univariate analysis.

CONCLUSION

We found that intraoperative complications during rectal cancer surgery significantly prolonged hospital length stay. The overall morbidity rate was not affected.

Minimally Invasive Management of Iatrogenic Ureteral Injuries with Ureteroscope Facilitated by Holmium Yttrium-Aluminum-Garnet Laser

The ureter is vulnerable during general, gynecologic, and urologic surgeries. The traditional open surgical approaches to treating the iatrogenic ureteral injuries have shown several disadvantages such as relatively high rate of severe complications. Although the applications of endourological techniques for management of lower ureteral strictures have been routinely introduced over the last 10 years, most of the different modalities were based on the utilization of hydrophilic instruments that can facilitate the traversal of strictures surrounded by the sutures with gradually increasing force. Interestingly, we have revealed the Ho:YAG laser as the outstanding auxiliary approach to incising the sutures during the ureteroscopy for its well-controlled penetration depth, minimal scarring, and precise cutting. As far as we know, the combined utilization of Ho:YAG laser to incise the sutures responsible for the strictures and double J ureteral stent for drainage has not been extensively reported. Normal ureters of the patients managed by this novel approach were shown by the follow-up 3-4 months later, which demonstrated that the available technique was promising to effectively treat the iatrogenic ureteral injuries.