Management of Complete Ureteral Avulsion and Literature Review: A Report on Four Cases

Incidental Detection of Urinary Leakage on FDG PET/CT Imaging

ABSTRACT

A 57-year-old woman previously diagnosed as cervical cancer underwent an 18 F-FDG PET/CT scan for restaging. A pelvic encapsulated effusion with intense FDG accumulation was incidentally revealed. The tracer activity was similar to that of urine, indicating presence of urinary leakage. Subsequent CT urography confirmed the complete avulsion of the right distal ureter.

Indications for and results of renal autotransplantation

PURPOSE OF REVIEW

To understand the indications and outcomes of renal autotransplantation, and when to consider this unique procedure for patients.

RECENT FINDINGS

Renal autotransplantation confers acceptably low rates of graft failure and prevents need for long-term dialysis. Renal autotransplantation remains an important management strategy in very select patients for complex renovascular disease, ureteral stricture disease, ureteral trauma, upper urinary tract urothelial carcinoma, renal cell carcinoma, and Loin-Pain Hematuria Syndrome. With advancements in minimally invasive procedures, the application of renal autotransplantation for refractory stone disease is rare but exists. Robot-assisted laparoscopic renal autotransplantation demonstrates reproducible graft success and complication rates with improved perioperative outcomes (ex. hospital length of stay) - though comparative studies are lacking. Patients would benefit from a multidisciplinary approach from renal transplant surgeons, vascular surgeons, urologists, nephrologists, dieticians, pain management providers, social workers, and psychiatrists.

SUMMARY

In experienced hands, renal autotransplantation is a reasonable treatment approach for complex and refractory renal vascular disease, Loin-Pain Hematuria Syndrome, ureteral strictures and trauma, upper urinary tract malignancy, and stone disease in highly select patients.

Inverted mucosa and avulsion ureteral injury in ureteroscopic procedure: A very rare complication of a common procedure in urology

An avulsion is very rare and the most serious complication that may occur during ureteroscopy in 0.06-0.45% of patients during the ureteral stone procedure. A sixty years-old female with a small stone in the upper third of the right ureter with high-grade hydronephrosis and underwent a ureteroscopy procedure. During withdrawal of the scope, the ureter was brought out in urethral meatus, with inverted fashion, nearly the whole length of the ureter was avulsed out. A nephrectomy of the right kidney was then performed. Knowledge about signs of the ureteral avulsion, pitfalls when to stop, and treatments is really important.

Case report series: management of complete ureteral avulsion with review of the relevant literature

Background

Endoscopic operations and ureteroscopy have become the first choice for ureteral calculi and ureter-related operations. The ratios of the complications, which are mostly iatrogenic, range between 9 and 11%. Total ureteral avulsion during URS is quite rare with a prevalence of 0–0.3%. We present three total ureteral avulsions we experienced in our clinic during the last 2 years and their treatment.

Case presentation

During the last 2 years, we experienced three total ureteral avulsions: one of these occurred in our clinic and the other two occurred in an external center and were referred to us. In two cases, the omental flap was rotated after ureteral reimplantation and the ureter was completely wrapped inside the omental flap. In the third case, boari flap was formed from the bladder. Due to the presence of extrarenal wide renal pelvis, anastomosis was made with boari flap after a y–v flap was rotated on the renal pelvis. D-J stents of the patients were removed at the end of 3 months. Although there was mild hydronephrosis, parenchymal thinning and a significant decrease in functions were not observed. Ureteral avulsion of the patients was successfully managed without the need for nephrectomy.

Conclusion

Ureteral avulsion management is an extremely difficult condition for both the surgeon and the patient. So, the most important thing is to prevent ureteral avulsion. Ureteroplasty and omental flap treatment are applicable methods with quite successful results for complete ureteral avulsions.

Management of ureteric avulsion during ureteroscopy: a systematic review and our experience

Background

Ureteric avulsion is a disastrous intraoperative complication that can happen to any urologist during a common endoscopic procedure like ureteroscopy. The aim of this study is to evaluate the various management options of ureteric avulsion during ureteroscopy and also report our relevant experience in this topic.

Results

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses of existing literature in English language was used in the period 1967–2019 with a literature search in PubMed, Cochrane Library and Google Scholar. Forty-three patients in twenty-three articles who had undergone management of ureteric avulsion during ureteroscopy were identified for review. There were 15 proximal, 19 two-point (“scabbard”) and 9 distal avulsions. All distal avulsions were managed successfully with ureteroneocystostomies or Boari flaps. Boari flaps and ureteropyelostomy with ureterovesicostomy were the common procedures used for proximal avulsions. Proximal avulsions had more varied outcomes with salvage rates of 86.9%. Procedures which incorporated the avulsed distal ureter for reconstruction had poor results.

Conclusion

Management of ureteric avulsion during ureteroscopy is a surgical challenge. While management of distal avulsions is straightforward in the form of ureteroneocystostomies and has uniformly good results in most hands, proximal avulsions need expertise in management and choosing ideal reconstruction, with variable results following reconstruction. Extended Boari flaps, ileal ureter and autotransplantation are good options for proximal avulsions. Reconstruction using the distal avascular ureter should be avoided for better long-term results.

Immediate ileal ureter replacement for ureteral avulsion during ureterescopy

INTRODUCTION

Complete ureteral avulsion represents a rare and fearsome complication of ureteroscopy, reported in less than 1% of cases. In literature there are few reports and different options are presented for its treatment. We present a case of a ureteral avulsion managed with ileal ureter replacement.

CASE PRESENTATION

A 67-year-old man with a left proximal ureter stone was treated at our department with ureteroscopy. During retrieval of the instrument a complete ureteral avulsion was discovered, with a so-called "scabbard lesion". We decided to proceed with immediate laparotomy and we performed a ileal ureter replacement.

CONCLUSION

Ureteral avulsion is a rare complication but must be known as a possible complication in high volume center. There is no standard definition regarding its treatment, and in our experience immediate treatment with ileal ureter replacement proved to be safe and effective without any changes in renal function.

Long segment right ureteric stricture following ureterorenoscopy for upper ureteric stone: A disastrous complication of endourology

Background:

Nephrolithiasis is a common ailment in developing countries such as India. Ureteroscopic management has superseded shockwave lithotripsy as the common treatment for upper urinary tract stones. The process of miniaturizing the instrument along with improved quality of video processor has amplified its potential application, maintaining the procedure safe and effective. However, with its extensive use, complications have risen in parallel, and one should be aware of its adverse effects. Ureteric stricture though rare is a serious problem and risks the loss of renal function.

Case presentation:

A 37-year-old male presented with right flank pain. On evaluation, he was diagnosed with right upper ureteric stone and left renal stone. The patient suffered ureteric perforation while the right ureterorenoscopy was being performed, and an open repair was done. On postoperative follow-up, he developed long segment ureteric stricture. Boari flap ureteroneocystostomy was done.

Conclusion:

Iatrogenic ureteric injury following ureterorenoscopy is common, minor and managed conservatively. Important tips to prevent major injury are: placement of the safety guide wire across the length of the ureter, small-calibre scopes during access if a tight gripping sensation is present and the use of lubricant along the length of the ureteroscope.

Reverse Tubularized Pelvis Flap Method for the Treatment of Long Segment Ureteropelvic Junction Obstruction

OBJECTIVE

The most common cause of urinary obstruction is ureteropelvic junction (UPJ) obstruction. In short stenosis, a dismembered pyeloplasty is performed, but for long segment stenosis, the procedure is not well defined. We present the reverse flap ureteroplasty method, which we prepared from the pelvis for use in long segment UPJ obstruction.

METHODS

Between 2007 and 2016, we operated on 6 cases (4 males, 2 females) with an age range of 2-6 months. After reaching the UPJ region, depending on the length of the long segment obstruction, a flap measuring 25-35 mm in length was prepared from the pelvis so that its width would be 10-12 mm on the pelvis side and 10 mm in the distal portion. It was then reversed and tubularized with an absorbable suture over a 10-French nelaton catheter. The end of this ureter and the end of the distal ureter were spatulated and anastomosed. A double J and minivac drain were used in each case.

RESULTS

There were no complications in the postoperative period of all our patients. They were all discharged with good health. Follow-up with renal ultrasonography showed that the anteroposterior diameters were decreased and that parenchymal thicknesses had returned to normal. Secondary stenosis, flap necrosis, and retraction did not develop.

CONCLUSION

Because the blood supply of the pelvis is increased in patients with UPJ obstruction, a reverse flap of adequate length with preserved blood supply can be achieved and tubularized. We suggest that this method will be appropriate for the treatment of long segment UPJ obstruction.

Feasibility of Boari Bladder Flap Procedure in Patients With Heterotrophic Renal Transplant

OBJECTIVES

Our goal was to investigate the safety and efficacy of the Boari bladder flap procedure in patients who received either allogeneic or autotransplant of kidneys.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of all patients with either allogeneic or autotransplant of kidneys who also underwent Boari bladder flap procedures between January 2007 and January 2018. Boari bladder flap was preferred in management of ureteral com-plications after allogeneic renal transplant or it was combined with renal autotransplant when ureteral length was not sufficient to allow ureterovesical anastomosis in patients with ureteral injury.

RESULTS

Boari bladder flap procedures were performed in 14 patients who had undergone heterotrophic renal transplant. Nine patients had undergone allogeneic renal transplant, and 5 patients had renal auto-transplant. The mean age of patients was 41.7 ± 13.4 years. The 5 patients with renal autotransplant procedures had simultaneous Boari flap procedures due to ureteral avulsion during retrograde ureter-orenoscopic surgery for urolithiasis. For the entire cohort, mean preoperative and postoperative (at month 1) serum creatinine levels were 1.42 ± 0.71 and 1.13 ± 0.43 mg/dL, respectively. At last visit, the mean creatinine level was 1.94 ± 1.88 mg/dL.

CONCLUSIONS

The Boari bladder flap procedure can be a safe and relevant choice in the management of challenging complications after heterotrophic (either allogeneic or autotransplant) renal transplant, allowing minimally invasive urologic surgery, no need for use of bowel segments, and no potential risk for the contralateral kidney.

Management of full-length complete ureteral avulsion

INTRODUCTION

Complete ureteral avulsion is one of the most serious complications of ureteroscopy. The aim of this report was to look for a good solution to full-length complete ureteral avulsion.

CASE PRESENTATION

A 40-year-old man underwent ureteroscopic management. Full-length complete avulsion of ureter occurred during ureteroscopy. Pyeloureterostomy plus greater omentum investment outside the avulsed ureter and ureterovesical anastomosis were performed 6 hours after ureteral avulsion. The patient was followed-up during 34 months. Double-J tube was removed at 3 months after operation. Twenty three months after the first operation, the patient developed hydronephrosis because of a new ureter upside stone, then rigid ureteroscopy and holmium laser lithotripsy were used successfully.

CONCLUSION

Pyeloureterostomy plus greater omentum investment outside the avulsed ureter and ureterovesical anastomosis may be a good choice for full-length complete ureteral avulsion.

Immediate successful renal autotransplantation after proximal ureteral avulsion fallowing ureteroscopy: a case report

The patient was a 51-year-old lady with left flank colicky pain accompanied with nausea and vomiting for a month. Transurethral lithotripsy and ureteral stent placement was considered for the patient. The patient had a narrow ureteral lumen and while bringing the ureteroscope out, ureteral avulsion occurred at a distance approximately 4 cm from ureteropelvic junction. After bringing the uretroscope out, the avulsed ureter was observed hanging at the tip of the ureteroscope. Anastomosis of the ureter to the bladder was accomplished with Lich-Gregoir technique. A drainage tube was inserted at the site of incision and the surgical wound closed. The patient was discharged with acceptable general condition after 3 days and the drainage tube removed. The ureteral stent was removed 4 weeks later by cystoscopy. An ultrasound imaging study of the genitourinary system 8 months into the patients follow up showed normal size, echo and cortical thickness in the operated kidney after renal autotransplantation.

Three-Dimensional Numerical Simulations of Peristaltic Contractions in Obstructed Ureter Flows

Ureteral peristalsis can be considered as a series of waves on the ureteral wall, which transfers the urine along the ureter toward the bladder. The stones that form in the kidney and migrate to the ureter can create a substantial health problem due to the pain caused by interaction of the ureteral walls and stones during the peristaltic motion. Three-dimensional (3D) computational fluid dynamics (CFD) simulations were carried out using the commercial code ansys fluent to solve for the peristaltic movement of the ureter, with and without stones. The effect of stone size was considered through the investigation of varying obstructions of 5%, 15%, and 35% for fixed spherical stone shape. Also, an understanding of the effect of stone shape was obtained through separate CFD calculations of the peristaltic ureter with three different types of stones, a sphere, a cube, and a star, all at a fixed obstruction percentage of 15%. Velocity vectors, mass flow rates, pressure gradients, and wall shear stresses were analyzed along one bolus of urine during peristalsis of the ureteral wall to study the various effects. It was found that the increase in obstruction increased the backflow, pressure gradients, and wall shear stresses proximal to the stone. On the other hand, with regard to the stone shape study, while the cube-shaped stones resulted in the largest backflow, the star-shaped stone showed highest pressure gradient magnitudes. Interestingly, the change in stone shape did not have a significant effect on the wall shear stress at the obstruction level studied here.

Evaluation of the tensile strength of the human ureter--preliminary results

BACKGROUND AND PURPOSE

Ureteral injuries such as avulsion are directly related to mechanical damage of the ureter. Understanding the tensile strength of this tissue may assist in prevention of iatrogenic injuries. Few published studies have looked at the mechanical properties of the animal ureter and, of those, none has determined the tensile strength of the human ureter. Therefore, the purpose of this work was to determine the tensile strength of the human ureter.

METHODS

We harvested 11 human proximal ureters from patients who were undergoing nephrectomy for either kidney tumors or nonfunctioning kidney. The specimens were then cut into multiple circumferentially and longitudinally oriented tissue strips for tensile testing. Strips were uniaxially stretched to failure in a tensile testing machine. The corresponding force and displacement were recorded. Finally, stress at failure was noted as the tensile strength of the sample. Circumferential tensile strength was also compared in the proximal and distal regions of the specimens.

RESULTS

The tensile strength of the ureter in circumferential and longitudinal orientations was found to be 457.52±33.74 Ncm(-2) and 902.43±122.08 Ncm(-2), respectively (P<0.001). The circumferential strength in the proximal portion of the ureter was 409.89±35.13 Ncm(-2) in comparison with 502.89±55.85 Ncm(-2) in the distal portion (P=0.08).

CONCLUSIONS

The circumferential tensile strength of the ureter was found to be significantly lower than the longitudinal strength. Circumferential tensile strength was also lower with more proximal parts of the ureter. This information may be important for the design of "intelligent" devices and simulators to prevent complications.

Significance of Extraction Forces in Kidney Stone Basketing

INTRODUCTION

Ureteroscopic stone extraction devices are effective tools in the management of urolithiasis, but on occasion, their improper use can cause injury to the ureter. Avulsion and perforation of the ureter as a result of excessive forces on the extraction device are some of the more serious complications of this treatment.

MATERIALS AND METHODS

In this article, avulsion and perforation forces were measured by two different test setups. Eleven clinicians were asked to apply three ranges of forces (safe, cautious, and dangerous).

RESULTS

The output force measurements were recorded and plotted for further analysis. The maximal average perforation forces were 7.13±2.36 N in the benchtop tests and 7.07±2.20 N in the ex-vivo porcine tests (P=0.54). The maximal average avulsion forces were measured to be 10.14±2.01 N in the benchtop tests. Although the average forces were similar in the proximal and distal parts of the ureter (P=0.27), higher values were recorded for the distal part. The operative time was noted to be significantly different in the safe and cautious force regions (P=0.006). The average forces were higher in the benchtop tests compared with the porcine ureter tests. The extraction forces were measured and were noted to be significantly different for attending physicians and residents. The results suggest the need for force feedback training for residents.

CONCLUSION

The findings can be used to design a "smart device" that can provide visual force feedback to clinicians while they are operating, leading to improved patient outcome.

Possible complications of ureteroscopy in modern endourological era: two-point or "scabbard" avulsion

Indication has led ureteroscopy to be a worldwide technique, with the expected appearance of multiple types of complications. Severe complications are possible including ureteral perforation or avulsion. Ureteral avulsion has been described as an upper urinary tract injury related to the action of blunt trauma, especially from traffic accidents, being the mechanism of injury, the result of an acute deceleration/acceleration movement. With the advent of endourology, that term is also applied to the extensive degloving injury resulting from a mechanism of stretching of the ureter that eventually breaks at the most weakened site, or ureteral avulsion is referred to as a discontinuation of the full thickness of the ureter. The paper presents a case report and literature review of the two-point or "scabbard" avulsion. The loss of long segment of the upper ureter, when end-to-end anastomosis is not technically feasible, presents a challenge to the urological surgeon. In the era of small calibre ureteroscopes these complications, due to growing incidence of renal stones will become more and more actual. Our message to other urologists is to know such a complication, to know the ways of treatment, and to analyse ureteroscopic signs, when to stop or pay attention.

How to manage total avulsion of the ureter from both ends: our experience and literature review

OBJECTIVES

To evaluate the treatment alternatives of total avulsion of the ureter from both ends including ureteropelvic junction (UPJ) and ureterovesical junction (UVJ).

METHODS

Total ureteral avulsion on both ends of the ureter was examined in 4 cases performing ureteroscopy. In two male patients of the four cases, avulsion was noticed intraoperatively and ureteral re-anastomosis at UPJ and re-implantation at UVJ were performed immediately. Boari flap was performed for one female patient immediately and for the other female patient who was referred from another hospital after the ureteroscopy, 4 days later.

RESULTS

One patient who had ureteral re-implantation was followed with 3-month intervals by ultrasonography and abdominal X-ray. At the end of 1 year, it was determined that kidney parenchyma was normal and the patient had kidney and upper ureteral stones. Percutaneous nephrolithotomy was performed, and the patient was stone-free at the end of the operation. Two years after the surgery, both kidneys were normal. This is the only case who had a successful ureteral re-implantation in literature. The other patient turned up a year later for routine checks after the ureteral stent was removed. Then, hydronephrosis and renal atrophy were detected. The patient did not accept nephrectomy or any other intervention and he was lost to follow-up. Boari flap procedure was performed after UPJ repair for the other two female patients. Their kidneys were both normal 3 months after the operation.

CONCLUSIONS

In case of ureteral avulsion from both ends of the ureter in the male patients, as bladder capacity is not enough for a Boari flap, proximal anastomosis and distal re-implantation could be a good choice for the management of this untoward event. This new approach also saves time for reconstructive treatments if necessary. If bladder capacity is enough to reach UPJ, Boari flap could be a good choice in female patients.

Tissue engineering and ureter regeneration: is it possible?

Large ureter damages are difficult to reconstruct. Current techniques are complicated, difficult to perform, and often associated with failures. The ureter has never been regenerated thus far. Therefore the use of tissue engineering techniques for ureter reconstruction and regeneration seems to be a promising way to resolve these problems. For proper ureter regeneration the following problems must be considered: the physiological aspects of the tissue, the type and shape of the scaffold, the type of cells, and the specific environment (urine). 
This review presents tissue engineering achievements in the field of ureter regeneration focusing on the scaffold, the cells, and ureter healing.

Full-length ureteral avulsion caused by ureteroscopy: report of one case cured by pyeloureterostomy, greater omentum investment, and ureterovesical anastomosis

The aim of this report was to look for a good solution to full-length ureteral avulsion. This report retrospectively analyzed the data of the patient. The patient underwent ureteroscopic management. Full-length avulsion of ureter occurred during ureteroscopy. Pyeloureterostomy plus greater omentum investment outside the avulsed ureter and ureterovesical anastomosis were performed immediately. The patient was followed-up 25 months. After the first operation, the patient developed hydronephrosis because of press of fibrosis tissue outside ureter and anastomotic atresia of ureter-bladder. When we finished the second operation, the renal function recovered well. Full-length avulsion of ureter is a severe complication. Pyeloureterostomy plus greater omentum investment outside the avulsed ureter and ureterovesical anastomosis are probably a good choice.