Suspected iatrogenic ureteric injury: An approach to diagnostic imaging

The Rendezvous Technique: A Minimally Invasive Non-Surgical Approach for the Management of Iatrogenic Ureteral Injuries

Background/Objectives: The aim of our study is to evaluate the feasibility and efficacy of the rendezvous technique for the treatment of iatrogenic ureteral injuries. Methods: From 2014 to 2019, 29 patients treated with the rendezvous technique for mono- or bilateral iatrogenic ureteral injuries were enrolled in this retrospective study. All the leaks were previously assessed by CT-urography and antegrade pyelography. Ureteral continuity was restored by performing the rendezvous technique, combining antegrade trans-nephrostomic access and a retrograde trans-cystostomic approach. A double J stent was antegradely inserted, and a nephrostomy tube was kept in place at the end of the procedure. A post-procedure CT-urography and a 30-day nephrostogram follow-up were performed. In the absence of a contrast leak, the nephrostomy tube was removed. Patient follow-up was set with CT-urography at 3, 6, and 12 months and stent substitution every 4 months. The CT-urography was performed to confirm the restored integrity of the ureter before stent removal. Results: The rendezvous technique was successful in all cases with the resolution of the ureteral leak. No major complications were observed. In all the patients, the nephrostomy tube was removed after 30 days. After performing CT-urography, the stent was removed permanently after 12 months. Only three cases showed local post-treatment stenosis treated with surgical ureteral reimplantation. Conclusions: The rendezvous technique is a safe and effective minimally invasive procedure that can be used to restore the continuity of the ureter, avoiding open surgery and providing valuable support for the management of complications after gynecological surgery.

Stenting Using the Rendezvous Technique for Postoperative Ureteral Complications in Cancer Patients

PURPOSE

This study aimed to retrospectively evaluate the safety and efficacy of ureteral stent placement using the rendezvous technique for the treatment of postoperative ureteral complications in cancer patients.

MATERIALS AND METHODS

From January 2005 to April 2015, 19 patients (2 men and 17 women; median age, 59; range, 42-79 years old) with unilateral ureteral lesions (ureteral leakages in 6, strictures in 4, and both in 9) underwent ureteral stent placement using the rendezvous technique. Percutaneous nephrostomy was performed, and stent placement was attempted via antegrade and retrograde approaches. The technical success, procedure-related complications, and clinical success were retrospectively analyzed.

RESULTS

The median follow-up period was 29.8 months (range, 0.3-116.5 months). The ureteral stent placement was successful in 17 out of 19 patients (89.5%). Double J ureteral stent was used in 6 patients, and straight catheter as an internal-external nephro-ureteral stent was used in 11 patients. The rendezvous technique was used in the retroperitoneal space and urinary tract in 6 and 11 patients, respectively. No major complications related to the rendezvous technique occurred. Finally, 4 patients achieved stent-free condition (21.1%), and periodic stent exchange was continued in 9 (47.4%). However, permanent external drainage and surgical reconstruction were needed in 4 (21.1%) and 2 (10.5%) patients, respectively. The final clinical success rate was 68.4% (13 out of 19 patients).

CONCLUSION

Ureteral stent placement using the rendezvous technique for the treatment of postoperative ureteral complications in cancer patients is safe and may be alternative to permanent external drainage and invasive surgical reconstruction.

LEVEL OF EVIDENCE

Level 4, Case series.

Insidious intraoperative ureteral injury as a complication in oblique lumbar interbody fusion surgery: a case report

BACKGROUND

Oblique lumbar interbody fusion surgery is a recently introduced minimally invasive lateral interbody fusion surgery for degenerative lumbar disease. There have been no reports of associated ureteral injury.

CASE PRESENTATION

A 77-year-old Japanese woman underwent oblique lumbar interbody fusion surgery for lumbar spondylolisthesis with refractory low back pain and pain in both legs. The patient experienced abdominal pain 2 days after surgery. Delayed contrast-enhanced computed tomography and retrograde urography revealed leakage of contrasted urine from the ureter into the retroperitoneal space, indicating a ureteral injury. Immediate percutaneous nephrostomy was performed to recover her condition, followed by additional ureteral stenting. She is now free from preoperative symptoms but requires periodic changing of the ureteral stent, with no urinary symptoms.

CONCLUSION

The current report described a rare but possible case of ureteral injury following oblique lumbar interbody fusion surgery. Iatrogenic ureteral injury, as reported in the current case, is uncommon following oblique lumbar interbody fusion surgery, and the injury may have been caused by a procedural error. Considering the findings from urological examinations, we speculate that the thread pin that fixates the retractor injured the ureter during its installation. This case highlights the importance of careful attention while exposing the retroperitoneal space to avoid minor organs, including the ureters, as well as major organs. Ureteral injuries should ideally be detected and diagnosed as soon as possible by careful physical and radiological examinations, such as with delayed contrast-enhanced computed tomography and retrograde urography, to salvage the injured nephroureteral system. The current report also highlights that careful use of surgical instruments is key for preventing intraoperative complications, including ureteral injury.

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

Iatrogenic ureteral injuries are a dramatic complication in medical practice. Nowadays there are no universal guidelines for their management. The aim of our study was to evaluate the feasibility of the percutaneous treatment in restoring ureteral integrity in 19 patients that came to our attention. In each case retrograde stenting failed and patients were candidates for re-surgery. Our strategy consists of two phases. The first step is the nephrostomy that allows an external urinary diversion putting dry the damaged ureteral segment. The second step is the anterograde ureteral double-J stenting that keeps near the two stumps promoting the healing of the injured tract. In complete sections, when both retrograde and anterograde stenting singularly failed, we performed a rendez-vous technique with a combined radiological trans-nephrostomic access and urological cystoscopic approach to realign and catheterize the ureteral stumps. In patients with Bricker urinary diversion, peri-anastomotic leaks were treated by positioning a multi-hole pig-tail catheter with the inner end in the renal pelvis and the distal portion outgoing from the cutaneous stoma. Subsequent pyelographic controls demonstrated the resolution of the ureteral leak in all patients and none required a surgical re-intervention. Nephrostomies were removed and ureteral stents were regularly changed. We conclude that interventional uro-radiology may offer a valid conservative option in iatrogenic urinary injuries.

Management of iatrogenic ureteric injury with retrograde ureteric stenting: an analysis of factors affecting technical success and long-term outcome

Background Iatrogenic ureteral injuries arise as serious complication following obstetrics, gynecological, general, and urological surgery with incidence in the range of 0.5-10%. Retrograde placement of double-J ureteric stent is a possible treatment option if the injury is not recognized at the time of surgery. Purpose To assess technical success and long-term outcome associated with retrograde ureteric stent insertion for iatrogenic ureteric injury. Material and Methods Between 1999 and 2011, 26 patients with initially unrecognized iatrogenic ureteric injury underwent initial management with retrograde ureteric stenting. Full case-notes were available for review in 25 patients. Results The mean interval from injury to attempted stenting was 19.4 days. Successful retrograde ureteric stenting was achieved in 21/25 patients (81%). Retrograde stenting failed in four patients, and nephrostomy followed by alternative procedures were performed instead. At a median follow-up interval of 9.7 months, normal anatomy was demonstrated on 12/21 patients (57%) and a stricture was observed in 6/21 patients (28%) with three requiring surgical intervention. Conclusion Retrograde stenting is a safe and efficient initial management in patients with iatrogenic ureteric injuries.