Interventional radiology in iatrogenic ureteral leaks: case series and literature review

A Novel Surgical Classification for Extremity and Pelvic Hemophilic Pseudotumors: The PUMCH Classification

BACKGROUND

A hemophilic pseudotumor (HPT) is a rare and challenging complication of hemophilia for which there is no classification system that provides uniformity of descriptions or that can be used to guide management. We have developed such a classification based on anatomical site, HPT severity, and corresponding surgical treatment.

METHODS

The PUMCH (Peking Union Medical College Hospital) classification was developed on the basis of clinical manifestations and imaging features. Extremity and pelvic HPTs were divided into 4 types and 6 subtypes according to anatomical site and whether or not there was destruction of adjacent bone. Associations between the PUMCH classification and surgical treatment, preoperative comorbidities, operative time, intraoperative bleeding, and postoperative complication rates were analyzed.

RESULTS

Forty-five patients with 53 HPTs that were treated at PUMCH between December 2005 and October 2021 were included. The mean age at the time of surgery was 35.4 ± 11.9 years, and the median follow-up duration was 60.3 months. Twenty-eight HPTs were classified as type I (13 IA, 7 IB, 8 IC); 3, as type II; 6, as type III; and 16, as type IV. All 20 type-IA and IB HPTs were treated with excision, and the 3 type-II HPTs were treated with curettage and bone grafting. Fourteen type-IV pelvic HPTs underwent excision, 2 of which needed concomitant pelvic reconstruction. Six type-IC HPTs and 1 type-III HPT underwent excision and osseous reconstruction. Amputation was required for 1 type-IC and 3 type-III HPTs. Type-IC HPTs had the longest mean operative time (194.3 ± 28.2 minutes) and the greatest intraoperative bleeding (2,000 mL [interquartile range, 1,100 to 3,000 mL]). Postoperative infection was more common in patients with type-III (50.0%) and type-IC (28.6%) HPTs, but not significantly so.

CONCLUSIONS

The PUMCH classification is based on the anatomic pathology and surgical strategy for HPTs. The classification of HPTs corresponds to surgical outcomes, and may be helpful for decision-making regarding their surgical treatment.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Urinary Tract Injury During Gynecologic Surgery: Prevention, Recognition, and Management

Lower urinary tract (LUT) injuries may occur during gynecologic surgery due to the close proximity of pelvic organs and vary by procedure, surgical indication, and route. Prevention of LUT injury should be a primary goal of gynecologic surgery. LUT injuries are more common in patients with aberrant anatomy, during difficult procedures, and with surgeons with less experience. Immediate recognition and management of LUT injuries is optimal, although delayed postoperative diagnoses may be unavoidable. Surgical management is based on the size and location of injury and should be performed by an experienced surgeon with thorough knowledge of pelvic anatomy, surgical technique, and postoperative management.

Application of Nonvascular Interventional Radiology Procedures in the Treatment of Iatrogenic Ureteral Injuries

Introduction. He most common ureteral injuries are iatrogenic injuries. Diagnosis of ureteral lesions includes ultrasound, computer tomography, intravenous urography, anterograde and retrograde ureterography. For a definitive diagnosis it is necessary to determine the existence of the extralumination of contrast media from the ureter. Minor ureteral injuries can be treated with nonvascular interventional radiology procedures.

Case presentation. We have presented two patients with iatrogenic ureteral injuries. Injury in the first patient occurred at the sigmoid colon resection and partial resection of the bladder, whereas in the second patient the lesion was formed as a result of cesarean section. In both patients, there was a history of previously conducted interventions, clinical picture included fever and pain, a diagnosis was made by intravenous and anterograde urography. Patients were treated with interventional radiology procedures and they have been definitely cured.

Conclusion. Methods of nonvascular interventional radiology can be successfully applied in the treatment of minor iatrogenic ureteral injuries.

Diagnostic and Interventional Radiology Management of Ureteral Iatrogenic Leakage after Gynecologic Surgery

OBJECTIVE

To report safety and efficacy of interventional radiology procedures in the treatment of gynecologic iatrogenic urinary leaks.

METHODS

A retrospective analysis of iatrogenic ureteral lesions treated between November 2009 to April 2019 was performed. Under ultrasound (US) and fluoroscopy guidance, an attempt to place a ureteral stent and nephrostomy was carried out in the same session using an anterograde percutaneous approach. At the end of any procedure, a fluoroscopic control and a cone-beam CT scan (CBCT) were performed to check the correct placement and functioning of the nephrostomy and DJ stent. In cases of difficult ureteral stent placement via the single anterograde approach, the collaboration of urologists was requested to perform a rendezvous technique, combined with the retrograde approach.

RESULTS

DJ stent placement was achieved using the anterograde approach in 12/15 (80.0%) patients and using the retrograde approach in 3/15 cases (20.0%). Moreover, in 3/15 (20.0%) patients, surgical treatment was needed: in one case because of the persistence of ureteral stenosis at 6 months, and in the other two cases due to ureter-vaginal fistula. No major complications were recorded; overall, minor complications occurred in 4/8 patients.

CONCLUSION

Percutaneous minimally invasive treatment of iatrogenic ureteral lesions after gynecological surgery is a safe and effective option.

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.