Iatrogenic ureteric injury: common medicolegal pitfalls

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.

Application of Nonvascular Interventional Radiology Procedures in the Treatment of Iatrogenic Ureteral Injuries

Introduction. He most common ureteral injuries are iatrogenic injuries. Diagnosis of ureteral lesions includes ultrasound, computer tomography, intravenous urography, anterograde and retrograde ureterography. For a definitive diagnosis it is necessary to determine the existence of the extralumination of contrast media from the ureter. Minor ureteral injuries can be treated with nonvascular interventional radiology procedures.

Case presentation. We have presented two patients with iatrogenic ureteral injuries. Injury in the first patient occurred at the sigmoid colon resection and partial resection of the bladder, whereas in the second patient the lesion was formed as a result of cesarean section. In both patients, there was a history of previously conducted interventions, clinical picture included fever and pain, a diagnosis was made by intravenous and anterograde urography. Patients were treated with interventional radiology procedures and they have been definitely cured.

Conclusion. Methods of nonvascular interventional radiology can be successfully applied in the treatment of minor iatrogenic ureteral injuries.

Early detection and endoscopic management of post cesarean section ureterovaginal fistula: a case series study

INTRODUCTION AND HYPOTHESIS

The aim of this study was to evaluate the endourologic management of post-cesarean section ureterovaginal fistula.

METHODS

Between February 2016 and March 2019, eight patients presented because of vaginal leakage after cesarean section. All presented within 15 days from their original operations. Three of the patients had a vague lower abdominal pain, and five had ipsilateral flank pain; all had vaginal leakage. Physical examination, ultrasonography, and IVP were done to confirm the diagnosis. Ureteroscopy was the first treatment attempt, using two or three guide wires to find the proximal part of the ureter and insert a JJ stent.

RESULTS

In six patients, we could insert guide wires, find the proximal part of the ureter, and finally insert a JJ stent. In two patients, we could not even pass a guide wire, so we changed the position, and ureteral reimplantation was done. The stents were removed after 6 weeks, and after 3 months an IVP was planned again that showed all fistulae had resolved with no evidence of ureteral stricture.

CONCLUSION

In cases of ureterovaginal fistula after cesarean section, ultrasonography and IVP with lateral view x-ray films may confirm the diagnosis. The traditional treatment for ureterovaginal fistula is ureteral reimplantation, but endoscopic management may be a viable technique with less invasiveness and faster results and recovery. Thus, retrograde stenting can be accomplished in selected patients with ureterovaginal fistula after cesarean section and may eliminate the need for reimplantation of the ureter.

[Management of ureteral injuries]

Ureteral injuries account for less than 3% of genitourinary injuries. Most of them are caused iatrogenically during abdominal surgery. The symptoms are often non-specific and do not aid in diagnosis. The later the injury is detected, the more often complications occur. Therefore, in such situations it is important to consider the possibility of ureteral injury and initiate further diagnostic steps as soon as possible. A variety of diagnostic tests are available. In addition to the direct inspection of the ureters and retrograde ureteropyelography, computed tomography (CT) urography is routinely used. Based on the time of diagnosis as well as the extent and the localization of the injury, the further procedure can be determined. For minor injuries, the insertion of a ureteral splint is usually the treatment of choice. In the case of higher grade damage, operative reconstruction by one of several possible surgical procedures is indicated.

Management of iatrogenic ureteric injury with retrograde ureteric stenting: an analysis of factors affecting technical success and long-term outcome

Background Iatrogenic ureteral injuries arise as serious complication following obstetrics, gynecological, general, and urological surgery with incidence in the range of 0.5-10%. Retrograde placement of double-J ureteric stent is a possible treatment option if the injury is not recognized at the time of surgery. Purpose To assess technical success and long-term outcome associated with retrograde ureteric stent insertion for iatrogenic ureteric injury. Material and Methods Between 1999 and 2011, 26 patients with initially unrecognized iatrogenic ureteric injury underwent initial management with retrograde ureteric stenting. Full case-notes were available for review in 25 patients. Results The mean interval from injury to attempted stenting was 19.4 days. Successful retrograde ureteric stenting was achieved in 21/25 patients (81%). Retrograde stenting failed in four patients, and nephrostomy followed by alternative procedures were performed instead. At a median follow-up interval of 9.7 months, normal anatomy was demonstrated on 12/21 patients (57%) and a stricture was observed in 6/21 patients (28%) with three requiring surgical intervention. Conclusion Retrograde stenting is a safe and efficient initial management in patients with iatrogenic ureteric injuries.

Iatrogenic urinary tract injuries: etiology, diagnosis, and management

Iatrogenic injury to the urinary tract, including the kidneys, ureters, bladder, and urethra, is a potential complication of surgical procedures performed in or around the retroperitoneal abdominal space or pelvis. While both diagnostic and interventional radiologists often play a central and decisive role in the identification and initial management of a variety of iatrogenic injuries, discussions of these injuries are often directed toward specialists such as urologists, obstetricians, gynecologists, and general surgeons whose procedures are most often implicated in iatrogenic urinary tract injuries. Interventional radiologic procedures can also be a source of an iatrogenic urinary tract injury. This review describes the clinical presentation, risk factors, imaging findings, and management of iatrogenic renal vascular and urinary tract injuries, as well as the radiologist's role in the diagnosis, treatment, and cause of these injuries.

Iatrogenic ureteric injuries following abdomino-pelvic operations: a 10-year tertiary care hospital experience in Tanzania

Background

Iatrogenic ureteric injuries are rare complications of abdomino-pelvic surgery but associated with high morbidity and even mortality. There is paucity of data regarding iatrogenic ureteric injuries in Tanzania and Bugando Medical Centre in particular. This study describes our experience in the management and outcome of ureteric injuries following abdomino-pelvic operations outlining the causes, clinical presentation and outcome of management of this condition in our local setting.

Methods

This was a retrospective descriptive study of patients with iatrogenic ureteric injuries following abdomino-pelvic operations that were managed in Bugando Medical Centre between July 2004 and June 2014.

Results

A total of 164 patients (M: F = 1: 1.6) were studied. Of these, 154 (93.9%) were referred to Bugando Medical Centre having had their initial surgeries performed at other hospitals, whereas 10 (6.1%) patients sustained ureteric injuries during abdomino-pelvic surgery at Bugando Medical Centre. The median age at presentation was 36 years. The most common cause of iatrogenic ureteric injuries was total abdominal hysterectomy occurring in 69.2% of cases. The distal ureter was more frequently injured in 75.6% of cases. Suture ligation was the commonest type of injury accounting for 36.6% of patients. One hundred and sixteen (70.7%) patients had delayed diagnosis but underwent immediate repair. Ureteroneocystostomy was the most frequent reconstructive surgery performed in 58.0% of cases. Of the 164 patients, 152 (92.7%) were treated successfully. Twelve (7.3%) patients died in hospital. The main predictors of deaths were delayed presentation, deranged renal function tests on admission, missed ureteric injuries and surgical site infections (P < 0.001). The overall median length of hospital stay was 12 days. Follow up of patients was generally poor as more than half of patients were lost to follow up.

Conclusion

Total abdominal hysterectomy still accounts for most cases of iatrogenic ureteric injuries in our environment. Meticulous surgical technique as well as identification of the course of the ureter and associated anatomic locations where injury is most likely to occur is important to decrease the risk of ureteric injury. Timely recognition of ureteric injury and its management is associated with good outcome.

The prophylactic use of a ureteral stent in laparoscopic colorectal surgery

BACKGROUND AND AIMS

The insertion of prophylactic ureteral stents in traditional colorectal surgery has been debated for a long time. The aim of this study is to investigate the results of ureteric stent insertion in elective laparoscopic colorectal surgery in terms of complications and costs.

MATERIAL AND METHODS

From June 2009 to June 2011 one or two prophylactic ureteral stents were placed in all patients undergoing elective laparoscopic resection of their colon or rectum.

RESULTS

A total of 89 patients took part in this study, 61% had a benign disease and 39% malignant. The mean time for ureteral stent insertion was 16 min if one-sided and 21 min if bilateral. Incidental findings were found in the bladder in four (4.5%) patients. In all, 13 (26%) male patients had a benign prostatic adenoma, and 3 (6%) male patients had a significant stenosis of the urethral meatus and required bouginage. Complications due to ureteral stent insertion were transient hematuria in 11 (12.3%) cases, postoperative urinary tract infections in 2 (2.2%) cases, and hydronephrosis in 2 (2.2%) cases. One patient suffered an accidental damage of the right ureter despite the presence of a stent; this was recognized intraoperatively. The total cost for a one-sided ureteral stent insertion is calculated at around €360, and for a bilateral ureteral stent insertion, it is around €410.

CONCLUSIONS

The prophylactic use of a ureteral stent in laparoscopic colorectal surgery leads to minor complications and may be cost-effective.

A case of ureteric injury postappendectomy presenting as ureterocutaneous fistula

Ureteric injuries, although uncommon, are a potential complication in pelvic and gynaecological surgeries and can have serious implications. The risk is mainly related to the complexity of the surgical procedure and the presence of eventual periureteric pathology. Ureteric injury during appendectomy is rare. The ureter may be damaged by laceration, being crushed, or thermal or ischaemic injury. The retrocaecal appendix, due to its proximity to the ureter, may also get accidentally injured. The most effective measure to prevent iatrogenic injury is to have a sound knowledge of abdominal and pelvic anatomy, meticulous surgical technique and an identification of factors that increase the likelihood of developing such complications.

Intraoperative ureteric injuries and litigation in the NHS

Objectives:

The objective of this article is to analyse medicolegal claims arising from intraoperative ureteric injuries across all surgical specialties and the consequent financial costs to the National Health Service (NHS) in the United Kingdom.

Materials and methods:

We conducted a retrospective review of medicolegal claims reported to the NHS Legal Authority between April 2007 and March 2013.

Results:

A total of 191 claims were reported with 122 claims being resolved at the time of data collation. Of these, 97 were successful with a total of £9.66 million paid by the NHS in indemnity, averaging £99,611 per successful claim. There was an increasing number of claims filed over the study years and a slight decrease in the average pay-out per successful claim. Gynaecology and obstetrics accounted for over two-thirds of successful claims, with the remainder being divided equally among urology and colorectal surgery. However, claims arising from colorectal surgery had higher indemnity pay-outs on average.

Conclusion:

This is the first study analysing medicolegal claims and cost burden pertaining to ureteric injuries across different specialties. The findings concur with clinical studies which indicate gynaecological procedures and other pelvic (e.g. colorectal) procedures are at increased risk of causing ureteric injury.

Near-infrared fluorescence imaging of both colorectal cancer and ureters using a low-dose integrin targeted probe

BACKGROUND

Irradical tumor resections and iatrogenic ureteral injury remain a significant problem during lower abdominal surgery. The aim of the current study was to intraoperatively identify both colorectal tumors and ureters in subcutaneous and orthotopic animal models using cRGD-ZW800-1 and near-infrared (NIR) fluorescence.

METHODS

The zwitterionic fluorophore ZW800-1 was conjugated to the tumor specific peptide cRGD (targeting integrins) and to the a-specific peptide cRAD. One nmol cRGD-ZW800-1, cRAD-ZW800-1, or ZW800-1 alone was injected in mice bearing subcutaneous HT-29 human colorectal tumors. Subsequently, cRGD-ZW800-1 was injected at dosages of 0.25 and 1 nmol in mice bearing orthotopic HT-29 tumors transfected with luciferase2. In vivo biodistribution and ureteral visualization were investigated in rats. Fluorescence was measured intraoperatively at several time points after probe administration using the FLARE imaging system.

RESULTS

Both subcutaneous and orthotopic tumors could be clearly identified using cRGD-ZW800-1. A significantly higher signal-to-background ratio was observed in mice injected with cRGD-ZW800-1 (2.42 ± 0.77) compared with mice injected with cRAD-ZW800-1 or ZW800-1 alone (1.21 ± 0.19 and 1.34 ± 0.19, respectively) when measured at 24 h after probe administration. The clearance of cRGD-ZW800-1 permitted visualization of the ureters and also generated minimal background fluorescence in the gastrointestinal tract.

CONCLUSIONS

This study appears to be the first to demonstrate both clear tumor demarcation and ureteral visualization after a single intravenous injection of a targeted NIR fluorophore. As a low dose of cRGD-ZW800-1 provided clear tumor identification, clinical translation of these results should be possible.

Ureteral penetration caused by drilling during internal pelvic bone fixation: delayed recognition

A 49-year-old man was referred to our department with profuse serous fluid discharge from a Penrose drain after undergoing internal fixation with metal screws for multiple pelvic bone fractures. A definite ureteral penetration was identified that was orientated from the lateral to the medial aspect of the right distal ureter. The patient was surgically treated with excision of the 2-cm injured ureteral segment, end-to-end ureteroureterostomy, and double J ureteral stent placement. To our knowledge, a penetrating ureteral injury caused by bone drilling has not been reported previously in the published literature. This case shows that surgeons who do pelvic surgery, including orthopedic surgeons, should be familiar with the anatomical relationship of the ureter and its potential injuries.

Intraoperative near infrared fluorescence guided identification of the ureters using low dose methylene blue: a first in human experience

PURPOSE

Near infrared fluorescence imaging is a promising technique that offers real-time visual information during surgery. In this study we report the first clinical results to our knowledge of ureteral imaging using near infrared fluorescence after a simple peripheral infusion of methylene blue. Furthermore, we assessed the optimal timing and dose of methylene blue.

MATERIALS AND METHODS

A total of 12 patients who underwent lower abdominal surgery were included in this prospective feasibility study. Near infrared fluorescence imaging was performed using the Mini-FLARE™ imaging system. To determine optimal timing and dose, methylene blue was injected intravenously at doses of 0.25, 0.5 or 1 mg/kg after exposure of the ureters. Imaging was performed for up to 60 minutes after injection.

RESULTS

In all patients both ureters could be clearly visualized within 10 minutes after infusion of methylene blue. The signal lasted at least up to 60 minutes after injection. The mean signal-to-background ratio of the ureter was 2.27 ± 1.22 (4), 2.61 ± 1.88 (4) and 3.58 ± 3.36 (4) for the 0.25, 0.5 and 1 mg/kg groups, respectively. A mixed model analysis was used to compare signal-to-background ratios among dose groups and times, and to assess the relationship between dose and time. A significant difference among time points (p <0.001) was found. However, no difference was observed among dose groups (p = 0.811).

CONCLUSIONS

This study demonstrates the first successful use of near infrared fluorescence using low dose methylene blue for the identification of the ureters during lower abdominal surgery.

[Aetiology and management of iatrogenic injury of the ureter: a review]

OBJECTIVE

Ureteric injuries (IU) are common complications occurring during abdomino-pelvic surgical procedures. Our aim was to review risk factors, treatment and methods of prevention of these iatrogenic UI.

MATERIAL AND METHODS

A literature review in English and French by Medline(®) was performed using the keywords: ureter; iatrogenic; injury; ureteroscopy; morbidity and endoscopy.

RESULTS

The analysis of the epidemiology of IU shows that the first two causes are gynecological and urological surgery. In 80% of cases, the pelvic ureter was concerned. Mechanisms of injury were essentially ligation, section and ischemia by altering the ureteral vasculature. The main risk factors found were pelvic inflammation (endometriosis, radiation…) and the occurrence of bleeding during surgery. In the presence of risk factors, placing a double J stent or a CT may be useful preoperatively. The choice of reparation technique depended on the location of the PU, the circumstances of the occurrence and experience of the surgical team.

CONCLUSION

Pelvic surgery is a provider of iatrogenic PU. Knowledge of the management of PU once occurred must be mastered before carrying out any risk surgery.

Ureteral injury in gynecologic surgery: a 5-year review in a community hospital

Purpose

We reviewed the cases of ureteral injury during gynecologic surgeries in a community hospital and attempted to find possible options for alleviating these distressing situations.

Materials and Methods

A total of 2,927 patients underwent gynecologic surgeries in the last 5 years at our hospital. We retrospectively analyzed the cases, particularly the possible risk factors and management according to the time of detection of the injury. Thirty-five cases (1.2%) were identified with ureteral injury in a total of 2,927 gynecologic surgeries. Risk factors included endometriosis, pelvic inflammatory disease, previous pelvic surgery, history of pelvic radiation, and congenital anomalies. Among 2,927 patients, 522 had predisposing factors for ureteral injuries.

Results

The incidence of ureteral injury in laparoscopic cases was 1.1%, similar to the cases of laparotomy (1.2%). The rate of ureteral injury was significantly higher in the group with risk factors (2.7%) than in the group without risk factors (0.9%; p=0.002). Prophylactic ureteral stenting was performed in 101 of 522 patients with risk factors according to the gynecologic surgeon's preference. The injury rate (1.0%) in the stenting group was lower than that in the non-stenting group (3.1%; p=0.324). Management of ureteral injuries was successful in all cases. Of the patients with postoperatively diagnosed injuries, two patients were managed with secondary procedures, such as retrograde balloon dilatation or ureteroneocystostomy.

Conclusions

The incidence of ureteral injury was significantly higher in cases having risk factors than in cases without risk factors. Surgeons should be cautious to avoid ureteral injury during gynecologic surgery, especially in patients with risk factors.

Percutaneous minimally invasive management of iatrogenic ureteral injuries

PURPOSE

To present experience with the percutaneous management of iatrogenic ureteral injuries.

PATIENTS AND METHODS

Eighteen women and six men with a mean age of 59.3 years (range 33-80 years) received a diagnosis of ureteral injury sustained during gynecologic, urologic, and general surgical procedures. In a total of 25 injured ureters, 12 had interruption of continuity of their lumen, 10 were associated with contrast extravasation, and 3 were related to both. A standard percutaneous nephrostomy tract was established on the side of the afflicted kidney. Combined use of hydrophilic guidewires and balloon dilations were performed to achieve antegrade recanalization of the ureteral lesion. Then, a ureteral stent was inserted to assure patency.

RESULTS

Average stricture length was 1.21 (range 0.5-1.9 cm). Success of the aforementioned technique was possible in 18 ureters. Successful management in one session took place in 14 ureters. Average hospitalization time was 1.8 days (range 0-5 d). The follow-up period ranged between 12 and 18 months, with mean follow-up time of 12.9 months. Ureteral patency was evident at 1 week follow-up in six patients with obstructed ureters. In the remaining patients, balloon dilation of the stricture was repeated, and another stent was placed. Extravasation of contrast was observed in two patients with extravasating ureters in the same period. Nephrostomy tubes were removed after a mean indwelling period of 5.9 weeks (range 1-12 wks). Two patients treated by the described method died during their hospitalization in the intensive care unit because of sepsis from peritonitis that was related to colon injury and multiple concomitant injuries. Major complications were not observed in the remaining 22 patients during the follow-up period.

CONCLUSION

The minimally invasive management of ureteral injuries is a safe and efficient method for both ureteral obstruction and/or laceration in a wide range of iatrogenic ureteral injuries.

Percutaneous management of ureteral injuries that are diagnosed late after cesarean section

Objective

We wanted to present the results of percutaneous management of ureteral injuries that were diagnosed late after cesarean sections (CS).

Materials and Methods

Twenty-two cases with 24 ureteral injuries that were diagnosed late after CS underwent percutaneous nephrostomy (PN), antegrade double J (DJ) catheter placement and balloon dilatation or a combination of these. The time for making the diagnosis was 21 ± 50.1 days. The injury site was the distal ureter in all cases (the left ureter: 13, the right ureter: 7 and bilateral: 2). Fifteen complete ureteral obstructions were detected in 13 cases. Ureteral leakage due to partial (n = 4) or complete (n = 3) rupture was noted in seven cases. Two cases had ureterovaginal fistula. All the cases were initially confirmed with antegrade pyelography and afterwards they underwent percutaneous nephrostomy. Balloon dilatation was needed in three cases. Antegrade DJ stents were placed in 10 cases, including the three cases with balloon dilatation. Repetititon of percutaneous nephrostomy with balloon dilatation and DJ stent placement was needed in one case with complete obstruction. All the cases were followed-up with US in their first week and then monthly thereafter for up to two years.

Results

Eighteen ureters (75%) were managed by percutaneous procedures alone. A total of six ureter injuries had to undergo surgery (25%).

Conclusion

Percutaneous management is a good alternative for the treatment of post-CS ureteral injuries that are diagnosed late after CS. Percutaneous management is at least preparatory for a quarter of the cases where surgery is unavoidable.

Laparoscopic management of iatrogenic lesions

PURPOSE

To present our series of patients who underwent laparoscopic correction of iatrogenic lesions and a review of the literature.

PATIENTS AND METHODS

We evaluated 23 patients who underwent laparoscopic correction of iatrogenic lesions. Thirteen patients had open surgery, 6 had an endoscopic procedure, and 4 had a laparoscopic approach as the first surgical procedure. Vesicovaginal fistulas (VVF) developed in seven patients after open abdominal hysterectomies, and 1 patient presented with a VVF after ureterolithotripsy. A urethral cutaneous fistula developed in one patient after a laparoscopic resection of endometriosis nodules, and 1 patient presented with a ureterovaginal fistula after a perineoplasty. Three patients presented with encrusted ureteral stents after ureterolithotripsy. Ureteral stenosis developed in seven patients: three after open abdominal surgery, three after ureteroscopy, and one after pyeloplasty. One patient had a ureteral injury during laparoscopic partial nephrectomy, and two patients had bowel injuries after a tension-free vaginal tape procedure and a laparoscopic radical prostatectomy.

RESULTS

All patients underwent laparoscopic correction of the iatrogenic injuries. One patient had an early recurrence of a VVF, and one patient had a recurrence of a ureteral stenosis. There was one conversion to open surgery because of technical difficulties and one major bleeding event that necessitated blood transfusion. A lower limb compartmental syndrome developed in one patient.

CONCLUSION

Despite the small number of patients and different types of surgeries performed, laparoscopic management of iatrogenic lesions seems to be feasible and safe in experienced hands. Its precise role in the management of this stressful condition still needs to be determined.

Prophylactic ureteric catheters in laparoscopic colorectal surgery

BACKGROUND

The purpose of this study was to evaluate the use of ureteric catheter placement in laparoscopic colorectal surgery and to assess the morbidity related to this procedure.

METHODS

Between 1994 and 2001, 313 elective laparoscopic colorectal surgeries were performed. Patients with and without ureteric catheters were retrospectively analyzed.

RESULTS

Catheter placement was attempted in 149 patients (catheter group) and was not attempted in 164 (controls). There were no significant differences between groups in the number of patients with prior colorectal resection (p=0.286) or other abdominal surgery (p=0.074). Crohn's disease and diverticulitis were more common in the catheter group than among controls (p<0.001). Concomitant intra-abdominal fistula or abscess was present in 29 patients (19.5%) in the catheter group vs. 14 (8.5%) in the control group (p=0.005). The duration of surgery was longer in the catheter group (p=0.001). There were no significant differences in conversion, duration of bladder catheter placement, or length of hospital stay. Urinary tract infection occurred in 3 patients (2.0%) in the catheter group and 7 (4.3%) in the control group (p=0.257) and urinary retention occurred in 3 patients (2.0%) and 11 patients (6.7%), respectively (p=0.045). No intraoperative ureteric injuries occurred in either group.

CONCLUSION

Ureteric catheter placement was successful in most cases and was not associated with intraoperative injuries. The increased length of surgery in patients with ureteric catheter placement may attest to the increased severity of pathology in these patients.

Iatrogenic ureteral lesions and repair: a review for gynecologists

Ureter injuries are a well-known complication of gynecologic surgery and a frequent cause of medicolegal problems. Because there are no randomized, controlled trials and the available studies are small series and case reports, the evidence on which to base treatment is weak. We therefore reviewed the complete English-language literature of ureter repair since 1990. In total, 608 ureter injuries were reported. Although it is widely believed that for laceration or section the prognosis is affected by a delay in diagnosis, we could not find evidence to substantiate this. An obstruction requires stenting only. For a laceration, stenting with suturing was more effective than stenting only (p = .006). A ureter anastomosis was successful in over 94% of cases either by laparotomy or laparoscopy. In conclusion, the literature data are scanty and heterogeneous and do not permit solid conclusions. Evidence, however, is emerging that a laceration should be treated by stenting and suturing. A ureter anastomosis over a stent could become a valid option especially when performed by laparoscopy.

Ureteral injuries during gynecologic surgery: treatment with a minimally invasive approach

PURPOSE

To report the safety and efficacy of percutaneous nephrostomy and primary antegrade recanalization for treatment of iatrogenic ureteral strictures after gynecologic surgery.

PATIENTS AND METHODS

Ten women had symptoms suggestive of ureteral obstruction during the immediate postoperative period (5 days-1 week after surgery). Under analgesia and conscious sedation, standard percutaneous nephrostomy was performed, and a long 7F sheath was placed in the upper ureter. The obstructions were traversed with the aid of a 0.0035-inch Glidewire and a 5F angled Glide catheter (Terumo, Japan). Subsequently, the areas were dilated with angioplasty balloons to a maximum diameter of 7 mm. Finally, an 8F percutaneous internal/external nephroureteral drainage stent was inserted to secure ureteral patency. Follow-up was carried out by serial nephrostomography until removal of the stent and by renal ultrasonography thereafter.

RESULTS

Twelve obstructions with a mean length of 1.4 cm (range 0.4-1.9 cm) were managed. The technical success rate was 100%. No major complications occurred, and normal renal function was restored. The mean follow-up was 12 months. In 60% of the patients, a patent ureter was depicted at 1 week, whereas in four patients, repeat dilation of the obstructed segment was required. The stents were removed after a mean period of 4.8 weeks.

CONCLUSION

Percutaneous nephrostomy and primary antegrade ureteral balloon dilation is safe and efficacious for treating ureteral injury after pelvic surgery and obviates open surgical manipulations.

Iatrogenic Ureteric Injuries: Incidence, Aetiological Factors and the Effect of Early Management on Subsequent Outcome

OBJECTIVE

To investigate the changing pattern in incidence, aetiological factors and the effect of early diagnosis and surgical treatment on the outcome of iatrogenic ureteric injuries in our Urology Unit over a 5 year period.

PATIENTS/METHODS

All patients with ureteric injuries caused as a result of any surgical procedures (iatrogenic ureteric injuries) were studied during a 5 year period (1998-2002). Data collected and analysed included yearly incidence of injury, aetiological factors, modalities of treatment and the outcome of management of the injuries. During the study period, our general surgical colleagues had a policy of requesting "J" stent insertion prior to major abdominopelvic surgical procedures. During the same period, in nearly all difficult cases of ureteroscopy (URS) + lithoclast lithotripsy+/-Dormia basket, a ureteric catheter or "J" stent was prophylactically inserted by urological surgeons.

RESULTS

There were 82 iatrogenic ureteric injuries in 75 patients over the 5 year period. The total number of iatrogenic ureteric injuries declined from 26 (31.7%) in 1998 to 10 (11.8%) in 2002. Urological, obstetrics and gynaecological and general surgical procedures were involved in 69(84.1%), 7(8.7%), and 4(4.9%) of the injuries respectively. The commonest types of injuries encountered were; injury to ureteric mucosa post URS or lithoclast calculi disintegration 34 (41.5%), complete ureteric perforation 15 (18.3%) and false passage 15 (18.3%). The most severe complications encountered were complete ureteric avulsions 3 (3.75%) and loss of ureteral segment 2 (2.4%). The commonest treatment options used were "J" stent insertion or ureteric catheter placement (48, 59.4%), percutaneous nephrostomy (17, 20.7%), laparotomy and removal of suture on tied ureters (5, 6.1%). Two (2.4%) nephrectomies were performed because of poor renal function in one patient and severe damage to a functioning renal unit during a difficult retroperitoneal surgery in another patient. Recognition and treatment of ureteric injuries at the time of surgery was associated with less morbidity compared to those in whom the diagnosis was delayed. The overall successful resolution of ureteric injuries in this series was 77/82 (93.9%). There was no mortality attributable to these ureteric injuries.

CONCLUSION

In our Unit, the incidence of significant iatrogenic ureteric injuries has shown a decline over a 5-year period. We attribute this trend to the prophylactic use of "J" stents or ureteric catheter placement and good surgical technique during major abdomino-pelvic surgeries in our hospital. Endourological procedures are the commonest causes of ureteric injuries. Prompt diagnosis and institution of appropriate corrective surgical procedures often result in a very satisfactory outcome in about 94% of cases.

Management of iatrogenic ureteric injuries associated with gynecological surgery

OBJECTIVE

This retrospective study defines the presentation and management of iatrogenic ureteric injuries consequent upon gynecological surgery in a teaching hospital in Punjab, Pakistan.

PATIENTS AND METHODS

18 patients with median age 35 years (range 18-80 years) with iatrogenic ureteric injuries associated with gynecological surgery were referred to the department of urology at Nishtar Hospital Multan Pakistan. Main presenting symptoms were urinary incontinence, loin pain and anuria. Median time since injury and presentation was 3 weeks (range 1 day to 7 years). In 16 (88%) patients injury resulted from abdominal hysterectomy. Other causes included ovarian cystectomy (one patient) and vaginal hysterectomy (one patient). 11 (61%) patients had ureterovaginal fistula, 5 (28%) patients had complete unilateral ureteric obstruction and 2 (11%) patients had bilateral ureteric obstruction and anuria. In 11 patients with ureterovaginal fistula ureteroneocystostomy was performed. In five patients with unilateral ureteric obstruction, one had end to end anastomosis of ureter, three had ureteroneocystostomy only and one had ureteroneocystostomy and psoas hitch done. Two had anuria secondary to bilateral ureteric obstruction. In one of these patients Boari flap and ureteroneocystostomy was carried out. The second patient had deligation of catgut sutures on ipsilateral side and ureteroneocystostomy on the contra-lateral side.

RESULTS

In 17 patients no major complication occurred. One patient who had deligation of catgut sutures, the distal ureter sloughed and re-exploration and ureteroneocystostomy was performed. Renal salvage was achieved in all cases.

CONCLUSION

Open surgical procedures for repair of iatrogenic ureteric injuries are associated with good outcome. Strategies to prevent these injuries include adequate surgical training and meticulous surgical techniques.

Minimally invasive management of ureteral injuries recognized late after obstetric and gynaecologic surgery

We evaluated whether iatrogenic ureteral injuries recognized late after obstetric and gynaecological surgery were likely to resolve with minimally invasive strategies. We reviewed our records of 30 patients with surgical ureteral injuries diagnosed after obstetric and gynaecological operations. From collected data, the outcome of minimally invasive strategies and operative repair was evaluated and compared. Thirteen patients were treated primarily by operative repair and 17 were treated by minimally invasive strategies including percutaneous nephrostomy drainage, ureteral stent placement, or both. All patients treated by operative repair obtained primary healing. Of 17 patients treated by minimally invasive strategies, 11 had recovery of injured ureters but additional procedures were needed in six. We conclude that minimally invasive strategies are not always successful in the management of ureteral injuries recognized late after obstetric and gynaecological surgery.