A Contemporary Case Series of Complex Surgical Repair of Surgical/Endoscopic Injuries to the Abdominal Ureter

The Japanese Urological Association's clinical practice guidelines for urotrauma 2023

The Japanese Urological Association's guidelines for the treatment of renal trauma were published in 2016. In conjunction with its revision, herein, we present the new guidelines for overall urotrauma. Its purpose is to provide standard diagnostic and treatment recommendations for urotrauma, including iatrogenic trauma, to preserve organ function and minimize complications and fatality. The guidelines committee comprised urologists with experience in urotrauma care, selected by the Trauma and Emergency Medicine Subcommittee of the Specialty Area Committee of the Japanese Urological Association, and specialists recommended by the Japanese Association for the Surgery of Trauma and the Japanese Society of Interventional Radiology. The guidelines committee established the domains of renal and ureteral, bladder, urethral, and genital trauma, and determined the lead person for each domain. A total of 30 clinical questions (CQs) were established for all domains; 15 for renal and ureteral trauma and five each for the other domains. An extensive literature search was conducted for studies published between January 1, 1983 and July 16, 2020, based on the preset keywords for each CQ. Since only few randomized controlled trials or meta-analyses were found on urotrauma clinical practice, conducting a systematic review and summarizing the evidence proved challenging; hence, the grade of recommendation was determined according to the 2007 "Minds Handbook for Clinical Practice Guidelines" based on a consensus reached by the guidelines committee. We hope that these guidelines will be useful for clinicians in their daily practice, especially those involved in urotrauma care.

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.

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.

Outcomes and treatment failure after open or robotic ureteral reconstruction for iatrogenic injuries

Objectives

The aim of this study is to assess the aetiology, perioperative outcomes and treatment failure of contemporary patients undergoing open or robot-assisted ureteral reconstruction for iatrogenic injuries.

Patients and methods

We retrospectively analysed consecutive patients who underwent ureteral reconstruction for iatrogenic injuries at two academic centres 07/2013 and 06/2022. A variety of open or robot-assisted procedures were performed, including uretero-cystoneostomy, Boari bladder flap, uretero-ureterostomy, ileal replacement and pyelo-ureteroplasty. All procedures were performed by a single surgeon with extensive experience in open and robot-assisted surgery and preference-based management. Outcome measures were aetiology, estimated blood loss, length of stay, postoperative complications and treatment failure, defined as upper tract obstruction requiring permanent urinary drainage. We also planned a subgroup analysis comparing the outcomes between open and robot-assisted procedures.

Results

Fifty-nine patients were included. Most injuries were consequent to endourological procedures (44%). The most frequently performed procedures were uretero-cystoneostomy (49.2%) and Boari bladder flap (32.2%). Forty (67.8%) were open, and 19 (32.2%) were robot-assisted procedures. Major postoperative complications were recorded in seven (11.9%) patients. After a median follow-up of 42 months (interquartile range 12-24), treatment failure was observed in seven (11.9%) cases. Robot-assisted versus open procedures were associated with decreased estimated blood loss (p = 0.01), length of stay (p < 0.001) and treatment failure (0/19 vs. 7/36, p = 0.04).

Conclusion

In our series of iatrogenic ureteral lesions requiring reconstructive surgery, endourological procedures were the most frequent cause. Major postoperative complications were infrequent, and treatment failure rate was low. The robot-assisted approach was associated with improved perioperative outcomes and lower failure rate compared with open.

Robotic Repair of Ureteral Strictures: Techniques and Review

PURPOSE OF REVIEW

To provide an overview and description of the different surgical techniques for the robotic repair of ureteral strictures.

RECENT FINDINGS

The robotic repair of ureteral stenosis has emerged as a useful option for treating strictures unsuitable for endoscopic resolution with good results, lower morbidity, and faster recovery than open techniques. Depending on the stricture's length and location, the reconstructive options are reimplantation, psoas hitch, Boari flap, ureteroureterostomy, appendiceal onlay flap, buccal mucosa graft (BMG) ureteroplasty, ileal replacement, or renal autotransplantation. The robotic approach offers a magnified vision and the possibility of adding near-infrared fluorescence (NIRF) imaging, indocyanine green (ICG), and Firefly^TM to facilitate the technique. Multicenter studies with extended follow-up still have to confirm the good results obtained in published case series. Robotic reconstructive techniques are useful for repairing ureteral strictures, obtaining good functional results with less morbidity and faster recovery than open procedures.