[Endoscopic management of postoperative ureteral wound. Retrospective unicentric study from October 2003 to June 2014]

Iatrogenic ureteral injury: What should the digestive surgeon know?

PURPOSE OF THE STUDY

Iatrogenic ureteral injury (IUI) is a rare but formidable complication of any abdominal or pelvic surgery. The aim of this study was to describe the epidemiology of IUI in colorectal surgery in the Basse-Normandie region over the period 2004-2022, as well as to review the literature on the management of this complication.

MATERIALS AND METHODS

This multicenter retrospective analysis of clinical data (medical records and operative reports) concerned 22 patients (13 men and 9 women) who suffered an IUI during colorectal surgery between 2004 and 2022. Ureteral resections for oncological purposes and endoluminal instrumental injuries (post-ureteroscopy) were excluded from the study. We also carried out a review of the literature concerning the incidence of IUI in colorectal surgery.

RESULTS

The incidence of IUI was 0.27% over the study period (22 ureteral injuries out of 8129 colorectal procedures). Colorectal cancer and sigmoid diverticulitis were the dominant surgical indications (85% of cases). Proctectomy and left colectomy were the most performed resection procedures (75% of cases). Surgery was scheduled in 68% of cases. The approach was open laparotomy in 59% and laparoscopy in 41% of cases. The IUI involved the left ureter in 63% of cases and the pelvic ureter in 77% of cases. Conservative endoscopic treatment by insertion of a double-J catheter stent had a success rate of 87.5%. Surgical repairs consisting of re-implantation techniques and uretero-ureteral anastomosis had a success rate of 75%. The nephrectomy rate was 13.6% (3/22) and the mortality rate 9% (2/22). A literature review identified sixteen studies, where the incidence of IUI varied from 0.1 to 4.5%.

FINDINGS

IUI occurring during colorectal surgery is a rare occurrence but remain a formidable complication. No means of prevention has proven its effectiveness to date, but guidance devices using illuminated ureteral catheters or dyes seem to constitute a promising approach. Injuries to the left pelvic ureter are the most common, and the majority can be treated endoscopically if diagnosed early.

[Results of conservative surgical management of ureteral injuries]

INTRODUCTION

The ureter is a retroperitoneal organ. Ureteral injuries are rare, with a prevalence of 0.083% of surgical interventions over 10 years. The objective of this study was to evaluate the surgical management of ureteric injuries according to the time of discovery, their size and their location. We also evaluated the results of this management on the renal repercussion as well as the predictive factors of the severity of the ureteric injuries.

MATERIAL AND METHODS

This was a monocentric retrospective study carried out on the basis of a systematic review of the CHU surgery files.

RESULTS

The average follow-up was 30 months. The average hospital stay was 8 days. Thirty-four patients (73.9%) underwent initial endoscopic management by attempting a double J probe. Only 20 patients received this double J probe and only 11 patients (55%) did not recidivate the ureteral injury with a median duration of maintenance of the double J probe of 90 days (28-240). Thirty-five patients received open surgical management (76.1%). We found 57% ureterovesical reimplantations (n=20), corresponding to pelvic ureteral injuries (n=32). We also found 20% of nephrectomies. No patient had recurrence of the ureteral injury. Eight patients had secondary dilatation of the pyelocalicious cavities (28.57%). The success of surgical treatment was therefore 57%.

CONCLUSION

The management of surgically treated ureter injuries provides good results but remains relatively diversified due to the different lesion levels. It was effective in 57% of cases including nephrectomies as failure of treatment.

LEVEL OF EVIDENCE

4.