Iatrogenic Ureteral Injury Research Articles

Rare ureteral injury in lumbar discectomy - two case reports

Introduction. Iatrogenic ureteral injuries are an important part of all ureteral injuries. They occur primarily during urological, gynecological, vascular, and general procedures. Urethral injury during spinal surgery is a rare complication. We wanted to emphasize that there should be limitations during the use of surgical instruments used in spine surgery. Outlines of cases. We present ureteral injury cases that occurred in two patients with lumbar disc herniation who were treated surgically at the Department of Neurosurgery. Ureteral repair was performed in both patients by the urology department. Their postoperative course was uneventful. Conclusion. This report emphasizes the importance of ureteral injury complications which are rare, but can cause medicolegal problems during lumbar disc surgery. Surgeons should consider this potential complication, which has devastating consequences, particularly in patients with abdominal pain in the early postoperative period.

Comparison of split-cuff nipple and modified Lich-Gregoir ureteroneocystostomy in iatrogenic distal ureteral injuries: tertiary care center experience.

In this study, we aimed to compare the results of split-cuff nipple and modified Lich-Gregoir ureteroneocystostomy, which are the most commonly used techniques in stage ≥ 3 iatrogenic distal ureteral injuries. The files of patients who were treated for iatrogenic distal ureteral injuries in our clinic between January 2013 and January 2019 were retrospectively reviewed. A total of 60 patients who underwent either intra-vesical split-cuff nipple ureteroneocystostomy (Group A) or extra-vesical modified Lich-Gregoir ureteroneocystostomy (Group B) operations were included in the study. The success of ureteroneocystostomy was defined as no additional surgery requirement, no progression of hydronephrosis on imaging, and normal contrast transition on imaging. Thirty-four patients underwent split-cuff nipple and 26 patients underwent modified Lich-Gregoir ureteroneocystostomy. The treatment was successful in 53 (88.3%) patients and failed in seven (11.7%). Complications occurred in 19 (31.7%) patients, of whom 14 (23.3%) had minor and five (8.3%) had major complications. The rate of postoperative complications was significantly higher in Group A than in Group B (p = 0.019). There was no significant difference between Group A and Group B in terms of the success ratio (p = 1), rate of major complications (p = 0.372), and postoperative hospitalization times (p = 0.254). In this study, a higher complication rate was found in patients with iatrogenic ureteral injuries who underwent ureteroneocystostomy with the split-cuff ureteral nipple technique compared to those who underwent this operation with the modified Lich-Gregoir technique. However, no significant difference was observed between these two techniques in terms of treatment success and major complications.

Inhibition of Ureteral Stricture by Pirfenidone-Loaded Nanoparticle-Coated Ureteral Stents with Slow-Release Pirfenidone.

Ureteral stricture caused by iatrogenic ureteral injury induced ureteral injury is more common and challenging to recover quickly. The effective prevention of ureteral stricture due to iatrogenic ureteral injury-induced ureteral damage is a current challenge for urologists. The purpose of this study was to evaluate the effectiveness of nanoparticle/pirfenidone complex-coated ureteral stents with slow-release pirfenidone for the prevention of ureteral stricture in rabbits. In this study, we developed a nanoparticle/pirfenidone complex-coated ureteral stent to deliver pirfenidone into the injured ureter to inhibit ureteral stricture. Twelve New Zealand rabbits were divided into four groups: Sham, US, US+ Unmodified ureteral stent, and US+NP/PFD ureteral stent; we constructed an irreversible electroporation model of ureteral injury in rabbits and placed unmodified ureteral stents and nanoparticle/pirfenidone complex-coated ureteral stents into the ureter. Two weeks later, we euthanized the rabbits and removed their bilateral kidneys and ureters. We evaluated the effect of ureteral stent prophylaxis by gross specimen observation, section staining, and Western Blot. We found that the nanoparticle/pirfenidone complexes could adhere uniformly to the surface of the ureteral stent. After placement into the ureter, the nanoparticle/pirfenidone complexes were able to remain on the surface of the ureteral stent. We found nanoparticle/pirfenidone complexes could diffuse in the ureteral epithelial tissue two weeks after the order. The study showed that nanoparticle/pirfenidone complex-coated ureteral stents placed into the ureter showed significantly less stenosis due to fibrosis than in US control rabbits and rabbits treated with unmodified ureteral stents. We used a novel platform based on nanoparticle/pirfenidone complex-coated ureteral stents for local and sustained delivery of pirfenidone, which can effectively deliver pirfenidone to the tissue and can slowly control the release of pirfenidone. Therefore, combining ureteral stents with nanoparticle/pirfenidone complexes was an effective measure to prevent ureteral stricture.

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

BackgroundSeventy 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.ObjectiveThe 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 methodsThis 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.ResultsTwelve 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.ConclusionOpen 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.

Iatrogenic ureteric injury during abdominal or pelvic surgery: a meta-analysis.

To assess the incidence of ureteric injuries, clinical value of prophylactic ureteric stenting and impact of intra- or postoperative detection of ureteric injuries in patients treated with gynaecological or colorectal surgery. Multiple databases were searched for articles published before September 2021 according to the Preferred Reporting Items for Systematic Review and Meta-Analyses statement. Studies were deemed eligible if they evaluated the differences in the rate of ureteric injuries between laparoscopic and open surgery, prophylactic ureteric stenting or not, and those of final treatment success between intra- and postoperative detection in patients who underwent gynaecological or colorectal surgery. Overall, 46 studies were eligible for this meta-analysis. Compared to open surgery, laparoscopic hysterectomy was associated with a higher incidence of ureteric injuries (pooled odds ratio [OR] 2.12, 95% confidence interval [CI] 1.71-2.62), but there was no statistically significant difference in colectomy (pooled OR 0.89, 95% CI 0.77-1.03). Prophylactic ureteric stenting was associated with a lower incidence of ureteric injuries during gynaecological surgery (pooled OR 0.61, 95% CI 0.39-0.96). The number needed to perform ureteric stenting to prevent one ureteric injury was 224 in gynaecological surgery. On the other hand, prophylactic ureteric stenting did not reduce the risk of ureteric injuries during colorectal surgery. Intraoperative detection of a ureteric injury was associated with a lower rate of complication management failure compared to postoperative detection (pooled OR 0.22, 95% CI 0.12-0.41). Laparoscopic hysterectomy seems to be associated with a higher rate of ureteric injuries compared to an open approach. Prophylactic ureteric stenting seems to reduce this risk during gynaecological surgery. Intraoperative detection of a ureteric injury during abdominal/pelvic surgery improves outcomes, suggesting the need for awareness and proactive problem identification. Further well-designed studies assessing the candidates who are more likely to benefit from prophylactic ureteric stenting including cost analysis are needed.

Long-Term Economic Impact of Iatrogenic Ureteral Injury in the US

Introduction: Iatrogenic ureteral injuries (IUI) are rare, serious complication that can occur during abdominopelvic surgeries, and may delay recovery; however, data on long-term healthcare use and cost attributable to IUI for patients and payers are limited. Methods: A retrospective observational study of the PharMetrics Plus claims database included US patients with IUI within 30 days of an abdominopelvic surgery between Jan 2016 - Dec 2018. Patients were followed for a year from the (index) surgery date. IUI patients were matched to those without, and attributable visits/cost to IUI were estimated as differences between matched pairs. Results: In total 542 IUI (median 49 years old, 80% female) and 359,221 non-IUI patients with pre-specified abdominopelvic surgeries were identified. Patients with IUI were more likely to have malignancy, diverticulitis, perforation, or endometriosis at baseline. Most (86.7%) IUIs were identified on the day of surgery. 515 IUI patients were matched to 1,545 patients without IUI. The number of annual healthcare visits was slightly higher in the IUI group, including a 12.9% higher 30-day readmission rate. Annual IUI attributable cost for patients were $374 [95% CI: -965 - 1,712] and $35,934 [26,269 - 45,599] for payers. The following CPT code ranges were most frequently associated with IUI: “Colon Resection Procedures” (15.3%), “Laparoscopic Procedures of the Abdomen/Peritoneum/Omentum” (14.2%), and “Abdominal hysterectomy” (13.8%). Conclusion: Annual healthcare visits were slightly higher among patients with IUIs, including readmission within 30 days. IUI attributable cost for patients were small, and payer’s cost were greater, driven by inpatient visits.

Laparoscopic nephrectomy with mini-incision kidney auto- transplantation in severe ureteral strictures: report of three cases and review of the literature

Severe and long ureteral injuries are difficult to be managed. In presence of a complex injury of the upper ureter, nephrectomy, bowel interposition, and kidney autotransplantation (KAT) are usually proposed. Kidney autotransplantation (KAT) represents a complex surgical procedure with a high risk of complications that could preserve renal function. We update our experience with renal autotransplantation for severe iatrogenic ureteral injuries. Three patients with complex ureteral injuries were referred for definitive management by KAT. Transperitoneal laparoscopic nephrectomy (LN) and open mini-incision KAT (mKAT) to the ipsilateral pelvis were attempted. After bench preparation of the graft, ureteral and vessel length and quality was adequate for autotransplantation in all cases. There were no intra- and postoperative complications and all grafts functioned immediately and at medium-term follow-up of 6 months. KAT gives excellent post-operative results without significant deterioration in renal function at medium-term follow-up. It represents a safe alternative method for the management of complex ureteric strictures when conventional surgical techniques have failed or are not suitable. Intensive collaboration with all transplant teams is crucial to ensure the high quality of the graft and to improve surgical and functional outcomes. Keywords: Ureteral stricture, autotransplantation, kidney, surgery

Real-Time Near-Infrared ICG Fluorescence Ureterography in Complex Rectal Resections: A Report of Two Cases

Iatrogenic ureteric injuries are a well-documented consequence of non-urological abdomino-pelvic surgeries. Colorectal resections for benign inflammatory diseases are associated with obliteration of the planes. In such situations, identifying and securing the ureter during laparoscopy is challenging due to the absence of tactile feedback. We describe the use of real-time near-infrared Indocyanine green (ICG) fluorescence guidance to avoid iatrogenic ureteric injuries during complex colorectal resections featuring extensive pelvic adhesions. The inert nature of ICG, its affinity for urothelium, ability to detect leaks, low cost, and convenience of use with real-time augmented images during surgery make real-time, near-infrared ICG fluorescence ureterography a crucial tool in a colorectal surgeon's armamentarium during complex colorectal surgery.

Functional outcomes of surgical treatment of ureteral injury following gynecological and obstetrical surgery

IntroductionIatrogenic ureteral lesions represent one of the serious complications that can follow obstetric and gynecological surgery. This condition has a fatal consequence on renal function if it's not promptly diagnosed and managed. ObjectiveThe aim of our study was to report our experience in the management of this pathology. Materials & MethodsThis is a retrospective study of 32 patients treated for an iatrogenic ureteral injury after gynecological or obstetrical surgery, collected in the urology department of the Rabta Hospital over a 15-year period (2005–2020). Clinical presentation, investigations, and operative and postoperative details were reviewed from the patients' charts. ResultsThe average age of the patients was 42.6 (21–61). Multiparity was observed in 90.6% of cases. Hysterectomy was the most common cause (71.87%), followed by cesarean operation (18.75%), mainly for patients with placenta percreta (12.5%), and lastly, cure of prolapse by the upper approach in 9.37% of cases. The symptoms were dominated by low back pain and urinary incontinence. Stenosis was the most frequent lesion in 25 cases, followed by a section in 4 cases. A ureterovaginal fistula was observed in 3 case s. The first-line treatment of the patients was drainage by a ureteral stent (15.6%) or by a percutaneous nephrostomy (84.4%). Ureterovesical reimplantation was performed in 26 cases (81.25%). However, one patient had an Ileal ureter replacement. During follow-up, treatment failure was noted in 7 patients. Four patients developed secondary hydronephrosis treated with a urethral stent while 3 patients required nephrectomy. The type of gynecological and obstetrical procedure (open hysterectomy), history of pelvic surgery, and malignant pathology were predictive factors of treatment failure. ConclusionsInjuries to the ureter during gynecological and obstetrical surgery are generally rare. The diversity of repair techniques and the contribution of endo-urological techniques most often allow renal preservation, knowing that the best treatment remains prevention.

Features of treatment of ureteral injuries

Choosing the optimal techniques for the treatment of ureteral injuries is necessary. Damage to the ureter accounts for 3% of cases of injuries of the genitourinary system. More than 70% of iatrogenic ureteric injuries are not detected during surgery. Approximately 75%80% of ureterotraumas are due to iatrogenic causes, of which 65%82% are due to gynecological surgeries. Mechanical injuries of the ureter are much less common than iatrogenic ones. Gunshot and stab wounds of the ureter prevail among mechanical injuries. Thirty-one patients who were treated at the I.I. Janelidze Research Institute of Emergency Medicine with various ureteral injuries from 2003 to 2019 were examined. Patients were divided into three groups according to the time of detection of ureteral injury. Group 1 included patients with ureteral injuries identified during surgery, group 2 included those with ureteral injuries diagnosed within 72 h, and group 3 consisted of patients with ureteral injures detected 72 h later. The choice of treatment techniques for ureterotrauma relied on the general condition of the patient, severity and level of damage to the ureter, timing of its diagnosis, and nature of the complications. On intraoperative detection of ureterotrauma in patients with a stable condition, reconstructive surgery of the ureter should be performed immediately to ensure the passage of urine from the upper urinary tract. If ureterotrauma is diagnosed before 72 h and there are no inflammatory complications, reconstructive ureteral surgery is also appropriate. If an infectious and inflammatory process develops, a staged operation is necessary to drain the upper urinary tract and relieve the developed posttraumatic complications. When ureterotrauma is diagnosed 72 h later, a staged operation is performed to eliminate complications and drainage of the upper urinary tract. Reconstructive surgery is performed not earlier than after 2 months.

Kidney autotransplantation: a method for treating ureteral lesions in urological and oncological practice

The first successful kidney autotransplantation was performed in 1902. The technique has undergone several changes since then. The indications and surgical technique are presented in this literature review. Kidney autotransplantation is the treatment of choice for preserving renal function. Three clinical observations on the use of kidney autotransplantation in urological and oncological practice are described: a patient after iatrogenic ureteral injury and two patients with primary retroperitoneal tumor. Literature analysis and clinical observations from urological and oncological practice show that kidney autotransplantation could be safely used for strictly selected indications.

A0971 - Use of allium ureteral stents for managing iatrogenic ureteric injuries

A0971 - Use of allium ureteral stents for managing iatrogenic ureteric injuries

A0181 - Prevention and detection of iatrogenic ureteral injury during abdominal or pelvic surgery: A systematic review and meta-analysis

A0181 - Prevention and detection of iatrogenic ureteral injury during abdominal or pelvic surgery: A systematic review and meta-analysis

Comment on renal autotransplantation: A final option to preserve the kidney after an iatrogenic ureteral injury.

To the Editor, Autologous Renal Transplantation (ART) since firstly described in 1963 by Hardy, has been used in various cases. There are various reasons for the transplantation such as iatrogenic ureteral damage, chronic kidney pain, unresectable renal tumors or renovascular diseases. Indications concerning the suitable patients for this kind of procedure are gradually increasing. Nevertheless, each case is unique, and the treatment must be personalized [...].

Case Report: Early Recognition and Repair of Distal Iatrogenic Ureteral Injury During Laparoscopic Rectal Surgery

Background: Ureteral injury is an uncommon complication of the colorectal procedure. The colorectal procedure is the second most common cause of ureteral injury. The laparoscopic approach for colorectal surgery has contributed to the increase of ureteral injury. Delayed diagnosis of the iatrogenic ureteral injury is associated with higher morbidity. However, the early diagnosis of ureteral injury during the operation is difficult. We presented an early recognition and laparoscopic repair of iatrogenic ureteral injury during laparoscopic rectal cancer surgery cases and the strategy for recognizing and managing that injury for the surgeon.Case Presentation: A Male, 34 years old, had an iatrogenic ureteral injury during laparoscopic low anterior resection for rectal cancer. The left distal ureter was transected by an energy device. The diagnosis of ureteral injury was prompt. The repair of the ureter was done endo-laparoscopically. The patient had an uneventful recovery and was discharged on day 6 after surgery.Conclusion: The iatrogenic ureteral injury, although uncommon, is a serious complication of laparoscopic colorectal surgery. Direct visual identification of the distal ureter is mandatory in every rectal surgery. The iatrogenic ureteral injury is not an indication for open conversion when there is an adequate resource to do the endo-laparoscopic ureteral repair.

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

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. 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. 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. 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.

Ureteral injury during laparoscopic rectal resection and concurrent laparoscopic repair by uretero-ureterostomy

Iatrogenic ureteral injury is an uncommon but severe complication of laparoscopic colorectal surgery. If it is detected intraoperatively, conversion to open surgery is usually inevitable. Here, we described a complete ureteral transection during laparoscopic low anterior resection, which was simultaneously repaired by laparoscopic uretero-ureterostomy. The most important points during the anastomosis of two tiny tubular tissues are dissecting the tubular organs without trauma, obtaining meticulous hemostasis without causing any necrosis, and achieving accurate approximation of tissues with the sutures. To the best of our knowledge, this is the first report that focused on laparoscopic repair of ureteral injury during laparoscopic colorectal surgery. As there are still few data on laparoscopic repair of ureteral lesions, no firm conclusions can be drawn. But, in appropriate cases, if intracorporeal suture expertise is available, laparoscopic repair can be done during colorectal surgery.

Impact of Delayed Recognition of Iatrogenic Ureteral Injury in a Retrospective Population-Based Study

Iatrogenic ureteral injuries (IUIs) are rare but can lead to significant consequences if unrecognized at the time of injury. We compare the impact of immediate vs delayed recognition of IUIs on clinical, cost and health care utilization outcomes. We conducted a population-based retrospective cohort study on patients who had a diagnosis of an IUI between 2003 and 2018. The primary independent variable was the time of diagnosis of IUI. The primary clinical outcomes evaluated included renal impairment and a composite outcome: hydronephrosis or stricture. Secondary outcomes included total direct health care costs and health care utilization. We identified 1,193 patients who experienced an IUI, 25.2% of whom had a delay in recognition. Delayed recognition of IUI was associated with hydronephrosis or stricture within 1 year following treatment of IUI (OR 2.27, 95% CI 1.69-3.04, p <0.0001) and renal impairment within 2 years following treatment of IUI (OR 2.69, 95% CI 1.84-3.94, p <0.0001) compared to immediate diagnosis. Total health care costs (incident rate ratio [IRR] 2.06, 95% CI 1.89-2.24, p <0.0001), emergency department visits (IRR 2.07, 95% CI 1.77-2.43, p <0.0001), hospitalizations (IRR 1.62, 95% CI 1.48-1.78, p <0.0001) and outpatient urology visits (IRR 1.45, 95% CI 1.31-1.60, p <0.0001) were significantly higher in those with delayed recognition compared to immediate. Previous radiation was significantly associated with delayed recognition of IUI (OR 0.64, 95% CI 0.42-0.97, p=0.04). Delayed recognition of IUI is associated with significant clinical, cost and health care utilization consequences.

Editorial Commentary

No AccessUrology PracticeBusiness of Urology1 Nov 2021Editorial CommentaryThis article comments on the following:Impact of Delayed Recognition of Iatrogenic Ureteral Injury in a Retrospective Population-Based Study Michael Naslund Michael NaslundMichael Naslund Division of Urology, University of Maryland School of Medicine, Baltimore, Maryland More articles by this author View All Author Informationhttps://doi.org/10.1097/UPJ.0000000000000253.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Commentary." Urology Practice, 8(6), p. 644 © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesUrology Practice23 Aug 2021Impact of Delayed Recognition of Iatrogenic Ureteral Injury in a Retrospective Population-Based Study Volume 8Issue 6November 2021Page: 644-644 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Naslund Division of Urology, University of Maryland School of Medicine, Baltimore, Maryland More articles by this author Expand All Advertisement PDF downloadLoading ...

Hospital Cost Associated with Preventing and Managing Iatrogenic Ureteral Injury in Inpatient Elective Colectomy

Hospital Cost Associated with Preventing and Managing Iatrogenic Ureteral Injury in Inpatient Elective Colectomy