Ureteric injury: a challenging condition to diagnose and manage. Nat Rev Urol. 2013;10:108-115. [PMID: 23318355 DOI: 10.1038/nrurol.2012.254]

Radiotherapy induced ureteric stenosis in locally advanced cervical cancer: A review of current evidence

BACKGROUND

Concurrent chemo-radiation followed by high dose rate brachytherapy is the standard of care for locally advanced cervical cancer. The proximity of the ureters to the tumor volume risks ureteric stenosis. Here we outline the current understanding of radiotherapy induced ureteric stenosis in patients treated for cervical cancer, focusing on the incidence, risk factors, clinical consequences, and management.

METHODS

Searches on EMBASE, PubMed, Science Direct, and Google Scholar were performed for publications reporting on radiotherapy, cervix cancer and ureteric stenosis. Multi and single center, prospective/retrospective, cohort, and cross-sectional studies were included.

RESULTS

This narrative review identified key issues relevant to radiation induced ureteric stenosis in cervical cancer in the literature. Thirteen studies were evaluated, identifying crude and actuarial rates of ureteric stenosis of 0.3-13.5% and 1.5-4.4% (at 5 years) respectively. The risk of ureteric stenosis is highest in the first 5 years after radiotherapy but continues to occur at a rate of 0.15% per year. Risk factors including advanced FIGO stage, tumor size >5 cm and baseline hydronephrosis increase the incidence of ureteric stenosis. EQD2 doses of ≥ 77Gy were significantly associated with ≥grade 3 ureteric morbidity. The majority of patients were managed with nephrostomy +/- ureteric stent insertion, with some requiring ureteral reimplantation, urinary diversion or nephrectomy.

CONCLUSIONS

This review has identified multiple considerations, highlighting the need to identify patients highest at risk of ureteric stenosis. There is also a need to recognize ureters as organs at risk, record dose exposure, and apply dose constraints, all of which set the landscape for allowing dose optimization.

The Rendezvous Technique: A Minimally Invasive Non-Surgical Approach for the Management of Iatrogenic Ureteral Injuries

Background/Objectives: The aim of our study is to evaluate the feasibility and efficacy of the rendezvous technique for the treatment of iatrogenic ureteral injuries. Methods: From 2014 to 2019, 29 patients treated with the rendezvous technique for mono- or bilateral iatrogenic ureteral injuries were enrolled in this retrospective study. All the leaks were previously assessed by CT-urography and antegrade pyelography. Ureteral continuity was restored by performing the rendezvous technique, combining antegrade trans-nephrostomic access and a retrograde trans-cystostomic approach. A double J stent was antegradely inserted, and a nephrostomy tube was kept in place at the end of the procedure. A post-procedure CT-urography and a 30-day nephrostogram follow-up were performed. In the absence of a contrast leak, the nephrostomy tube was removed. Patient follow-up was set with CT-urography at 3, 6, and 12 months and stent substitution every 4 months. The CT-urography was performed to confirm the restored integrity of the ureter before stent removal. Results: The rendezvous technique was successful in all cases with the resolution of the ureteral leak. No major complications were observed. In all the patients, the nephrostomy tube was removed after 30 days. After performing CT-urography, the stent was removed permanently after 12 months. Only three cases showed local post-treatment stenosis treated with surgical ureteral reimplantation. Conclusions: The rendezvous technique is a safe and effective minimally invasive procedure that can be used to restore the continuity of the ureter, avoiding open surgery and providing valuable support for the management of complications after gynecological surgery.

Recent developments in ureteral stent: Substrate material, coating polymer and technology, therapeutic function

The ureteral stent is an effective treatment for clinical ureteral stricture following urological surgery, and the functional coating of the stent could effectively inhibit bacterial colonization and other complications. The present review provides an analysis and description of the materials used in ureteral stents and their coatings. Emphasis is placed on the technological advancements of functional coatings, taking into consideration the characteristics of these materials and the properties of their active substances. Furthermore, recent advances in enhancing the therapeutic efficacy of functional coatings are also reviewed. It is anticipated that this article will serve as a valuable reference providing insights for future research development on new drug-loaded ureteral stents.

Urinoma Masquerading as Post-hysterectomy Hematoma: The Role of Accurate Diagnosis and Imaging-Guided Intervention

Although rare, ureteric injuries can occur during gynecological surgical interventions, and their diagnosis can be challenging, especially when delayed. If left untreated, missed ureteric injuries can lead to severe complications, including prolonged hospitalization, sepsis, renal damage, and potentially even loss of the affected kidney. We present a unique case of a urinoma caused by bilateral ureteric injuries following abdominal hysterectomy, which was initially misdiagnosed as an intraperitoneal hematoma. However, further radiological investigations enabled accurate diagnosis without the need for exploratory laparotomy, demonstrating the importance of thorough evaluation for all possible complications in patients presenting with post-operative issues. In cases of pelvic collections of unclear origin or ureteric injury, a computed tomography (CT) scan is the gold standard diagnostic modality, providing precise diagnosis and expedited management.

Female Bladder Dysfunction Following Boari Bladder Flap Ureteral Reconstruction

OBJECTIVE

To describe our institution's experience with Boari flap ureteral reconstruction, specifically focusing on the development of postoperative lower urinary tract symptoms (LUTS).

METHODS

A retrospective review of all Boari flaps performed at our institution between 2013 and 2023 was performed, excluding patients with urothelial carcinoma and males, given the frequency of LUTS from benign prostatic hyperplasia. Primary outcome was the development of new onset LUTS and subsequent treatment. Secondary outcomes included postoperative infections and ureteral stricture.

RESULTS

Twenty-nine total patients were identified. Mean age was 52.2 years (standard deviation (SD) 13.1). Mean follow-up was 22.3 months (SD 25.3). Primary reasons for ureteral reconstruction were radiation damage (37.9%) and iatrogenic surgical injury (37.9%). A concurrent psoas hitch was performed in 18/29 (62%) cases, nephropexy was utilized in 1/29 (3.4%) cases, and contralateral bladder pedicles were ligated in 10/29 (34.5%) for increased bladder mobilization. Postoperatively, 8 patients (27.6%) developed new-onset LUTS, effectively managed with oral anticholinergics. Recurrent urinary tract infections occurred in 5 patients (17.2%) and pyelonephritis in 1 (3.4%) patient. Two patients (6.9%) developed ureteral strictures, one treated with ileal ureter replacement and the other with ureteral balloon dilation.

CONCLUSION

Boari bladder flap ureteral reconstruction leads to moderate rates of new onset LUTS postoperatively, which is important information when counseling women on reconstructive options. Boari flap ureteral reconstruction has a high success rate, and serious complications are rare. In the setting of ureteral injury, reconstruction using Boari flaps with or without psoas hitch should be considered for definitive management.

Ultrasound contrast agent assisted ultrasonography guidance percutaneous nephrostomy for non-hydronephrotic kidney

BACKGROUND

Given the limited success rate and considerable challenges associated with conventional ultrasonography (US) guidance for percutaneous nephrostomy (PCN) in non-hydronephrotic kidneys, this study proposed a solution with ultrasound contrast agent to enhance the success rate and mitigate the difficulties.

MATERIALS AND METHODS

From January 2017 to August 2023, a total of thirteen patients diagnosed with non-hydronephrotic kidney were included in the study. Following routine ultrasonography examination, no significant dilatation of the renal collecting system was observed. US-guided percutaneous nephrostomy PCN was performed with the assistance of ultrasound contrast agent (UCA). The patients were subsequently monitored to assess the improvement of symptoms and postoperative recovery.

RESULTS

The success rate was found to be 100% for all patients (13/13) and kidneys (20/20). The average volume of UCA solution used was 19 ± 6.7 mL (range, 11-35 mL), while the mean duration of the operation was 18.92 ± 8.96 min (range, 7-36 min). A majority of the patients (12/13) underwent a single puncture procedure. Throughout the follow-up period, no serious complications were observed, and surgery resulted in significant alleviation of symptoms in all patients.

CONCLUSION

The use of UCA-assisted US guidance PCN has been shown to be effective in achieving urinary diversion and alleviating associated clinical symptoms in non-hydronephrotic kidneys. In comparison to traditional methods, this approach demonstrates a high success rate and safety profile, while also offering a simplified operative procedure. Consequently, it presents a novel method and concept for managing non-hydronephrotic kidneys afflicted by urine leakage.

Long-term economic outcomes of ureteral injury in the United States

OBJECTIVES

Ureteral injuries (UIs) during surgical procedures can have serious consequences for patients. Although UIs can result in substantial clinical burden, few studies report the impact of these injuries on payer reimbursement and patient cost-sharing. This retrospective study evaluated 30-day, 90-day, and 1-year healthcare resource utilization for patients with UIs and estimated patient and payer costs.

METHODS

Patients aged ≥ 12 years who underwent abdominopelvic surgery from January 2016 to December 2018 were identified in a United States claims database. Patients were followed for 1 year to estimate all-cause healthcare visits and costs for patients and payers. Surgeries resulting in UIs within 30 days from the surgery date were matched to surgeries without UIs to estimate UI-attributable visits and costs.

RESULTS

Five hundred and twenty-two patients with UIs were included. Almost a third (29.9%) of patients with UIs had outpatient surgery. Patients with UIs had slightly more healthcare visits and a 15.3% higher 30-day hospital readmission rate than patients without UIs. Patient costs due to UIs were not statistically significant, but annual payer costs attributable to UIs were $38,859 (95% CI = 28,142-49,576), largely driven by inpatient costs.

CONCLUSIONS

UIs add substantial cost for payers and result in more healthcare visits for patients. These findings highlight the importance of including inpatient and outpatient settings for UI prevention. Although UIs are rare, the associated patient and payer burdens are high; thus, protocols or techniques are needed to recognize and avert UIs as current guideline recommendations are lacking.

Ileal ureter replacement and ileocystoplasty for the treatment of bilateral ureteral strictures and bladder contracture: technique and outcomes

BACKGROUND

The aim of this study was to explore the feasibility of ileal ureter replacement and ileocystoplasty for the treatment of bilateral long-segment ureteral strictures combined with bladder contracture.

METHODS

A retrospective review of clinical data from seven patients who underwent bilateral Ileal Ureter Replacement and ileocystoplasty from April 2019 to February 2023 was conducted. The surgeries were performed using open, laparoscopic, and robot-assisted laparoscopic approaches. Baseline characteristics, perioperative, and mid-term results of the patients were collected. Follow-up period of 3-28 months. A detailed description of the technique was reported.

RESULTS

The mean age of the patients was 52.86±6.06 years. The average duration of surgery was 365±28.54 minutes, and the estimated intraoperative blood loss was 357.14±184.06 mL. The mean length of harvested ileum was 37.86±8.40 cm. The preoperative serum creatinine level was 88.02±18.05 μmol/L, postoperative day 1 creatinine level was 90.7±12.93μmol/L, postoperative 3-month creatinine level was 93.77±33.34 μmol/L, and the mean creatinine level at the last follow-up was 94.89±27.89μmol/L. The postoperative bladder capacity was 249.43±32.50 mL on average. The average length of hospital stay was 26.57±15.46 days. No complications of Clavien-Dindo grade 3 or higher were observed. During the follow-up period, no patients experienced deterioration of renal function after surgery.

CONCLUSIONS

Bilateral ileal ureter replacement and ileocystoplasty are effective surgical technique for the treatment of bilateral long-segment ureteral strictures combined with bladder contracture caused by radiation therapy.

[Update on ureteral reconstruction 2024]

Ureteral strictures can occur along the entire course of the ureter and have many different causes. Factors involved in the development include, among other things, congenital anomalies, iatrogenic injuries during endoscopic as well as open or minimally invasive visceral surgical, gynecological, and urological procedures as well as prior radiation therapy. Planning treatment for ureteral strictures requires a detailed assessment of stricture and patient characteristics. Given the various options for ureteral reconstruction, various methods must be considered for each patient. Short-segment proximal strictures and strictures at the pyeloureteral junction are typically surgically managed with Anderson-Hynes pyeloplasty. End-to-end anastomosis can be performed for short-segment proximal and middle ureteral strictures. Distal strictures are treated with ureteroneocystostomy and are often combined with a Boari and/or Psoas Hitch flap. Particularly, the treatment of long-segment strictures in the proximal and middle ureter remain a surgical challenge. The use of bowel interposition is an established treatment option for this, offering good functional results but also potential associated complications. Robot-assisted surgery is increasingly becoming a minimally invasive treatment alternative to reduce hospital stays and optimize postoperative recovery. However, open surgical ureteral reconstruction remains an established procedure, especially after multiple previous abdominal operations.

In vitro and in vivo assessment of a bilayered degradable rapamycin-eluting stent for ureteral stricture caused by holmium: YAG laser lithotripsy

Ureteral stricture caused by holmium: YAG laser lithotripsy is one of the most challenging issues for urologists. Currently, evidence for rapamycin application in reducing ureterostenosis is not sufficient. This study aimed to assess the inhibition of ureteral stricture of rapamycin-eluting stents in vitro and in vivo. A bilayered drug-eluting ureteral stent consisted of drug blending with poly (lactic-co-glycolic acid) (PU/drug stent), which was over-layered by polycaprolactone (PCL) by ultrasonic atomizing spraying. Stent morphology was observed by scanning electron microscope. A kidney-ureter-bladder model was established to simulate the stents-releasing condition, and high-performance liquid chromatography was used to measure the drug release rate. The inhibitory proliferation was detected by CCK-8. The bladder of rats was injured through electro tome, and stents were implanted for 7, 14, and 28 days. The effects of drug-eluting stents was investigated by hematoxylin-eosin staining, immunofluorescence staining, real-time quantitative polymerase chain reaction and western blot. The bilayered stents could block the burst loss of the drug and maintained a sustained delivery period because of the 5.3 μm thickness of the PCL layer. The relative growth rates of cells plotted inhibitory effect on the proliferation of human urethral scar fibroblast cells. For in vivo results of 28 days, the bilayered stent maintained structural integrity and induced less deposition of crystals, thinner and less lamina propria connective tissues were formed, and α-SMA and TGF-β1 were downregulated. Bilayered rapamycin-eluting stent is significantly effective in alleviating fibrosis in in vitro and in vivo models. STATEMENT OF SIGNIFICANCE: The occurrence of ureteral stricture resulting from holmium: YAG laser lithotripsy presents a significant challenge for urologists. Traditional double J stents have not been proven to offer a shorter indwelling time or improved inhibition of tissue blocking. While drug-eluting stents containing rapamycin, paclitaxel, and other substances have been extensively used in treating artery stenosis, there is insufficient evidence supporting their application in reducing ureterostenosis. Consequently, a biodegradable polymer ureteric scaffold incorporating rapamycin was fabricated in this study, employing ultrasonic atomization spraying technology to optimize the bilayers composed of 75/25 poly (lactic-co-glycolic acid) (PLGA) and polycaprolactone (PCL). The efficacy of the scaffold was subsequently confirmed through in vitro and in vivo experiments.

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.

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.

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.

Preoperative stricture length measurement does not predict postoperative outcomes in robotic ureteral reconstructive surgery

PURPOSE

We sought to determine whether preoperative stricture length measurement affected the choice of procedure performed, its correlation to intraoperative stricture length, and postoperative outcomes.

METHODS

The Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database was queried for patients undergoing robotic ureteral reconstructive surgery from 2013 to 2021 who had surgical stricture length measurement. From this cohort, we identified patients with and without preoperative stricture length measurement via retrograde pyelogram or antegrade nephrostogram. Outcomes evaluated included intraoperative complications, 30-day complications greater than Clavien-Dindo grade II, hardware-free status, and need for additional procedures.

RESULTS

Of 153 patients with surgical stricture length measurements, 102 (66.7%) had preoperative radiographic measurement. No repair type was more likely to have preoperative measurement. The Pearson correlation coefficient between surgical and radiographic stricture length measurements was + 0.79. The average surgical measurement was 0.71 cm (± 1.52) longer than radiographic assessment. Those with preoperative imaging waited on average 5.0 months longer for surgery, but this finding was not statistically significant (p = 0.18). There was no statistically significant difference in intraoperative complications, 30-day complication rates, hardware-free status at last follow-up, or need for additional procedures between patients with and without preoperative measurement. The only significant predictive factor was preoperative stricture length on 30-day postoperative complications.

CONCLUSIONS

Despite relatively high prevalence of preoperative radiographic stricture length measurement, there are few measures where it offers clinically meaningful diagnostic information towards the definitive surgical management of ureteral stricture disease.

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.

Conservative Management of Postoperative Urinary Leak and Intra-Abdominal Abscess

Ureteral injury is a rare occurrence in medical practice. Most cases encountered stem from blunt trauma or are iatrogenic, occurring during open abdominal or pelvic surgery and laparoscopic procedures. Prompt diagnosis of ureteral injury allows clinicians to avoid complications including ureteral strictures, abscess, renal failure, sepsis, and loss of the ipsilateral kidney. Treatment depends on whether the ureteral injury was discovered intraoperatively or if it was a delayed diagnosis. Several procedures can be used, including ureteroureterostomy, ureteroileal interposition, and nephrectomy. Stenting can also be a viable option as it can reestablish urinary drainage. Herein, we present the case of a 43-year-old male who presented with complaints of progressive abdominal pain that was subsequently diagnosed as a left ureteral injury and how the use of a ureteral stent allowed him to have a full recovery with optimized normal ureteral function.

Evaluation of the Utilization of Near-Infrared Fluorescent Contrast Agent ASP5354 for In Vivo Ureteral Identification in Renal Diseases Using Rat Models of Gentamicin-Induced Acute Kidney Injury

ASP5354 was recently developed as a near-infrared fluorescence (NIRF) contrast agent for intraoperative ureteral identification, and its use has been evaluated in healthy animals. However, the utilization of ASP5354 for ureteral identification has not been evaluated in animals with renal injury. In this study, we assessed the application of ASP5354 for ureteral imaging using rat models of gentamicin-induced mild, moderate, and severe acute kidney injury (AKI), using a clinically available NIRF detection system. NIRF was detected in the abdominal cavity and ureters after laparotomy, and the efficiency of ASP5354 was evaluated based on the NIRF signal intensity over 60 min. After the intravenous injection of ASP5354 into rats with mild or moderate AKI, the ureters were clearly imaged at a high ratio of NIRF intensity in the ureter to that in the tissues around the ureter. Six days after intravenous injection, the use of ASP5354 in rats with moderate AKI did not affect the biochemical kidney functions or histopathological conditions of the kidney tissues, as compared to those with no injection of ASP5354. In rats with severe AKI, ureteral imaging was not effective due to the relatively strong NIRF expression in the tissues around the ureters. These data indicate that ASP5354 holds potential as a contrast agent for intraoperative ureteral identification in patients with limited renal injury.

Long-term Outcomes of Minimally Invasive Rendezvous Procedures to Treat Complex Ureteric Strictures and Injuries

Background

Complex ureteric strictures and injuries occurring during major abdominal and pelvic operations may cause significant morbidity and distress to patients. A rendezvous procedure is an endoscopic technique used in case of such injuries.

Objective

To evaluate perioperative and long-term outcomes of rendezvous procedures to treat complex ureteric strictures and injuries.

Design setting and participants

We retrospectively reviewed patients undergoing a rendezvous procedure for ureteric discontinuity including strictures and injuries, treated between 2003 and 2017 at our Institution and completing at least 12 mo of follow-up. We divided patients into two groups: early postsurgical obstruction, leakage, or detachment (group A) and late strictures (oncological/postsurgical; group B).

Outcome measurements and statistical analysis

If appropriate, we performed a retrograde study ± rigid ureteroscopy to assess the stricture 3 mo after the rendezvous procedure, followed by a MAG3 renogram at 6 wk, 6 mo, and 12 mo, and annually thereafter for 5 yr.

Results and limitations

Forty-three patients underwent a rendezvous procedure, 17 in group A (median age 50 yr, range 30-78) and 26 in group B (median age 60 yr, range: 28-83). Ureteric strictures and ureteric discontinuities were stented successfully in 15 out of 17 patients in group A (88.2%) and 22 out of 26 patients (84.6%) in group B. For both groups, the median follow-up was 6 yr. In group A, of 17 patients, 11 (64.7%) were stent free with no further interventions, two (11.7%) had a subsequent Memokath stent insertion (38%), and two (11.7%) required reconstruction. Of 26 patients in group B, eight (30.7%) required no further interventions and were stent free, ten (38.4%) were maintained with long-term stenting, and one was managed with a Memokath stent (3.8%). Of the 26 patients, only three (11.5%) required major reconstruction, while four patients with malignancy (15%) died during follow-up.

Conclusions

With a combined antegrade and retrograde approach, the majority of complex ureteric strictures/injuries can be bridged and stented with an overall immediate technical success rate of above 80%, avoiding major surgery in unfavourable circumstances and allowing time for stabilisation and recovery of the patient. Additionally, in case of technical success, further interventions may be unnecessary in up to 64% of patients with acute injury and about 31% of patients with late stricture.

Patient summary

The majority of complex ureteric strictures and injuries can be resolved using a rendezvous approach, avoiding major surgery in unfavourable circumstances. Moreover, this approach can help avoid further interventions in 64% of such patients.

Post-Surgical Imaging Assessment in Rectal Cancer: Normal Findings and Complications

Rectal cancer (RC) is one of the deadliest malignancies worldwide. Surgery is the most common treatment for RC, performed in 63.2% of patients. The type of surgical approach chosen aims to achieve maximum residual function with the lowest risk of recurrence. The selection is made by a multidisciplinary team that assesses the characteristics of the patient and the tumor. Total mesorectal excision (TME), including both low anterior resection (LAR) and abdominoperineal resection (APR), is still the standard of care for RC. Radical surgery is burdened by a 31% rate of major complications (Clavien-Dindo grade 3-4), such as anastomotic leaks and a risk of a permanent stoma. In recent years, less-invasive techniques, such as local excision, have been tested. These additional procedures could mitigate the morbidity of rectal resection, while providing acceptable oncologic results. The "watch and wait" approach is not a globally accepted model of care but encouraging results on selected groups of patients make it a promising strategy. In this plethora of treatments, the radiologist is called upon to distinguish a physiological from a pathological postoperative finding. The aim of this narrative review is to identify the main post-surgical complications and the most effective imaging techniques.

Ureteral identification with indocyanine green in laparoscopic colorectal surgery

INTRODUCTION

Fluorescence-guided surgery has emerged as a complement of traditional laparoscopic surgery with the advantage that is adaptable to existent platforms. The purpose of this article is to describe our technique for ureteral identification with indocyanine green (ICG) during laparoscopic colorectal surgery.

MATERIALS AND SURGICAL TECHNIQUE

We report a case series of all patients who underwent laparoscopic colorectal surgery and ureteral injection of ICG in a private third level hospital.

RESULTS

We performed 30 laparoscopic colorectal surgeries in which we used this technique to identify the ureters. Mean age was 52.6 ± 15.28 years; 16 (53.3%) were men. The indication for surgery was diverticulitis in 18 patients. Mean urological operative time was 22.4 minutes. There were no immediate or delayed adverse effects attributable to intra-ureteral ICG administration.

DISCUSSION

Although ureteric iatrogenic injury is uncommon, when it does happen, it significantly increases the patient's morbidity. We consider this technique has the potential to make laparoscopic surgeries safer mostly in patients with cancer, diverticular disease or endometriosis who have extensive fibrosis, adhesions, and inflammation.

A 6-year retrospective clinical review of iatrogenic ureteric injuries repaired in a resource-deprived setting

Background

Seventy percent of ureteric injuries result from iatrogenic causes with about 75% of these diagnosed in the postoperative period. It may have fatal complications such as sepsis and or renal functional damage increasing morbidity and treatment cost.

Objective

The study aimed to identify the risk factors for iatrogenic ureteric injuries from open surgical procedures and the intervention outcome in a resource-poor setting.

Patients and methods

This was a multi-centre study. The clinical records of patients with iatrogenic ureteric injuries seen between 2015–2021 who were managed at the urology units of the Margaret Marquart Catholic Hospital, and the Ho Teaching Hospital, in the Volta region of Ghana, were retrieved. The data extracted included patients’ demographic factors, the clinical presentation, the primary surgery details, the time from surgery to presentation, the intervention offered, and the outcomes. The data were analysed using the Statistical Package for Social Scientists (SPSS) version 24.0.

Results

Twelve patients aged between 24–54 years with a total of 19 ureteric injuries were managed. The injuries resulted from a hysterectomy in 10 cases (83.3%), and one each from emergency caesarean section and inguinal hernia repair with traction and transection injuries respectively (16.7%). Seven out of 12 cases were diagnosed 48 h after surgery. Bilateral injuries occurred in 7 cases (14/19 injuries). Intraoperative recognition was common in unilateral injuries and surgeries performed by specialist surgeons. Ureteroneocystostomy (14/19), uretero-ureterostomy (1/19), and open suture release were the management procedures performed as in the intervention.

Conclusion

Open hysterectomy (83.7%) was the most common procedure leading to iatrogenic ureteric injuries in this study. Intra-operative recognition occurred when trained specialist surgeons performed the surgery. Late presentation with more severe morbidity was found amongst non-specialist surgeons. Thus, improvement in training to allow intra-operative diagnosis should be encouraged in general practitioners to reduce morbidity and improve outcomes.

Urinoma formation following renal mass cryoablation treated with nephroureteral stent placement

Renal cryoablation (CA) has become an accepted treatment option for patients with small renal tumors and co-morbidities that make them less favorable for surgical intervention. Complications from renal CA have been previously reported and are generally associated with increasing size and central location of the tumor. Ureteral injury from renal CA, although rare, can be difficult to manage and may require complex surgeries in patients who are poor surgical candidates to begin with. We report a case of a renal mass CA complicated by proximal ureteral necrosis and transection, treated with multiple minimally invasive procedures ultimately resulting in successful bridging of the necrotic segment with nephroureteral stent and thus avoiding major surgery.

Spinal osteomyelitis and epidural abscess caused by ureterovertebral fistula: A case report

Background:

Ureteral fistulas are abnormal connections between the ureters and other organs. Maintaining a high index of suspicion is important because they can precipitate dangerous complications such as sepsis and renal failure. Connections to a vertebral body have only been documented in the setting of trauma. Here, we present a 67-year-old female with a ureterovertebral fistula extending into the L3 vertebral body.

Case Description:

A 67-year-old female with a history of endometrial adenocarcinoma underwent surgery and radiation therapy complicated by a right ureteral obstruction requiring stent placement. Five months later, she developed back pain and MR-documented L2-L4 level osteomyelitis/discitis with a psoas phlegmon/abscess, which required drainage. A fistula was later identified between the right ureter and the psoas phlegmon. Despite percutaneous nephrostomy placement and aggressive IV antibiotic treatment, she was readmitted for persistent signs of infection over the next few months during which time she was repeatedly and unsuccessfully treated with multiple antibiotics. Sixteen months following her original stent placement, she developed right leg weakness and urinary incontinence attributed to the MR-documented ureteropsoas fistula extending into the L3 vertebral body. Following a nephrectomy with ureteral ligation, an L3 anterior corpectomy with interbody fusion for discitis at both L2-L3 and L3-L4, and an L1-L5 posterolateral fusion, she was discharged to a rehabilitation center.

Conclusion:

In patients with recurrent sepsis, osteomyelitis/discitis, or psoas abscess of unknown origin or who have a significant history (e.g., pelvic malignancy, radiation, and instrumentation), it is important to consider urodynamic testing to look for a ureteral leak or fistula.

Perioperative serum creatinine change and delayed urologic complications following total laparoscopic hysterectomy for benign indications

Objectives:

The objective of the study was to investigate the association between perioperative serum creatinine change and delayed urologic complications following total laparoscopic hysterectomy (TLH) for benign indications.

Materials and Methods:

A total of 510 cases (503 cases without delayed urologic injuries and 7 cases with delayed urologic injuries) in which TLH was performed for benign indications were retrospectively reviewed. The patient characteristics and surgical outcomes were compared between patients with and without delayed urologic injuries. Laboratory markers (serum creatinine level at the preoperative and postoperative periods, white blood cell [WBC] ratio, and C-reactive protein [CRP] ratio) were analyzed to evaluate the diagnostic value of these laboratory markers.

Results:

There were no statistically significant differences in age, parity, body mass index, the presence of diabetes mellitus, preoperative GnRH agonist use, previous history of abdominal surgery or the performance of adnexal surgery, ASRM score, the presence of cul-de-sac obliteration, operative time, blood loss or weight of the resected specimens between the two groups. The proportions of patients who showed an elevated creatinine level on postoperative day 1 was significantly higher in the delayed urologic injury group (9.9% vs. 57%, P < 0.001). The combination of the three laboratory markers yielded an area under the ROC curve value of 0.75 (95% confidence interval, 0.491–1) in the detection of delayed urologic injuries.

Conclusion:

A change in the serum creatine level over baseline after surgery may indicate the possibility of urologic injuries. The combination of creatinine change and other factors, such as WBC or CRP would be helpful for detecting urologic complications after TLH.

Safety and Clinical Value of Prophylactic Ureteral Stenting Before Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Prophylactic ureteral stents (PUS) are typically placed prior to complex abdominal or pelvic operations at the surgeon's discretion to help facilitate detection of iatrogenic ureteral injury. However, its usefulness and safety in the setting of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) have not been examined. This study aims to evaluate the potential clinical value and risk profile of prophylactic ureteral stent placement prior to CRS-HIPEC.

METHODS

We performed a single-institutional retrospective analysis of 145 patients who underwent CRS-HIPEC from 2013 to 2021. Demographic and operative characteristics were compared between patients who underwent PUS placement and those that did not. Ureteral stent-related complications were evaluated.

RESULTS

Of the 145 patients included in the analysis, 124 underwent PUS placement. There were no significant differences in patient demographics, medical comorbidities, or tumor characteristics. Additionally, PUS placement did not significantly increase operative time and was not associated with increased pelvic organ resection. However, patients who underwent prophylactic ureteral stenting had significantly higher peritoneal carcinomatosis index score (15.1 vs 9.1, P=.002) and increased rate of ureteral complications (24.2% vs 14.3%, P=.04), which led to lengthened hospital stay (13.2 days vs 8.1 days, P= .03). Notably, the sole ureteral injury and three cases of hydronephrosis were seen in patients who underwent PUS.

CONCLUSION

Prophylactic ureteral stent placement in patients undergoing CRS-HIPEC may be useful, particularly in patients with predetermined extensive pelvic disease. However, PUS placement is not without potential morbidity and should be selectively considered in patients for whom benefits outweigh the risks.

Laparoscopic onlay lingual mucosal graft ureteroplasty combined with ureterovesical reimplantation for one-stage reconstruction of complex ureteral strictures: a case report

The treatment of ureteral stricture is a challenging task, especially when multiple strictures are present. Here, we report on a 63-year-old male patient diagnosed with hydronephrosis with left ureteral strictures who was admitted to our hospital. During treatment, a left percutaneous nephrostomy tube was inserted for hydronephrosis. Antegrade and retrograde pyelography were performed simultaneously. The results suggested there were 3 segment ureteral strictures in the left ureter: 2 located in the distal ureter and 1 in the proximal ureter. The treatment choices for multiple ureteral strictures are kidney autotransplantation or an ileal ureteral replacement (IUR), which are both morbid procedures and are technically challenging. With the excellent results of lingual mucosal graft (LMG) in ureteroplasty, this patient underwent a one-stage left ureter reconstruction with combined laparoscopic LMG ureteroplasty and ureterovesical reimplantation. However, disease of the oral mucosa and a reduced bladder volume caused by radio cystitis or chemical cystitis, may limit the use of this technique. Regular postoperative antegrade pyelography and the Whitaker test showed the unimpeded drainage of the left ureter. Based on the satisfactory outcome of this patient, combined laparoscopic LMG ureteroplasty and ureterovesical reimplantation for unilateral multiple ureteral strictures is a viable option that has fewer complications.

Single ileal segment in a cat-tail configuration for bilateral ureteric strictures

Introduction

Management of bilateral long length ureteric strictures is difficult with few options for reconstruction. In this report, we describe our experience with the use of a single, 15- 20 cm ileal segment for reconstruction of bilateral long length (involving more than 2/3^rd ureter) ureteric strictures.

Patients and Methods

A retrospective analysis of 5 cases operated between 2015 and 2020for bilateral long length ureteric strictures, using a single segment ileal interposition in a cat tail configuration was performed. We evaluated renal function, surgical success, incidence of urinary tract infection and complications of the procedure. Surgical success was defined as an asymptomatic patient with no hydronephrosis and/or prompt drainage of the kidney on radiological investigations.

Results

The average age of presentation was 42.8 ± 7.4 years (33-53) years). All the cases were secondary to a gynaecological intervention. The mean creatinine prior to surgery was 0.81 ± 0.36 mg % (range 0.5 -1.4 mg%). Mean duration of follow-up was 28.6 ± 20.6 months (Range 10 - 56 months). Mean hospital stay was 14.4 ± 3.36 days (range 12-20 days). Two patients developed ileus and one patient developed deep venous thrombosis in the post-operative period. One patient developed pyelonephritis within one month of surgery. There was no deterioration of renal function with the mean serum creatinine at last follow-up being 0.9 ± 0.36 mg% (range 0.6 - 1.5 mg%).

Conclusion

The use of an ileal segment in cat-tail configuration for bilateral simultaneous ileal replacement is a feasible and safe option. The medium-term result states that it is effective in the preservation of renal function and provides a good conduit for drainage.

Metal stent for the ureteral stricture after surgery and/or radiation treatment for malignancy

BACKGROUND

To assess the efficacy and safety of self-expanding metal ureteral stent for the stricture following surgery and/or radiation for malignancy.

METHODS

We performed 36 metal ureteral stent insertion procedures (32 patients) between May 2019 and June 2020. The main inclusion criterion was the patients with ureteral stricture due to surgery and/or radiation treatment for malignancy. The diagnosis of stricture was ascertained by history and radiographic imaging. The etiologies underlying the strictures were: surgery and/or radiation therapy for cervical and rectal cancer, surgery for ovarian cancer. The primary outcome was the stent patency rate, and the secondary outcomes were the postoperative complications and glomerular filtration rate (GFR). Stent patency was defined as stent in situ without evident migration, unanticipated stent exchange or recurrent ureteral obstruction. Cost analysis was calculated from stent cost, anesthesia cost and operating room fee.

RESULTS

The pre-metallic stent GFR was 22.53 ± 6.55 mL/min/1.73 m². Eight patients were on double-J stents before insertion of metallic stents. The total annual cost of per patient in our study was $10,600.2 US dollars (range $9394.4-$33,527.4 US dollars). During a median follow-up time of 16 months (range 8-21 months), 27 cases (31 sides, 84%) remained stent patency. Twelve patients died from their primary malignancy carrying a patency stent. Stent migration was observed in 4 patients within 10 months after insertion. Ectopic stents were endoscopically removed and replaced successfully. Three stents were occluded, and no encrustation was seen in our study. Three and four patients had postoperative fever and gross hematuria, respectively. Infection was observed in 2 cases, mandating antibiotics therapy. In addition, postoperative volume of hydronephrosis postoperatively was significantly reduced compared with preoperation (54.18 ± 15.42 vs 23.92 ± 8.3, P = 0.019). However, no statistically significant differences regarding GFR, creatinine levels, blood urea nitrogen and hemoglobin existed between preoperation and last follow-up.

CONCLUSIONS

The current study demonstrated that metal ureteral stent is effective and safe in the treatment of stricture following surgery and/or radiation therapy for malignant cancer. Patients hydronephrosis could be improved by the stent placement.

A Review on the Etiology, Prevention, and Management of Ureteral Injuries During Obstetric and Gynecologic Surgeries

Iatrogenic ureteral injuries are a rare but serious complication of some gynecological and obstetric procedures with both high morbidity and legal implications. The incidence varies widely depending on the type and extent of the surgeries with about 70% unrecognized intraoperatively. When recognized intraoperatively and promptly managed, the prognosis is good. Ureteral injuries recognized postoperatively come with dire consequences for the patients and are litigation prone. Due to the proximity of the lower half of the ureters to the pelvic organs, 50% of the cases of injuries to the ureter occur within the jurisdiction of gynecological and obstetric practice. A good knowledge of the etiology, predisposing factors, appropriate surgical skills, proper identification of the course and deviation of the ureters, and intraoperative recognition of inadvertent damage to the ureter and its vasculature is required by all obstetricians and gynecologists to reduce the incidence of ureteral injuries by at least 50%. This review aims to add to what is already known, particularly among obstetricians and gynecologists practicing in resource-constrained settings.

Randomized, Double-Blind, Controlled Study to Evaluate Safety and Pharmacokinetics of Single Ascending Doses of ASP5354, an Investigational Imaging Product, in Healthy Adult Volunteers

Intraoperative ureter identification helps reduce the risk of ureteral injury. Currently, no suitable agents for real‐time ureter visualization are approved. ASP5354 (TK‐1) is a novel indocyanine green derivative. In this first‐in‐human phase 1, double‐blind, sequential ascending‐dose study, urethral catheters were placed in 6 healthy volunteers who were randomized to single‐dose, intravenous ASP5354 0.1 mg (n = 4) or placebo (n = 2). Sequential dose escalations to 0.5‐, 2‐, 8‐, and 24‐mg ASP5354 in new cohorts were contingent upon Dose‐Escalation Committee approval after review of pharmacokinetic (PK) and safety data. Blood and urine samples were collected over 24 hours following dose administration. Objectives were to assess the safety/tolerability and PK of ASP5354. Treatment‐emergent adverse events (TEAEs) were reported in 3 (15%) and 2 (20%) participants in the ASP5354 and placebo groups, respectively. In the former, there were 6 TEAEs (5/6 grade 1‐2). One ASP5354 participant experienced grade 3 pyelonephritis, attributed to the catheter. No TEAEs were related to ASP5354. Mean plasma terminal elimination half‐life ranged from 2.1 to 3.6 hours, with near complete urinary excretion of unchanged ASP5354 within 24 hours after administration. Linear and dose‐proportional PK were observed. These results support further evaluation of ASP5354 at doses up to 24 mg for intraoperative near‐infrared fluorescence ureter visualization.

Urinary Tract Injury During Gynecologic Surgery: Prevention, Recognition, and Management

Lower urinary tract (LUT) injuries may occur during gynecologic surgery due to the close proximity of pelvic organs and vary by procedure, surgical indication, and route. Prevention of LUT injury should be a primary goal of gynecologic surgery. LUT injuries are more common in patients with aberrant anatomy, during difficult procedures, and with surgeons with less experience. Immediate recognition and management of LUT injuries is optimal, although delayed postoperative diagnoses may be unavoidable. Surgical management is based on the size and location of injury and should be performed by an experienced surgeon with thorough knowledge of pelvic anatomy, surgical technique, and postoperative management.

Ureteral stents cannot decrease the incidence of ureteroileal anastomotic stricture and leakage: A systematic review and meta-analysis

BACKGROUND

The ileal conduit and ileal orthotopic neobladder were the most popular methods for urinary diversion following radical cystectomy. Stenting the anastomosis of ileo-ureter or ureter-neobladder was a common practice. However, it is still controversial if ureteral stents could prevent complications such as ureteroileal anastomosis stricture (UIAS) and ureteroileal anastomosis leakage (UIAL) after ureteral anastomosis.

OBJECTIVES

This study aims to investigate the role of the ureteral stent in preventing UIAS and UIAL.

DATA SOURCES

We systematically searched the related studies in PubMed, Embase, and Cochrane Library up to June 2020.

STUDY ELIGIBILITY CRITERIA

Cohort studies that identified the use of stent and the incidence of UIAS or UIAL were recorded.

DATA SYNTHESIS

Comparative meta-analysis was conducted on four cohort studies for comparison of UIAS and UIAL between the stented and nonstented groups. Besides, eleven studies which reported the events of UIAS and UIAL were used for meta-analysis of single proportion.

RESULTS

A total of 11 studies were qualified for analysis. Comparative meta-analysis identified that the incidence of UIAS was higher in the stented group than that in the nonstented group, but this did not reach a significant difference (odds ratio [OR]: 1.64; 95% confidence interval [CI]: 0.88-3.05; P = 0.12). Besides, there was no difference in the incidences of UIAL between the stented and the nonstented groups. On meta-analysis of single proportion, the incidence of UIAS was 7% (95% CI: 3%-10%) in the stented group and 3% (95% CI: 1%-6%) in the nonstented group. The UIAL rate was 1% (95% CI, 0%-4%) in stented patients and 2% (95% CI, 1%-4%) in nonstented patients.

CONCLUSION

Stenting the ureteroileal anastomosis resulted in a higher incidence of UIAS. There is no evidence to support ureteral stents could prevent the occurrence of UIAL after urinary diversion.

Hospital Ownership, Geographic Region, Patient Age, Comorbidities and Insurance Status Appear to Influence Patient Selection Robotic-Assisted Ureteral Reimplantation for Benign Disease: A Population-Based Analysis

BACKGROUND

Robotic-assisted ureteral reimplantation (RAUR) is a relatively new minimally-invasive surgery. As such, research is lacking, and the largest adult cohort studies include fewer than 30 patients. Our aim was to be the first population-based study to report on national utilization trends, factors associated with patient selection, inpatient outcomes, and the relative cost of RAUR for adults with benign ureteral disease (BUD).

MATERIALS AND METHODS

The National Inpatient Sample (2010-2015) was queried to identify all elective, non-transplant related, open and robotic-assisted reimplants for adult BUD. Survey-weighted logistic regression using Akaike Information Criterion identified patient-/hospital-level factors associated with robotic surgery. Survey-weighted regression models examined the association of robotic surgery with outcomes and charges.

RESULTS

A weighted-total of 9,088 cases were included: 1,688 (18.6%) robotic-assisted and 7,400 (81.4%) open. There were significantly increased odds of RAUR across consecutive years (OR 3.0, p < 0.001) and among patients operated on at private for-profit hospitals (OR 2.1; p = 0.01), but significantly decreased odds among older patients (OR 0.98, p < 0.001), those with Medicaid (OR 0.5, p = 0.02), those with 2+ comorbidities (OR 0.6, p = 0.009) and those operated on in Western (OR 0.5; p = 0.005) states. RAUR was significantly associated with a reduced length-of-stay (IRR: 0.60; p <0.001), decreased odds of blood transfusion (OR: 0.40; p <0.001) and a lower mean ratio of total hospital charges (Ratio: 0.71; p = 0.006).

CONCLUSIONS

This is the first population-based study to report on the utilization and clinical benefits of RAUR for adult BUD. Open reimplantation remains the most common surgical technique utilized, despite the potential benefits of RAUR. Future research is needed to explore the mechanisms behind patient-/hospital-level factors and surgical selection. Work to investigate potential barriers in access to robotic surgery can help us provide equitable care across patient populations.

Postoperative complications of colorectal cancer

Colorectal cancer is the third most common cancer, and surgery is the most common treatment. Several surgical options are available, but each is associated with a range of potential complications. The timely and efficient identification of these complications is vital for effective clinical management of these patients in order to minimise their morbidity and mortality. This review aims to describe the range of commonly performed surgical treatments for colorectal surgery. In addition, frequent post-surgical complications are explored with investigative options explained and illustrated.

Feasibility of ureter delineation and dose recording in the assessment of ureteric stenosis during brachytherapy for cervical cancer

INTRODUCTION

Ureteric stenosis is the commonest complication to affect the ureter after radiotherapy for cervical cancer; despite this ureters are not contoured as organs at risk and limited dosimetric data exist for them.

METHODS/MATERIALS

Bilateral ureters were retrospectively delineated on brachytherapy planning imaging for patients treated for cervical cancer between 2014 and 2019. Ureteric stenosis toxicity data and D2cc, D1cc, D0.1cc of the right and left ureter were collated. Ureter V80, V100, V120, and V150 were also analyzed. Univariate analysis was performed to identify predictors of high ureter dose and ureteric stenosis.

RESULTS

95 patients were identified and 190 ureters contoured on brachytherapy planning imaging, with a median follow-up duration of 24 months (IQR23.7). 4.2% (4) of patients had grade 3/4 ureteric stenosis. Mean ureter D0.1cc, D1.0cc and D2.0cc on the right were 80.4Gy (±28.9), 56.2Gy (±7.2) and 52.8Gy (±7.6), and on the left were 75.6Gy (±14.6), 54.3Gy (±5.5) and 52.7Gy (±5.5) respectively. Significantly higher ureter doses were present in patients with baseline hydronephrosis (p < 0.002) and interstitial needle use (p = 0.047). Ureters affected by ureteric stenosis received D0.1cc doses between 60-98Gy. 10-14% received point doses in excess of 150% of the prescribed dose (7Gy) with no resulting ureteric stenosis. No significant difference in D0.1cc was found in patients with or without ureteric stenosis.

CONCLUSIONS

It is feasible to accurately contour ureters on brachytherapy planning imaging. Baseline hydronephrosis and interstitial needle use contribute to higher ureter doses. No association between dose and ureteric stenosis was found.

Etiology and Ureteral Reconstruction Strategy for Iatrogenic Ureteral Injuries: A Retrospective Single-Center Experience

OBJECTIVE

To analyze the etiology, characteristics, and ureteral reconstruction strategies of iatrogenic ureteric injuries in a high-volume center.

METHODS

Between September 2010 and August 2019, we retrospectively collected patients who underwent ureteral reconstruction due to iatrogenic ureteric injuries. Patient profiles, laboratory data, imaging studies, perioperative data, and complications were recorded.

RESULTS

Sixty-eight patients were enrolled in this study. The upper, middle, and lower thirds of the ureter were affected in 30, 2, and 36 cases, respectively. Of the 68 ureteric injuries, 69.1% occurred during urological procedures, followed by gynecological procedures, general surgery, radiotherapy, and orthopedic surgery. The majority of urological injuries (41, 87.2%) occurred due to stone removal. There was a significant difference in the age, sex, and location of ureteric injuries between the urological and nonurological groups. The median follow-up time was 17.9 months. The overall symptom remission rate was 91.2% and ranged from 87.5 to 100% for different reconstructive surgeries.

CONCLUSIONS

Urological procedures were the most common cause of iatrogenic ureteric injury; thus, extra care should be taken. Timely detection and appropriate treatment of the ureteric injuries are necessary. Treatment strategies should be depended on the location and length of injury.

Intraoperative ureter identification with a novel fluorescent catheter

Iatrogenic ureteral injuries (IUI) occur in 0.5–1.3% of cases during abdominal surgery. If not recognized intraoperatively, IUI increase morbidity/mortality. A universally accepted method to prevent IUI is lacking. Near-infrared fluorescent imaging (NIRF), penetrating deeper than normal light within the tissue, might be useful, therefore ureter visualization combining NIRF with special dyes (i.e. IRDye 800BK) is promising. Aim of this work is to evaluate the detection of ureters using stents coated with a novel biocompatible fluorescent material (NICE: near-infrared coating of equipment), during laparoscopy. female pigs underwent placement of NICE-coated stents (NS). NIRF was performed, and fluorescence intensity (FI) was computed. Successively, 0.15 mg/kg of IRDye 800BK was administered intravenously, and FI was computed at different timepoints. Ureter visualization using NS only was further assessed in a human cadaver. Both methods allowed in vivo ureter visualization, with equal FI. However, NS were constantly visible whereas IRDye 800BK allowed visualization exclusively during the ureteral peristaltic phases. In the human cadaver, NS provided excellent ureter visualization in its natural anatomical position. NS provided continuous ureteral visualization with similar FI as the IRDye 800BK, which exclusively allowed intermittent visualization, dependent on ureteral peristalsis. NS might prove useful to visualize ureters intraoperatively, potentially preventing IUI.

Experience managing distal ureteral strictures with Boari flap-psoas hitch and comparison of open and laparoscopic procedures

Background

To summarize our experience with the Boari flap-psoas hitch and compare the indications, perioperative data and outcomes between open and laparoscopic procedures.

Methods

This study retrospectively reviewed 35 patients with complex distal ureteral stricture between January 2015 and April 2019. All patients were treated with Boari flap-psoas hitch by either an open or a laparoscopic procedure. Selection criteria were based on the etiology, comorbidities, medical history, and patient preference.

Results

All surgeries were performed successfully. The median operation time was 201 min (range, 120 to 300 min), and the median estimated blood loss was 50 mL (range, 20 to 400 mL). The median postoperative hospitalization was 9 days (range, 3 to 46 days). Nineteen patients were treated by the open procedure, and 16 were treated by the transperitoneal laparoscopic procedure. The surgical indication of open surgery was broader than that for laparoscopic surgery. For patients experiencing iatrogenic injury and ureterovesical reimplantation failure, no significant differences in sex, laterality, operative time, ASA score or postoperative hospitalization stay were observed between the two groups. The median estimated blood loss was lower in the laparoscopic group than in the open group (P=0.047). Patients in the open group had more surgical complications than patients in the laparoscopic group (P=0.049). The postoperative follow-up showed the radiological resolution of hydronephrosis in 33 patients.

Conclusions

With the appropriate surgical considerations, Boari flap-psoas hitch is a valid method to bridge distal ureteral defects. For select patients, laparoscopic surgery had advantages being a minimal invasive surgery with less estimated blood loss and fewer surgical complications.

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.

Does Timing of Diagnosis and Management of Iatrogenic Ureter Injuries Affect Outcomes? Experience From a Tertiary Center

OBJECTIVE

To report urologic outcomes from a series of IUIs, sustained during nonurologic procedures, with regards to timing of diagnosis and management of the injury. Iatrogenic ureteral injury (IUI) is the most common mechanism of ureteral trauma. Injuries can be intraoperatively diagnosed (IOD) or postoperatively diagnosed (POD).

METHODS

This was a retrospective chart review of adult patients at a single institution who sustained an IUI from a non-urologic procedure between 2008 and 2019. Primary outcome was tube-dependence (ureter stent or nephrostomy tube) and nephrectomy rates at last follow-up. Secondary outcome was the number of additional urologic procedures required to manage subsequent complications of IUI.

RESULTS

There were 30 patients with IOD and 57 patients with POD. In the IOD group, at mean follow up of 6.3 months, 4 patients (14.3%) were tube dependent. In the POD group, at mean follow up of 13.1 months, 5 patients (10%) were tube dependent (P = .570). Rate of nephrectomy was higher in POD group compared to IOD, but the difference was not statistically significant (12.3% vs 6% respectively, P = .414). Additionally, in the POD group, 56% and 19.3% required a secondary and tertiary procedure to manage IUI complications, respectively. These rates were 16.7% (P < .001) and 3.3% (P = .002) in the IOD group.

CONCLUSION

Delayed diagnosis of IUI was significantly associated with increased number of procedures needed to manage the injury. The rate of nephrectomy and tube dependence in this group was higher but not statistically significant. Delayed diagnosis of IUI is associated with higher treatment burden.

[Research progress of ureteral injury in oblique lumbar interbody fusion]

Objective

To summarize the research progress of ureteral injury in oblique lumbar interbody fusion (OLIF).

Methods

The literature about incidence, clinical manifestations, diagnosis, and treatment of ureteral injury complications in OLIF was reviewed.

Results

OLIF surgery poses a risk of ureteral injury because its surgical approach is anatomically adjacent to the left ureter. Ureteral injuries in OLIF are often insidious and have no specific clinical manifestations. CT urography is a common diagnostic method. The treatment of ureteral injury depends on a variety of factors such as the time of diagnosis, the location and degree of injury, and the treatment methods range from endoscopic treatment to replacement reconstruction.

Conclusion

Surgeons should pay attention not to damage the ureter and find the abnormality in time during OLIF. High vigilance of abnormalities is conducive to the early diagnosis of ureteral injury. Furthermore, it is important to be familiar with ureter anatomy and gentle operation to prevent ureteral injury.

Laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures: our experience and strategy

PURPOSE

To present our experience of laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures and summarize our treatment strategies for these challenging scenarios.

METHODS

From March 2018 to January 2020, 53 patients with long proximal/middle ureteral strictures (2-6 cm) who underwent laparoscopic or robotic onlay flap/graft ureteroplasty were retrospectively enrolled. Different reconstruction techniques were chosen based on our management strategy: pelvic flap (PF) was the first choice for proximal stricture if pelvic tissue was sufficient for repair, while appendiceal flap (AF) was preferred over oral mucosa graft for both proximal and middle strictures.

RESULTS

A total of 28 PFs, 9 AFs and 16 lingual mucosa grafts (LMGs) onlay ureteroplasty were performed successfully, with 33 laparoscopic procedures and 20 robotic procedures being undertaken. No intraoperative complications or conversion occurred. The median stricture length was 4 cm (range 2-6 cm). Compared with laparoscopic procedures, robotic procedures showed significantly shorter operative time (P = 0.008), shorter postoperative hospital stay (P = 0.011) but higher hospital cost (P < 0.001). At a mean follow-up of 12.8 months, the overall success rate was 94.3%. There was no difference in postoperative complications or the success rate between the approaches.

CONCLUSION

Laparoscopic and robotic onlay flap/graft ureteroplasty can be safe and feasible to repair long proximal/middle ureteral strictures while robotic procedures showed higher efficiency, faster recovery but higher cost. Our algorithmic strategies may provide beneficial references for their standardization and dissemination into clinical care.

Complications Associated With Ureteroscopic Management of Upper Tract Urothelial Carcinoma

OBJECTIVES

To compile and examine safety data from clinical studies of endoscopic management of patients with low-grade upper tract urothelial carcinoma (UTUC) to identify rates and factors associated with reported complications.

METHODS

Ovid Medline and Ovid Medline Daily (with Embase as secondary search) including citations from 1946-2018 were queried using the following terms: ureteroscopy, ureter, catheter, endoscopy, complication, adverse events, morbidity, ablation, laser, upper tract urothelial carcinoma, ureteral stricture, ureteral stenosis, and ureteral injury. Abstracts were reviewed for relevance; diagnostic studies, case studies, and reviews were excluded.

RESULTS

Thirty-eight publications (7 prospective, 31 retrospective) representing >1100 patients were identified. Ureteral stricture was the most frequently reported complication (studies; rates) (26/38; 0-27%), with incidence associated with number of procedures and treatment method. Bleeding, infection, and fever were most common with adjuvant treatment (BCG or mitomycin). Serious and fatal complications were rare.

CONCLUSIONS

Ureteral stricture is the most frequent complication of endoscopic UTUC management but can be managed successfully in most cases. Most complications were minor. Although additional prospective studies are needed, these results support the safety of ureteroscopic management of UTUC in appropriately selected patients.

Simultaneous multipurpose fluorescence imaging with IRDye® 800BK during laparoscopic surgery

BACKGROUND

IRDye® 800BK is a fluorophore, currently undergoing clinical translation, which has both biliary and renal clearance. To date, there is no description of a fluorophore, which can be simultaneously used for non-invasive, near-infrared fluorescence-based (NIRF) visualization of different structures and perfusion evaluation. The purpose of this study was to evaluate IRDye® 800BK for the simultaneous assessment of bowel perfusion, lymphography, ureter and bile duct delineation.

METHODS

Six pigs received a 0.15 mg/kg dye as a single bolus intravenous injection (IV). With the FLER (fluorescence-based enhanced reality) software, fluorescence intensity (FI) of 5 regions of interest (ROI) in an ischemic bowel loop was measured along with the time to reach the FI peak, and capillary lactate was measured from the same ROI, followed by the assessment of the ureters and bile ducts for a maximal duration of 180 min after dye administration. In 3 animals, the procedure was initiated via gastroscopic injection of a 0.6 mg (1 mg/mL) dye in the gastric submucosa followed by lymphography in a NIRF setting.

RESULTS

Excellent visualization of the ureters and bowel perfusion was obtained under NIRF imaging. Additionally, the bile duct and gastric lymph ducts and nodes were visualized. A positive correlation was found between the time to peak FI in the ischemic bowel loop and the corresponding capillary lactate levels (rho 0.59, p < 0.001).

CONCLUSION

In this study, we successfully demonstrated the simultaneous multipurpose IRDye® 800BK applicability during laparoscopic surgery. This fluorophore has the potential to become a powerful and versatile image-guided surgery tool.

[Application of indocyanine green in complex upper urinary tract repair surgery]

OBJECTIVE

To evaluate the clinical application of indocyanine green (ICG) visualization by near infrared fluorescence laparoscopy (NIFL) in complex upper urinary tract reconstructions surgery.

METHODS

This was a retrospective study of 7 patients who underwent complex surgeries of ureteral reconstruction between May 2019 and October 2019. There were 6 males and 1 female with the age ranging from 24 to 57 years (median age was 47 years). There were 5 cases of right ureteral strictures, of which 3 were proximal ureteral strictures and 2 were multiple and long ureteral strictures caused by radiotherapy. There were 2 cases of left ureteral strictures, of which 1 was ureteropelvic junction stricture and 1 was proximal ureteral stricture. There were 4 cases of secondary repair operations and 3 cases of primary operations. All the patients underwent laparoscopic surgery via the abdominal approach. ICG was injected into the ureter via nephrostomy tube during the operations, and the diseased ureter was identified by NIFL. Among the patients, 2 cases underwent IUPU (Institute of Urology, Peking University) modified ileal ureter replacement, 2 cases underwent ureteroureterostomy, 2 cases underwent appendiceal onlay flap ureteroplasty, and 1 case underwent lingual mucosa onlay flap ureteroplasty.

RESULTS

All the operations were successfully completed without open conversion. The localization and separation of ureteral lesions were completed under NIFL. The mean operative time was 187 (135-300) min. The duration of ureteral separation was 15-27 min, and the mean time was 18 min. The estimated blood loss was 15-200 mL, the mean estimated blood loss was 50 mL. There was one patient with ileal ureter replacement who had fever after surgery and responded well to antibiotics. The mean (range) length of postoperative hospital stay was 7 (6-10) days and no postoperative complications of a high grade (Clavien-Dindo Ⅲ and Ⅳ) occurred. Up to now, the mean follow-up duration was 9 (6-11) months, and no indocyanine green toxicity occurred. All D-J stents and nephrostomy were removed successfully 2 months after the operation. Ultrasound showed no obvious hydronephrosis, and CTU (computed tomography urography) showed that the urinary tract was unobstructed and the kidney function was normal.

CONCLUSION

The application of ICG in the complex upper urinary tract reconstructive surgery is a safe and easy method to help surgeon to identify the ureter which may reduce the risk of iatrogenic damage and protect the ureteral blood supply.

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

BACKGROUND

Iatrogenic ureteral injuries are devastating complications potentially resulting in irreversible impairment of renal function and/or infectious sequelae. Only few data are available on the management of such injuries to the abdominal ureter.

OBJECTIVE

To report the etiology, perioperative outcomes, and treatment failure rate of different reconstructive surgical interventions for iatrogenic injuries to the abdominal ureter in a contemporary case series.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed consecutive patients who underwent reconstructive surgery for iatrogenic injuries to the abdominal ureter at our academic centers between July 2013 and April 2019. All interventions were performed via either an open or a robot-assisted approach by a single expert surgeon.

SURGICAL PROCEDURE

Different surgical reconstructive procedures, such as Boari bladder flap, ureteroureterostomy, ileal replacement, and pyeloureteroplasty, have been adopted.

MEASUREMENTS

Outcome measures were the etiology of iatrogenic injuries, rate of postoperative complications, and rate of treatment failure, defined as upper urinary tract obstruction requiring permanent urinary drainage.

RESULTS AND LIMITATIONS

Nineteen patients were included. Injuries were consequent to endourological procedures in nine (47.4%), gynecological procedures in two (10.5%), colonic surgery in two (10.5%), vascular surgery in two (10.5%), and other surgeries in four (21.1%) cases. Boari bladder flap was performed in 12 (63.2%), ureteroureterostomy in two (10.5%), ileal substitution in two (10.5%), and pyeloureteroplasty in three (15.8%) cases. Only four (21.1%) procedures were performed robotically. Major postoperative complications were recorded in three (15.8%) patients. After a median follow-up of 16 (interquartile range 12-24) mo, treatment failure was observed in two (15.8%) cases. We accept the limitations of a small retrospective single-surgeon series with preference-based management choice.

CONCLUSIONS

In our series, endourological procedures were the most frequent cause of iatrogenic injuries to the abdominal ureter requiring reconstructive surgery. A Boari bladder flap was the preferred option to bridge extensive ureteral defects. Despite the complexity of such procedures, major postoperative complications were infrequent and treatment failure rate was low.

PATIENT SUMMARY

We report on a contemporary series of patients with disparate iatrogenic injuries to the abdominal ureter requiring complex reconstructive surgery. Despite the difficulty of such procedures, we found that major postoperative complications were infrequent and treatment failure rate was low.

A Near-Infrared Fluorescent Probe Coated with β-Cyclodextrin Molecules for Real-Time Imaging-Guided Intraoperative Ureteral Identification and Diagnosis

Although iatrogenic ureteral injury and its lack of recognition due to ureteral invisibility are serious incidents in open and laparoscopic abdominal surgeries, there are currently no safe and effective methods for intraoperative ureteral identification (IUI) and diagnosis (IUD). In this study, I designed and chemically synthesized a near-infrared fluorescence (NIRF) imaging probe (CD-NIR-1) and evaluated its clearance and ability for IUI and IUD in animal models. CD-NIR-1 demonstrated high specificity and ultrarapid clearance by rat kidneys to the urinary bladder following intravenous administration of a single dose (25 nmol/kg of body weight), with 96% of the dose ultimately excreted at the first urination with no chemical modification. Furthermore, urine containing CD-NIR-1 in ureters showed strong NIRF, thereby enabling IUI and IUD via NIRF imaging. These results demonstrated the efficacy of CD-NIR-1 for clinical use.