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

Abstract

BackgroundUreteric 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.ResultsThe 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.ConclusionManagement 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.