Outcomes of Iatrogenic Genitourinary Injuries During Colorectal Surgery

Preventing iatrogenic ureteral injury in colorectal surgery: a comprehensive and systematic review of the last 2 decades of literature and future perspectives

Iatrogenic ureteral injury (IUI) during colorectal surgery is a rare complication but related to a serious burden of morbidity. This comprehensive and systematic review aims to provide a critical overview of the most recent literature about IUI prevention techniques in colorectal surgery. We performed a comprehensive and systematic review of studies published from 2000 to 2022 and assessed the use of techniques for ureteral injury prevention and intraoperative localization. 26 publications were included, divided into stent-based (prophylactic/lighted ureteral stent and near-infrared fluorescent ureteral catheter [PUS/LUS/NIRFUC]) and fluorescent dye (FD) groups. Costs, the percentage and number of IUIs detected, reported limitations, complication rates and other outcome points were compared. The IUI incidence rate ranged from 0 to 1.9% (mean 0.5%) and 0 to 1.2% (mean 0.3%) in the PUS/LUS/NIRFUC and FD groups, respectively. The acute kidney injury (AKI) and urinary tact infection (UTI) incidence rate ranged from 0.4 to 32.6% and 0 to 17.3%, respectively, in the PUS/LUS/NIRFUC group and 0-15% and 0-6.3%, respectively, in the FD group. Many other complications were also compared and descriptively analyzed (length-of-stay, mortality, etc.). These techniques appear to be feasible and safe in select patients with a high risk of IUI, but the delineation of reliable guidelines for preventing IUI will require more randomized controlled trials.

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.

Assessment of Risk Factors for Iatrogenic Genitourinary Injuries During a Proctectomy

BACKGROUND

It is critical to avoid iatrogenic injuries affecting genitourinary organs in order to prevent postoperative urinary or sexual dysfunction, which lead to lengthier recovery and possibly reoperation.

METHODS

Using the 2016-2019 American College of Surgeons National Quality Improvement Program (ACS NSQIP) Targeted Proctectomy Database, we collated 2577 patients with non-metastatic rectal cancer who underwent a laparoscopic or open proctectomy. Univariate analysis was used to identify differences in perioperative factors and genitourinary injuries (GUIs) between operative approaches, and multivariate logistic regression was used to identify independent risk factors for sustaining an intraoperative GUI.

RESULTS

The rates of preoperative comorbidities were significantly higher among patients who received an open operation. The proportion of GUIs was also significantly higher in this patient population. Multivariate logistic regression demonstrated that patients who underwent a laparoscopic proctectomy were associated with a 51.4% lower risk of sustaining a GUI. Furthermore, >10% body weight loss in the past 6 months and ASA class 3 status were independently associated with a higher risk of GUI regardless of operation type.

CONCLUSION

Patients who undergo a laparoscopic proctectomy are associated with a lower risk of GUI. On the other hand, patients with >10% body weight loss and ASA class 3: Severe Systemic Disease were associated with a higher risk of GUI.

A case of one-stage laparoscopic drainage and ureterocystoneostomy for iatrogenic ureteral injury associated with infected urinoma

Introduction

Iatrogenic ureteral injury is a rare but often encountered complication of abdominal and gynecological surgery. This is a case of iatrogenic ureteral injury with infected urinoma treated with one-stage laparoscopic drainage and ureterocystoneostomy.

Case presentation

An 80-year-old man with rectal cancer had robot-assisted low anterior rectum resection and left lateral lymph node dissection after colostomy and preoperative chemoradiotherapy. On the 14th postoperative day, he had a fever, and a noncontrast-enhanced computed tomography scan revealed a low-density polycystic area in the left pelvic cavity. Retrograde pyelography revealed contrast medium leaking from the left lower ureter, preventing ureteral stent placement. We identified it as a delayed ureteral injury with infected urinoma and performed laparoscopic one-stage drainage and ureterocystoneostomy.

Conclusion

This study reported a case of one-stage laparoscopic drainage and ureterocystoneostomy for iatrogenic ureteral injury with infected urinoma.

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.

Abdominopelvic Surgery: Intraoperative Ureteral Injury and Prophylaxis in the United States, 2015-2019

INTRODUCTION

Preoperative ureteral catheterization/stenting (stenting) and intraoperative diagnostic cystoscopy (cystoscopy) may help prevent or identify intraoperative ureteral injuries (IUIs) during abdominopelvic surgery. In order to provide a comprehensive, single source of data for health care decision makers, this study aimed to catalog the incidence of IUI and rates of stenting and cystoscopy across a wide spectrum of abdominopelvic surgeries.

METHODS

We conducted a retrospective cohort analysis of United States (US) hospital data (October 2015-December 2019). IUI rates and stenting/cystoscopy use were investigated for gastrointestinal, gynecological, and other abdominopelvic surgeries. IUI risk factors were identified using multivariable logistic regression.

RESULTS

Among approximately 2.5 million included surgeries, IUIs occurred in 0.88% of gastrointestinal, 0.29% of gynecological, and 1.17% of other abdominopelvic surgeries. Aggregate rates varied by setting and for some surgery types were higher than previously reported, especially in certain higher-risk colorectal procedures. Prophylactic measures were generally employed at a relatively low frequency, with cystoscopy used in 1.8% of gynecological procedures and stenting used in 5.3% of gastrointestinal and 2.3% of other abdominopelvic surgeries. In multivariate analyses, stenting and cystoscopy use, but not surgical approach, were associated with a higher risk of IUI. Risk factors associated with stenting or cystoscopy, as well as those for IUI, largely mirrored the variables reported in the literature, including patient demographics (older age, non-White race, male sex, higher comorbidity), practice settings, and established IUI risk factors (diverticulitis, endometriosis).

CONCLUSION

Use of stenting and cystoscopy largely varied by surgery type, as did rates of IUI. The relatively low use of prophylactic measures suggests there may be an unmet need for a safe, convenient method of injury prophylaxis in abdominopelvic surgeries. Development of new tools, technology, and/or techniques is needed to help surgeons identify the ureter and avoid IUI and the resulting complications.

Ureteral injuries in colorectal surgery and the impact of laparoscopic and robotic-assisted approaches

BACKGROUND

Ureteral injury is a feared complication in colorectal surgery that has been increasing over the past decade. Some have attributed this to an increased adoption of minimally invasive surgery (MIS), but the literature is hardly conclusive. In this study we aim to further assess the overall trend of ureteral injuries in colorectal surgery, and investigate propensity adjusted contributions from open and MIS to include robotic-assisted surgery.

METHODS

This is a retrospective analysis of colorectal surgeries from 2006 to 2016 using the Nationwide Inpatient Sample (NIS) database. Multivariable logistic regression was performed to identify predisposing and protective factors. Demographics, hospital factors, and case-mix differences for open and MIS were accounted for via propensity analysis. The NIS coding structure changed in 2015, which could introduce a potential source of incongruity in complication rates over time. As a result, all statistical analyses included only the first nine years of data, or were conducted before and after the change for comparison.

RESULTS

Of 514,162 colorectal surgeries identified there were 1598 ureteral injuries (0.31%). Ureteral injuries were found to be increasing through 2015 (2.3/1000 vs 3.3/1000; p < 0.001) and through the coding transition to 2016 (4.8/1000; p < 0.001). This trend was entirely accounted for by injuries made during open surgery, with decreasing injury rates for MIS over time. Adjusted odds ratio (OR) for ureteral injury with all MIS vs. open cases was 0.81 (95% CI 0.70-0.93, p = 0.003) and for robotic-assisted surgery alone versus open cases was 0.50 (95% CI 0.33-0.77, p = 0.001).

CONCLUSIONS

The incidence rate of ureteral injuries during open colorectal surgery is increasing over time, but have been stable or decreasing for MIS cases. These findings hold even after using propensity score analysis. More research is needed to further delineate the impact of MIS and robotic-assisted surgery on ureteral injuries.

Iatrogenic ureteral injury during retroperitoneal laparoscopy for large renal cysts: What we learned and a review of the literature

PURPOSE

To avoid Iatrogenic ureteral injury during retroperitoneal laparoscopy for large renal cyst (diameter > 70 mm), we present two cases of iatrogenic ureteral injury and discuss their clinical courses and final outcomes.

PATIENTS AND METHODS

Two male patients (47 years old and 74 years old) with large left simple renal cysts underwent a retroperitoneal laparoscopic operation to treat the cysts. In the first patient, the left proximal ureter was partially transected (Grade 3) during the operation. The injury was identified intraoperatively. The transection was managed with a primary ureteroureterostomy (end to end) along with a double J ureteral stent. In the second patient, the left proximalureter was partially transected (Grade 4). However, the injury was unrecognized postoperatively for two days. After recognition of the complication, the injury was managed with an early primary ureteroureterostomy, which followed a failed attempt to place ureteral stent endoscopically.

RESULTS

In the first patient, a postoperative urinary leakage developed and lasted for 13 days. During long term follow-up of the first patient after the urine leak resolved, there were no reports of pain in the lumbar region or other discomfort. No recurrence of the renal cyst occurred, which was confirmed with an ultrasound at one year postoperatively. In the second patient a ureteral fistula and severe perirenal infection occurred and lasted for 86 days. The patient ultimately underwent a left nephrectomy after conservative management for this surgical complication failed. This patient developed a chronic wound infection that lasted for 3.14 months following the nephrectomy. During follow-up post nephrectomy, the patient developed stage 3B moderate chronic kidney disease (CKD) (GFR = 30 -44 ml/min).

CONCLUSIONS

For single large (diameter > 70 mm) renal cysts located at the lower pole of the kidney, it is recommended to not completely dissect out and mobilize the entire renal cyst for cyst decortication in order to avoid injuring the ureter. Iatrogenic ureteral injury increases the risk of readmission and serious life-threatening complications. The immediate diagnosis and proper management ureteric injury can reduce complications and long term sequalae.

Rendezvous procedure to establish ureteral continuity from a delayed ureteral leak following pelvic surgery. A case report

BACKGROUND

Iatrogenic damage to the ureter as a result of an abdominal or pelvic surgical procedure is unusual. However, it does occur and the surgeon must be prepared to deal knowledgeably with the injury. Leaks that are recognized within the operating theater are managed, for the most part, at the same surgical procedure oftentimes with urologic consultation. A delayed leak presents unique problems in that direct access to the site of the leak is not possible except by a reoperative procedure. Delayed leaks present a clinical situation involving the urologist, interventional radiologist, as well as the surgeon.

METHODS

A patient who developed delayed urine leakage following a partial sacrectomy to remove recurrent mucinous appendiceal malignancy was studied. The leakage was controlled using a nephroureteral stent. Placement of the nephroureteral stent was made possible by the rendezvous procedure.

RESULTS

The sequence of procedures to reestablish ureteral continuity following a delayed leak are important in the successful placement of a nephroureteral stent. After establishing the site of the injury a percutaneous nephrostomy must be placed. Then, through the nephrostomy, a guidewire is placed in the ureter to be recovered and advanced into the bladder using a ureteroscope and grasping forceps. A nephroureteral stent is placed over the guidewire to bridge the gap and stent the ureteral defect.

CONCLUSIONS

The rendezvous procedure can be successful a large percentage of the time with a delayed ureteral leakage. Successful recovery of a guidewire in the ureter by ureteroscopy requires a combined interventional radiology and urologic procedure.

A novel method for near-infrared fluorescence imaging of the urethra during perineal and transanal surgery: demonstration in a cadaveric model

AIM

Transanal total mesorectal excision is a promising novel sphincter-saving procedure for low rectal cancer. However, the transanal bottom-up dissection is associated with increased rates of iatrogenic urethral injuries. Near-infrared fluorescence (NIRF) imaging, given its deeper tissue penetration, has been explored in a limited number of studies for enhanced intra-operative urethral visualization. In this study, we explored the feasibility of a novel, ultrabright, biocompatible fluorescent polymer to coat urinary catheters for the purpose of intra-operative urethral visualization.

METHODS

In an ex vivo experiment, using a near-infrared laparoscope, the fluorescent signal of a coated catheter (near-infrared coating of equipment, NICE) was qualitatively and quantitatively compared to the signal of indocyanine green (ICG)/Instillagel® mixtures and ICG-filled catheters at several concentrations. Also, in three male human torsos, using fluorescent urinary catheters, NIRF-guided perineal dissections and a transanal total mesorectal excision were performed. Intra-operative NIRF-based urethral visualization was performed systematically.

RESULTS

During the qualitative and quantitative fluorescence signal assessment, NICE-coated catheters were clearly superior to the ICG-based solutions. In the cadaveric experiments, enhanced urethral visualization was possible even at early stages of dissection, when the organ was covered by several tissue layers.

CONCLUSIONS

NICE-coated catheters represent a promising potential to allow for NIRF-based intra-operative urethral visualization.

The effects of rectal cancer surgery on the anatomical localisation of ureters - a prospective observational study

Introduction

Anatomical changes after surgery and fibrotic adhesions increase the organ laceration risk, including that of the ureter, in recurrent cases and secondary operations. The aim of this study was to investigate the changes in the anatomical localisations of the ureters via computed tomography urography in patients undergoing rectal cancer surgery.

Material and methods

The study involved prospectively collected data on the changes of ureteral location preoperatively and postoperatively in patients with operated rectal cancer. Distances (mm) of ureters determined midline in the computed tomography urogram phase.

Results

A total of 18 patients were included. The mean distances between the right (R₁) and left (L₁) ureters and the mid-vertebral line before the surgery were 30.9 ±5.4 mm and 34.5 ±9.9 mm, respectively. The postoperative distances between them (R₂ and L₂) were 26.4 ±9.1 mm and 29.5 ±9.9 mm, respectively. The R₂ measurement showed that 83.3% (15/18) of the right ureters had deviated medially, whereas 16.7% (3/18) of them had deviated laterally. The L₂ measurements showed that 88.8% (16/18) of the left ureters had deviated medially, whereas 11.2% (2/18) of them had deviated laterally. The differences between the preoperative and postoperative measurements of the right and left ureter positions were 4.5 ±9.2 mm and 4.9 ±4.6 mm, respectively, with the displacement in the left ureter being statistically significant (p ≤ 0.001).

Conclusions

Rectal cancer surgery causes medially deviated changes in the positions of the ureters.

Iatrogenic ureteral injuries and their prevention in colorectal surgery: results from a nationwide survey

AIM

Iatrogenic ureteral injury (IUI) occurs rarely during colorectal surgery but is associated with significant mortality, morbidity and medicolegal issues. Few cases are reported, and recommendations regarding prevention are lacking. The aim of this study is to describe the current state of practice regarding IUI and its prevention among general surgeons in Switzerland.

METHOD

All Swiss general surgeons who are members of either the Swiss Association of Laparoscopic and Thoracoscopic Surgery or the Swiss Surgical Society were invited to participate in an anonymous online survey. Demographics, surgical practice, rate of IUI and methods used to prevent IUI were investigated.

RESULTS

All participants were board-certified general surgeons, 63.4% were certified visceral surgeons and 17.9% were certified colorectal surgeons. The mean level of experience in colorectal surgery was 15.6 ± 9.2 years. Formal ureter identification was considered mandatory during sigmoid or rectal surgery by 83.7% of participants, and 31.7% considered identification of the right ureter during right colectomy to be mandatory. In total, 61.8% of the participants and 78.4% of surgeons with more than 20 years of experience had encountered at least one IUI. Prophylactic ureteral stenting was considered useful in complex procedures by 93.5% of participants, and 56.9% had used stents at least once in the past 12 months. Noninvasive techniques for identifying ureters would be considered in regular daily practice by 54.5% of the participants.

CONCLUSION

Most general surgeons experience IUI. Ureter identification is widely integrated in colorectal procedures. Prophylactic stenting is widely used for difficult cases. Noninvasive methods to improve ureter identification are now needed.

Retrograde Endoscopic Management of Completely Transected Ureter Discovered Postoperatively

Inadvertent injury of the ureter is a known risk of pelvic surgery. If the injury is noticed intraoperatively, the treatment is relatively straightforward. However, if the discovery of the injury is delayed, the treatment is more difficult and less assured. We encountered a case of a completely transected ureter that had occurred during laparoscopic sigmoid colectomy and was diagnosed on the 8th postoperative day. The patient was treated with minimally invasive retrograde endoscopic realignment with excellent results. Therefore, we decided to report this case and perform a literature review on this subject.

Ureteral catheters for colorectal surgery: Influence on operative times and complication outcomes: An observational study

Purpose

Placement of pre-operative ureteral catheters for colorectal surgery can aid in the identification of ureteral injuries. This study investigates whether simultaneous ureteral catheterization with surgery skin preparation can minimize operating room times without increasing post-operative complications.

Materials and Methods

Patients undergoing simultaneous colorectal surgery skin preparation and placement of pre-operative ureteral catheters (n=21) were compared to those who underwent these events sequentially (n=28). Operative time-points of anesthesia ready (AR), surgery procedure start (PS), dorsal lithotomy and catheter insertion (CI) times were compared to assess for differences between groups. Complications were compared between groups.

Results

There were no differences in age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA), comorbidities, current procedure terminology (CPT) or International Classification of Diseases, 9th revision (ICD-9) codes between groups. Simultaneous catheterization saved 11.82 minutes of operative time between CI to PS (p=0.005, t-test). There was a significant difference in mean time between CI to PS (11.82 minutes, p=0.008) between simultaneous and sequential ureteral catheterization groups in a linear regression multivariate analysis controlling for age, BMI, CPT and ICD-9 codes. There were 4 complications in the simultaneous (19%) and 3 in the sequential group (11%) (p=0.68).

Conclusions

Ureteral catheterization and colorectal surgery skin preparation in a simultaneous fashion decreases the time between CI and PS without significant increase in complications. Mean time saved with simultaneous ureteral catheterization was 11.82 minutes per case. Simultaneous ureteral catheterization may be an option in colorectal surgery and may result in cost savings without additional complications.

Trends of ureteral stent usage in surgery for diverticulitis

BACKGROUND

Many believe that the use of ureteral stents in colorectal surgery for diverticulitis aids prevention and easier identification of ureteral injuries; others argue that the added time, cost, and risks of stent placement negate potential benefits. Even among providers who use stents, selective use is common. Among unclear consensus, it remains unknown if the use of stents is growing.

MATERIALS

Patients in the National Inpatient Sample who underwent a partial colectomy or anterior rectal excision for diverticulitis between 2000 and 2013 were included (n = 811,071). Trends in ureteral stent use, multivariate logistic regression of factors influencing stent placement, and linear regression of length of stay (LOS) and costs associated with stent use were examined.

RESULTS

Usage of ureteral stents increased from 6.66% in 2000 to 16.30% in 2013 (P < 0.0001). Rates of stent usage were higher with laparoscopic surgery (19.31% versus 12.31% open, P < 0.0001). Regression demonstrated patients in the Northeast (Midwest odds ratio (OR) 0.49 [0.37-0.66] P < 0.0001, South OR 0.60 [0.45-0.80] P = 0.0004, West OR 0.30 [0.22-0.41], P < 0.0001), and those whose admission was elective (OR 2.37 [2.08-2.69], P < 0.0001) were more likely to receive stents. Stent use was associated with an increased LOS (0.55 days, P < 0.0001) and cost ($1,983, P < 0.0001).

CONCLUSIONS

The use of ureteral stents in surgery for diverticulitis has steadily increased since 2000, despite the lack of consensus of their overall benefit. Stent usage is associated with laparoscopic surgery and varies widely among regions of the country. Further studies are required to truly understand the risk-benefit ratio of ureteral stenting and to determine if its increased use is warranted.

Fluorescence to highlight the urethra: a human cadaveric study

Background

Urethral injury is a complication feared by surgeons performing transanal TME (TaTME) or abdominoperineal excision (APE) procedures. Injury during TaTME occurs when the prostate is inadvertently mobilised or as a direct injury similar to the direct injury during the perineal dissection of APE procedures. We performed a proof of principle study to assess the feasibility of using indocyanine green (ICG) to fluoresce the urethra in human cadavers.

Methods

Indocyanine green at varying doses was mixed with Instillagel and infiltrated into the urethra of male human cadavers. The urethra was exposed through either a perineal incision or by mobilisation of the prostate during a TaTME dissection and fluorescence observed using a PINPOINT laparoscope (NOVADAQ). Brightness was assessed on the images using ImageJ (National Institute of Health).

Results

Eight cadavers were included in the study. Fluorescence was visualised in the urethra in all eight cadavers. Minimal dissection was required to obtain fluorescence transperineally. In one cadaver, the urethra was demonstrated under fluorescence using a simulated TaTME with additional fluorescence also being observed in the prostate. There was no correlation between brightness and dosing.

Conclusions

This novel proof of principle study demonstrates a simple way in which the urethra may be easily identified preventing it from injury during surgery.

Electronic supplementary material

The online version of this article (doi:10.1007/s10151-017-1615-y) contains supplementary material, which is available to authorized users.

Supramolecular Metallo-Bioadhesive for Minimally Invasive Use

A novel metallo-bioadhesive to be used as tissue sealant in minimally invasive procedures is reported. Metal complexation can be used to render gelatin derivatives adhesive, which occurs in minutes, is efficient, and fully biodegradable within weeks.