The ureteral "J" sign: radiographic demonstration of iatrogenic distal ureteral obstruction after ureteral reimplantation

Management of iatrogenic ureteral injury

Iatrogenic injury to the ureter is a potentially devastating complication of modern surgery. The ureters are most often injured in gynecologic, colorectal, and vascular pelvic surgery. There is also potential for considerable ureteral injury during endoscopic procedures for ureteric pathology such as tumor or lithiasis. While maneuvers such as perioperative stenting have been touted as a means to avoid ureteral injury, these techniques have not been adopted universally, and the available literature does not make a case for their routine use. Distal ureteral injuries are best managed with ureteroneocystostomy with or without a vesico-psoas hitch. Mid-ureteral and proximal ureteral injuries can potentially be managed with ureteroureterostomy. If the distal segment is unsuitable for anastomosis then a number of techniques are available for repair including a Boari tubularized bladder flap, transureteroureterostomy, or renal autotransplantation. In rare cases renal autotransplantation or ureteral substitution with gastrointestinal segments may be warranted to re-establish urinary tract continuity. Laparoscopic and minimally invasive techniques have been employed to remedy iatrogenic ureteral injuries.

Reoperative ureteroneocystostomy: review of 69 patients

Reoperative ureteroneocystostomy in 69 patients with primary vesicoureteral reflux was reviewed. Of the renal units 49 were obstructed and 48 had reflux. Postoperative obstruction was caused by mechanical factors in 61 per cent of the renal units, distal ureteral scarring in 31 per cent and a previously unrecognized functionally neurogenic bladder (without a neurological lesion) in 8 per cent. Persistent postoperative reflux was secondary to a short submucosal tunnel in 94 per cent of the renal units and occult neurogenic bladder in 6 per cent. Reoperative ureteroneocystostomy was successful in 79 per cent of the renal units, with a mean followup of 33 months. The modified Paquin technique (omitting the ureteral cuff) yielded consistently superior results in children undergoing reoperation for ureterovesical junction obstruction. In patients with postoperative vesicoureteral reflux a variety of techniques produced similar and gratifying results. That 52 per cent of our patients had no symptoms indicates clearly the absolute necessity of careful followup after ureteral reimplantation. Furthermore, 20 per cent of our patients had late failure (4 to 10 years after initial ureteroneocystostomy), which suggests the need for careful monitoring of the reimplanted ureter past puberty.