Pattern of iatrogenic ureteral injuries in a tertiary health center in Nigeria

Abstract

Objective: To assess etiology, nature of injuries, and reconstruction techniques employed in the management of iatrogenic ureteral injuries. Patients and Methods: A retrospective review of patients with iatrogenic ureteral injuries from January 2009 to December 2013 was done. Records of the patients were reviewed with respect to etiology, mode of presentation, nature of injury, and type of repair done. Results: Twenty patients with iatrogenic ureteral injuries underwent a total of 28 ureteral reconstruction procedures at our institution over the 5-year period. There were 19 female patients (95.5%) and only 1 male patient (4.5%). The mean age of the female patients was 34.5 ± 3.8 years. Of the iatrogenic injuries to the ureter, 50% occurred on the left side while 8 (28.6%) were bilateral. In majority of the cases, 26 (92.9%), these injuries were the result of inadvertent ligation of the ureter. The average time at presentation after the injuries was 29.1 weeks with a range of 2 days to 8 years. The most common gynecological operation implicated was total abdominal hysterectomy (TAH) (55%) followed by myomectomy (20%), ovariectomy (10%), cesarean section (10%), and excision of the right colonic tumor (5%). The commonest mode of presentation was leakage of urine from the vagina as seen in 10 (50.0%) patients while 25% had complete anuria. Ureteroneocystostomy (UNC) was performed in 19 (67.8%) ureters. Psoas hitch and Boari flap were done in four (14.3%) and three (10.7%) cases, respectively. One patient (3.6%) required a transureteroureterostomy (TUU) and another one (3.6%) required a right nephroureterectomy. Outcome of the treatment was judged as satisfactory in all the cases as defined by improvement or resolution of the symptoms and normalization of renal function. Conclusion: Abdominal hysterectomy still remains the dominant cause of iatrogenic injury to the ureter. UNC can often be used to establish ureteral continuity in most cases of iatrogenic injuries to the distal ureter. Injuries to the right ureter are more likely to involve the middle third of the ureter, requiring some form of bladder mobilization or bladder flap to establish ureteral continuity. Attention to preventive measures, especially during gynecological surgeries, will help to reduce the incidence of ureteric injuries.