Three different laparoscopic techniques for the management of iatrogenic ureteral injury: A multi-institutional study with medium-term outcomes

Clinical efficacy of ureteroscopy-assisted laparoscopic ureteroplasty in the treatment of ureteral stricture after pelvic surgery

OBJECTIVE

This study is to investigate the safety and efficacy of ureteroscope-assisted laparoscopic ureteroplasty in treating ureteral stricture after pelvic surgery.

METHODS

A retrospective analysis of the clinical data of 95 patients treated for ureteral stricture at Ganzhou People's Hospital from June 2017 to March 2023 after pelvic surgery. In this group, 49 patients underwent ureteroscope and laparoscopic ureteroplasty under lithotomy position. The control group consisted of 46 patients who underwent simple laparoscopic ureteroplasty in a supine position. Postoperative data from both groups were collected and compared, including operation time, amount of blood loss during surgery, postoperative hospital stay, incidence of complications, success rate of ureteroplasty, and effectiveness of the operation.

RESULTS

The success rate of end-to-end ureteral anastomosis in the observation group was 93.88%, and the operation effectiveness rate was 100%. The success rate in the control group was 78.26% and the operation effectiveness rate was 89.1%.The average operation time and intraoperative blood loss in the observation group were (121.3 ± 44.6) min and (137.5 ± 34.2) ml, respectively, while in the control group they were (151.2 ± 52.3) min and (165.6 ± 45.8) ml, the difference were statistically significant (P < 0.05). The incidence of perioperative complications in the observation group was 2%, significantly lower than that in the control group (19.6%) (P < 0.05).

CONCLUSION

Ureteroscope-assisted laparoscopic ureteroplasty for ureteral stricture after pelvic surgery has the advantages of shortened operation time, increased success rate, and reduced incidence of complications, making it an optional surgical scheme in clinical practice.

Laparoscopic ureteroneocystostomy with bladder flap for benign ureteral stenosis: our initial experience

To present our experience with laparoscopic ureteroneocystostomy with bladder flap (LUCBF) for treating benign ureteral stenosis and evaluate its feasibility and efficacy. The clinical data of 27 patients with benign ureteral stenosis who underwent LUCBF were retrospectively analyzed. After identification and excision of the ureteral stenosis segment, the healthy ureteral stump was dissected and incised longitudinally. A U-shaped or spiral bladder flap was harvested from the anterolateral bladder wall for ureteroplasty. All patients underwent LUCBF successfully, including 14 patients were combined with psoas hitch technique, between 90 and 220 min (median, 155 min). The median length of ureteral defect was 6 cm (range, 5-17 cm). The median blood loss was 40 ml (20-150 ml). The median indwelling time of double-J stent was 8 weeks (range, 4-8 weeks). Five patients (10.6%) suffered postoperative complications during the follow-up period (range, 12-48 months), including fever, hematuria, urinary tract infection and recurrent stenosis. The success rate was 96.3% (26/27). Patients with long ureter defects had longer operative time and more blood loss than short ureter defects. LUCBF was a safe and feasible technique for benign ureteral stenosis. Long ureter defect was related to longer operative time and more blood loss.

Real-time auto-segmentation of the ureter in video sequences of gynaecological laparoscopic surgery

BACKGROUND

Ureteral injury is common during gynaecological laparoscopic surgery. Real-time auto-segmentation can assist gynaecologists in identifying the ureter and reduce intraoperative injury risk.

METHODS

A deep learning segmentation model was crafted for ureter recognition in surgical videos, utilising 3368 frames from 11 laparoscopic surgeries. Class activation maps enhanced the model's interpretability, showing its areas. The model's clinical relevance was validated through an End-User Turing test and verified by three gynaecological surgeons.

RESULTS

The model registered a Dice score of 0.86, a Hausdorff 95 distance of 22.60, and processed images in 0.008 s on average. In complex surgeries, it pinpointed the ureter's position in real-time. Fifty five surgeons across eight institutions found the model's accuracy, specificity, and sensitivity comparable to human performance. Yet, artificial intelligence experience influenced some subjective ratings.

CONCLUSIONS

The model offers precise real-time ureter segmentation in laparoscopic surgery and can be a significant tool for gynaecologists to mitigate ureteral injuries.

Summary Paper of the Updated 2023 European Association of Urology Guidelines on Urological Trauma

CONTEXT

The European Association of Urology (EAU) Guidelines Panel for Urological Trauma has produced guidelines in order to assist medical professionals in the management of urological trauma in adults for the past 20 yr. It must be emphasised that clinical guidelines present the best evidence available to the experts, but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients regarding other parameters such as experience and available facilities. Guidelines are not mandates and do not purport to be a legal standard of care.

OBJECTIVE

To present a summary of the 2023 version of the EAU guidelines on the management of urological trauma.

EVIDENCE ACQUISITION

A systematic literature search was conducted from 1966 to 2022, and articles with the highest certainty evidence were selected. It is important to note that due to its nature, genitourinary trauma literature still relies heavily on expert opinion and retrospective series.

EVIDENCE SYNTHESIS

Databases searched included Medline, EMBASE, and the Cochrane Libraries, covering a time frame between May 1, 2021 and April 29, 2022. A total of 1236 unique records were identified, retrieved, and screened for relevance.

CONCLUSIONS

The guidelines provide an evidence-based approach for the management of urological trauma.

PATIENT SUMMARY

Trauma is a serious public health problem with significant social and economic costs. Urological trauma is common; traffic accidents, falls, intrapersonal violence, and iatrogenic injuries are the main causes. Developments in technology, continuous training of medical professionals, and improved care of polytrauma patients reduce morbidity and maximise the opportunity for quick recovery.

Combination of robot-assisted laparoscopy and ureteroscopy for the management of complex ureteral strictures

BACKGROUND

To summarize the efficacy of combined robot-assisted laparoscopy and ureteroscopy in treating complex ureteral strictures.

METHODS

Eleven patients underwent combined robot-assisted laparoscopy and ureteroscopy for ureteral strictures between January 2020 and August 2022. Preoperative B-ultrasound, glomerular filtration rate measurement, and intravenous pyelography showed different degrees of hydronephrosis in the affected kidney and moderate to severe stenosis in the corresponding part of the ureter. During the operation, stricture segment resection and end-to-end anastomosis were performed using the da Vinci robot to find the stricture point under the guidance of a ureteroscopic light source in the lateral or supine lithotomy position.

RESULTS

All the patients underwent robot-assisted laparoscopy and ureteroscopy combined with end-to-end ureterostenosis. There were no conversions to open surgery or intraoperative complications. Significant ureteral stricture segments were found in all patients intraoperatively; however, stricture length was not significantly different from the imaging findings. Patients were followed up for 3-27 months. Two months postoperatively, the double-J stent was removed, a ureteroscopy was performed, the ureteral mucosa at the end-to-end anastomosis grew well, and the lumen was patent in all patients. Furthermore, imaging examination showed that hydronephrosis was significantly improved in all patients, with grade I hydronephrosis in three cases and grade 0 hydronephrosis in eight cases. No recurrence of ureteral stricture was observed in patients followed up for > 1 year.

CONCLUSION

Robot-assisted laparoscopy combined with ureteroscopy is an effective method for treating complex ureteral strictures and can achieve accurate localization of the structured segment.

2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery

Iatrogenic urinary tract injury (IUTI) is a severe complication of emergency digestive surgery. It can lead to increased postoperative morbidity and mortality and have a long-term impact on the quality of life. The reported incidence of IUTIs varies greatly among the studies, ranging from 0.3 to 1.5%. Given the high volume of emergency digestive surgery performed worldwide, there is a need for well-defined and effective strategies to prevent and manage IUTIs. Currently, there is a lack of consensus regarding the prevention, detection, and management of IUTIs in the emergency setting. The present guidelines, promoted by the World Society of Emergency Surgery (WSES), were developed following a systematic review of the literature and an international expert panel discussion. The primary aim of these WSES guidelines is to provide evidence-based recommendations to support clinicians and surgeons in the prevention, detection, and management of IUTIs during emergency digestive surgery. The following key aspects were considered: (1) effectiveness of preventive interventions for IUTIs during emergency digestive surgery; (2) intra-operative detection of IUTIs and appropriate management strategies; (3) postoperative detection of IUTIs and appropriate management strategies and timing; and (4) effectiveness of antibiotic therapy (including type and duration) in case of IUTIs.

Comparison of split-cuff nipple and modified Lich-Gregoir ureteroneocystostomy in iatrogenic distal ureteral injuries: tertiary care center experience

PURPOSE

In this study, we aimed to compare the results of split-cuff nipple and modified Lich-Gregoir ureteroneocystostomy, which are the most commonly used techniques in stage ≥ 3 iatrogenic distal ureteral injuries.

METHODS

The files of patients who were treated for iatrogenic distal ureteral injuries in our clinic between January 2013 and January 2019 were retrospectively reviewed. A total of 60 patients who underwent either intra-vesical split-cuff nipple ureteroneocystostomy (Group A) or extra-vesical modified Lich-Gregoir ureteroneocystostomy (Group B) operations were included in the study. The success of ureteroneocystostomy was defined as no additional surgery requirement, no progression of hydronephrosis on imaging, and normal contrast transition on imaging.

RESULTS

Thirty-four patients underwent split-cuff nipple and 26 patients underwent modified Lich-Gregoir ureteroneocystostomy. The treatment was successful in 53 (88.3%) patients and failed in seven (11.7%). Complications occurred in 19 (31.7%) patients, of whom 14 (23.3%) had minor and five (8.3%) had major complications. The rate of postoperative complications was significantly higher in Group A than in Group B (p = 0.019). There was no significant difference between Group A and Group B in terms of the success ratio (p = 1), rate of major complications (p = 0.372), and postoperative hospitalization times (p = 0.254).

CONCLUSION

In this study, a higher complication rate was found in patients with iatrogenic ureteral injuries who underwent ureteroneocystostomy with the split-cuff ureteral nipple technique compared to those who underwent this operation with the modified Lich-Gregoir technique. However, no significant difference was observed between these two techniques in terms of treatment success and major complications.

Laparoscopic ureteral reimplantation with a Boari flap for long-segment ureteric avulsion or ureteric strictures: our experience

BACKGROUND

This study was designed to evaluate the feasibility of laparoscopic ureteral reimplantation with a Boari flap for long-segment ureteric avulsion or ureteric strictures of the middle and lower ureters. By observing its curative effect and prognosis, we can provide a safer and reliable treatment option for patients with middle and lower ureteral injury.

METHODS

In this study, of the eight cases under study, five were diagnosed with long-segment ureteric strictures, one had long-segment ureteric avulsion, one was diagnosed with ureteral rupture caused by surgical injury of appendicitis, and the remaining one underwent ureterostomy after ureteral injury. The location of ureteral injury was in the middle lower segment. All eight patients underwent laparoscopic ureteral reimplantation with a Boari flap from January 2018 to October 2021. In this study, two patients were treated with a Boari bladder flap with psoas hitching. All procedures were performed by the same surgeon with over 20 years of experience in urological surgery.

RESULTS

The mean length of ureteric avulsion or ureteric strictures was 7.94 cm (range, 4-15 cm). Laparoscopic ureteral reimplantation with a Boari flap was performed successfully between 120 and 240 min. The mean duration of postoperative hospital stay was 6 days, and no major complications related to the procedure in the perioperative period occurred. Postoperative follow-up showed no obvious hydronephrosis on computed tomography urography or urinary ultrasound in all eight patients. Postoperative reexamination did not reveal any significant hydronephrosis, urinary tract infection, or ureteral reflux, and none of the postoperative renal functions were abnormal.

CONCLUSIONS

Laparoscopic ureteral reimplantation with a Boari flap is safe and feasible for experienced physicians. In our case, the length/width ratio of bladder flap is more than 4:1, with good blood supply and no obvious complications, it provides a longer alternative length.