Iatrogenic Ureteral Injury as a Complication of Posterior or Lateral Lumbar Spine Surgery: A Systematic Review of the Literature

Ureter position and risk of ureteral injury during lateral lumbar interbody fusion

BACKGROUND

Ureteral injury during lateral lumbar interbody fusion (LLIF) is uncommon. However, it is a serious complication that may require additional surgery should it occur. The objective of this study was to evaluate whether there was any change in the position of the left ureter between preoperative biphasic contrast-enhanced CT scanned in the supine position and intraoperative scanning in the right lateral decubitus position after stent placement, to assess the risk of ureteral injury in the actual surgical position.

METHODS

The position of the left ureter scanned with the O-arm navigation system with the patient in the right lateral decubitus position and its position on preoperative biphasic contrast-enhanced CT images scanned with the patient in the supine position were investigated comparing their positions at the L2/3, L3/4, and L4/5 levels.

RESULTS

The ureter was located along the interbody cage insertion trajectory in 25 of 44 disc levels (56.8%) in the supine position, but in only 4 (9.5%) in the lateral decubitus position. The proportion of patients in whom the left ureter was located lateral to the vertebral body (along the LLIF cage insertion trajectory) at each level was 80% in the supine position and 15.4% in the lateral decubitus position at the L2/3 level, 53.3% in the supine position and 6.7% in the lateral decubitus position at the L3/4 level, and 33.3% in the supine position and 6.7% in the lateral decubitus position at the L4/5 level.

CONCLUSION

The proportion of patients in whom the left ureter was located on the lateral surface of the vertebral body when the patient was in the actual surgical position (lateral decubitus position) was 15.4% at the L2/3 level, 6.7% at the L3/4 level, and 6.7% at the L4/5 level, suggesting that caution is required during LLIF surgery.

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.

How to treat jatrogenic ureteral injury after posterior spinal surgery? Case report and review of literature

Introduction

Entry into the retroperitoneal space during open posterior spinal surgery introduces the rare possibility of iatrogenic ureteral injury.

Case presentation

We describe a case of ureteral injury after spinal surgery in a 49-year-old female with persistent lumbar pain and high fever 2 weeks after spinal surgery. After admission to the urology department, a computer tomography scan was performed and revealed right-side hydronephrosis grade III and large retroperitoneal fluid collection. After radiological confirmation of right ureteral injury, a ureteral stent was placed, but 4 weeks later, ureteral stricture was confirmed on antegrade pyelography. Therefore, surgical ureteroplasty was indicated 2 months after initial admission to the urology department. Six weeks later, the stent was removed, and intravenous pyelography revealed a normal ureteral passage.

Conclusion

There should be a low threshold for ureteral injuries after spinal cord surgery in patients with high fever and elevated blood creatinine levels.

Ureteral Injury Following Posterior Lumbar Interbody Fusion After Five Years: A Rare Case

Introduction: Ureteral injuries are considered as rare complications of posterior lumbar interbody fusion (PLIF). There are few reports in the literature on ureteral injuries following PLIF. The present report presented a case of right ureteral injury by passing five years from PLIF. Case Presentation: The patient was a 51-year-old woman who has been referred to urologist with the complaints of flank pain, fever, anorexia, vomiting, and nausea, and a history of PLIF five years ago. After radiological examinations, ureteral obstruction was diagnosed and then open surgery was performed. Severe adhesions and fibrosis were observed in the retroperitoneal next to the lumbar vertebra implant. Thereafter, the ureteral stenosis was removed, the ureter was anastomosed end-to-end, and Double J was placed. The anastomosis site was covered with a flap of perinephric adipose tissue in order to prevent re-fibrosis. Conclusions: This report aimed to inform surgeons of a rare complication, a ureteral injury that has happened five years after PLIF, along with its non-specific signs.

Ureteral injury following anterior thoracolumbar spinal instrumented fusion for adolescent idiopathic scoliosis: a case report with CT angiography analysis of surgically relevant anatomy

PURPOSE

To report a rare ureteral injury following anterior spinal fusion for adolescent idiopathic scoliosis (AIS) that resulted in complete nephrectomy and to delineate the anatomical relationship between the proximal ureter and the anterior lumbar spine based on CT angiography (CTA).

METHODS

Thoracolumbar spine CTAs of children with AIS were reviewed. We measured the following relationships to the ureters: lateral-most aspect of vertebral body, anterior psoas at intervertebral disc/vertebral body levels, and lateral psoas at vertebral body level. Spine level at which the renal arteries originated from the aorta was identified. Distance from origin to corresponding vertebral body/intervertebral disc also was measured.

RESULTS

Forty-one girls and seven boys (mean age 12 years, range 7-18) were analyzed. Scoliosis lumbar convexity was left 94% and right 6%. From L1 to L4, ureter was identified within 1-2 cm of vertebral body. Distance between ureter and vertebral body and ureter and anterior psoas at intervertebral disc/vertebral body levels was less on left vs. right from L1 to L4 (p < 0.0001). Distance between ureter and lateral psoas was less on left vs. right from L1 to L2 (p = 0.0205; p = 0.0132) and greater on left vs. right from L3 to L4 (p = 0.0022; p = 0.0076). Renal artery originated at L1/L2 in > 50%. There was no difference in distance from renal artery origin to vertebral body/intervertebral disc (p = 0.4764).

CONCLUSION

Ureteral injury is a potentially morbid complication of anterior spine surgery. Injury can occur secondary to disrupted blood supply and mechanical tissue damage. Surgeons must clearly understand the juxta-spinal anatomy to limit dissection and modify retraction to reduce risk.

LEVEL OF EVIDENCE

Level IV.

Genitourinary complications in orthopaedic surgery

Genitourinary complications following orthopaedic intervention are uncommon but well-described occurrences and exist on a spectrum of severity. These complications vary depending on the anatomic location and surgical approach, with surgery of the spine, hip, and pelvis of particular concern. Injuries to the urinary tract may present acutely with urinary retention or hematuria. However, they often have a delayed presentation with severe complications such as urinary fistula and recurrent infection. Delayed presentations may place the onus of timely and proper diagnosis on the orthopaedic provider, who may serve as the patient's primary source of long-term follow-up. Detailed knowledge of anatomy and at-risk structures is key to both preventing and identifying injury. Although iatrogenic injury is not always avoidable, early identification can help to facilitate timely evaluation and management to prevent long-term complications such as bladder dysfunction, obstructive renal injury, sexual dysfunction, and chronic pain.  Keywords: urologic injury, bladder injury, genitourinary injury, hip arthroplasty, pelvic ring injuries, spine surgery.