Ureteral Avulsion Research Articles

Ureteral Replacement Using Segment of Ileum: An Approach Totally Intracorporeal

Abstract Introduction: The ureteral avulsion during ureteroscopic procedures is a rare complication (incidence 0%–2%).1 Surgical options in this situation include ileal ureter replacement, autotran...

Categorization of intraoperative ureteroscopy complications using modified Satava classification system

To review our experience with ureteroscopy (URS) in the treatment of ureteral calculi and stratify intraoperative complications of URS according to the modified Satava classification system. We performed a retrospective analysis of 1,208 patients (672 males and 536 females), with a mean age of 43.1 years (range 1-78), who underwent ureteroscopic procedures for removal of ureteral stones. Intraoperative complications were recorded according to modified Satava classification system. Grade 1 complications included incidents without consequences for the patient; grade 2 complications, which are treated intraoperatively with endoscopic surgery (grade 2a) or required endoscopic re-treatment (grade 2b); and grade 3 complications included incidents requiring open or laparoscopic surgery. The stones were completely removed in 1,067 (88.3%) patients after primary procedure by either simple extraction or after fragmentation. The overall incidence of intraoperative complications was 12.6%. The most common complications were proximal stone migration (3.9%), mucosal injury (2.8%), bleeding (1.9%), inability to reach stone (1.8%), malfunctioning or breakage of instruments (0.8%), ureteral perforation (0.8%) and ureteral avulsion (0.16%). According to modified Satava classification system, there were 4.5% grade 1; 4.4% grade 2a; 3.2% grade 2b; and 0.57% grade 3 complications. We think that modified Satava classification is a quick and simple system for describing the severity of intraoperative URS complications and this grading system will facilitate a better comparison for the surgical outcomes obtained from different centers.

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.

Comparison of SWL and RIRS in Lower Calyceal Stones

Background: The efficacy of extracorporeal shock wave lithotripsy(SWL) in kidney stones in the lower calices was compared using retrograde intrarenal surgery(RIRS). Methodology And Materials: Between January 2008 and May 2011, 64 patients (40 male and 24 female) undergoing SWL and 60 patients (38 male 22 female) undergoing flexible URS were analyzed retrospectively, and success rates were compared. Using the Storz Medical Modulith SLK, patients underwent the SWL process prior to the induction of anesthesia. On the other hand, the 8 f Storz flex X2 flexible URS was used for URS after general anesthesia and RIRS. During the RIRS process, stones were crushed using the 0.2 mm diameter holmium: YAG laser probe, and stone fragments larger than 2 mm were extracted. In some cases, double J or ureteral catheters were placed in the ureter. Results: In the 64 patients undergoing SWL with lower caliceal stones, the following ranges were noted: stone diameter: 6-35 mm (mean 15.9 mm), age: 16-72 years (mean , sessions required: 1-4 sessions (mean: 1.6), the number of shots: 1000-7650 (mean: 4124.6), fire intensity: 25-75 (mean: 60). Ten percent of patients required analgesia, and the success rate of the procedure was 87.5%. Hematuria occurred in 65% of patients as a minor complication and in 2%,streinstrasse occurred as a major complication. Inpatients undergoing RIRS, the following ranges were noted: stones size: 7-30 mm in diameter (average 15.2 mm), age: 21-60 years (mean 39.75),duration of operation: 30-85 minutes(mean: 48.8 minutes), respectively. An access sheath was used in all 32 patients. Balloon dilation was performed in 8 patients with distal ureteral stenosis, and a double J catheter was placed in 2 patients because of stenosis in the upper ureter and four weeks later, the stones were treated with fURS. Patients were discharged on an average of 1.2 days (1-3 days). A ureteral laceration was noted in 30% of patients while 75% of patients had hematuria. Partial ureteral avulsion occurred in one patient with an overall success rate of 96.4%. Conclusions: During the treatment of lower caliceal stones, the success and complication rate of RIRS is higher than SWL.

Kidney Autotransplantation in Complete Iatrogenic Injury of Ureter

Introduction: Ureteral injuries represent less than 1% of all genitourinary traumas. In 75% of cases such complications are iatrogenic in nature and are induced by a medical procedures or physical intervention on tissues. Only 18% of the total can be attributed to urologic treatment, mainly to endoscopic procedures. There are many corrective measures to counteract urethral injuries however the mode or type of an intervention is dependent on a damage location and the length of urethral loss. As for the total ureter damage, it is recommended to replace the ureter by ileal interposition or to perform kidney autotransplantation. Materials and methods: 32 year old man was hospitalized due to URS induced ureteral avulsion located at lower kidney pole. In his case URS had been conducted to treat stone of left ureter. In view of the mentioned complications he qualified for kidney autotransplantation. After performed nephrectomy prepared kidney was repositioned to a right iliac fossa and renal artery and vein were anastomosed with iliac external vessels end-to-side. Subsequently ureter was anastomosed with urinary bladder by Lich -Gregoira technique. The patient left hospital 10 days after the procedure had been carried out. Control tests conducted 3 weeks after the autotransplantation showed correct vessels anastomosis as well as right renal secretion function Summary: Kidney autotransplantation is definitely the optimal form of treatment applied to ureteral injuries as it allows to maintain physiological urine outflow and to preserve other organ functions. As opposed to ileal interposition in this scenario we can avoid abnormal mucous secretion, electrolyte absorption, bacteriuria and vesicoileal reflux. Despite of kidney autotransplantation being a complicated procedure taking into account the requirement of extensive expertise in vascular surgery, it provides unrivaled choice to young men who would find kidney loss extremely hard to accept. In addition, from medical point of view kidney autotransplantation constitutes a rare but fascinating example where urology and transplantology as two distinctive fields of medicine come together to preserve patients quality of life.

Early experience in ureteroscopy for the management of ureteric stone

Ureteroscopy has revolunized the management of ureteric calculus and it has become the need of every urology center today. The purpose of this study is to report our experience and results in the management of ureteric calculus by semi-rigid ureteroscopy and pneumatic lithotripsy and also to access the safety of procedure in untrained hands. Retrospective analysis of 48 consecutive patients of ureteric calculus treated by semi-rigid ureteroscopy and pneumatic lithotripsy between June 2010 and October 2010 in urology unit, College of Medical Sciences, Bharatpur, Nepal was done. 34 female patients (70.8%) and 14 male patients (29.2%) were identified. Mean age of female was 30.9years (range 17 to 45 years) and that of male was 46.4 years (range 33 to 63years). Mean stone size in female was 8.91mm (range 6.5 to 11.2mm) and in male it was 9.11mm (range 6 to 14.2mm). Lower ureteric calculus was present in 29 and 8(77.1%), mid ureteric calculus in 2 and 2(8.3%) and upper ureteric calculus in 3 and 4(14.6%) female and male patients respectively. Ureteric perforation occurred in 2 patients (4.2%). Ureteric avulsion occured in 1 female patient (2.1%) with upper ureteric calculus. DJ stent was keept in 34(70.8%) cases but in 11 cases (32.6%) DJ stent had to be removed earlier than 4 weeks due to stent related problems. Urine culture was sent before ureteroscopy in all the patients and was sterile in 24 patients (50%), contaminated growth in 12 patients (25%), grew E-coli in 8 patients (16.7%) and Kliebsella pneumonia in 2 patients(4.2%). Average duration of stay was 2.7 days. 5 patients developed fever post operatively, managed by intravenous antibiotics. There was no mortality. Though ureteroscopy has become a boon for the management of ureteric calculus, complications like perforation, ureteric avulsion, residual stone and stone migration are more in upper ureteric calculus and stone size > 1cm. Stenosed ureteral assess can be made with proper guide wire selection and prior dilatation .The procedure is relatively safe even in inexperienced hands. Journal of College of Medical Sciences-Nepal,2011,Vol-7,No-4, 28-33 DOI: http://dx.doi.org/10.3126/jcmsn.v7i4.6738

Curative effect of using spiral pedunculated bladder muscle flap in long ureteral segment defect repairing

Objective To investigate the effects of using spiral pedunculated bladder muscle flap ureteroplasty in the treatment of long ureteral segment defects ( ＞ 20 cm). Methods A retrospective analysis was conducted on the clinical effects of five patients who encountered long ureteral segment defects caused during ureteroscopic lithotripsy.The five patients included three males and two females with an age range from 37 to 59 yrs ( average age 48 ).Four of the cases had defects on the left and one case on the right.Two cases had whole ureteral mucosal avulsion and three cases had whole ureteral ruptur from the pelvis to the bladder junction.Defect lengths measured from 21 to 25 cm( mean length 22.5 cm).All five patients underwent emergency surgery using spiral pedunculated bladder muscle flap ureteroplasty and 7 F double J stent placement in the repaired ureters which was fixed on psoas muscles.The average length of the new ureters using spiral pedunculated bladder muscle flap was 22.5 cm. Results All the operations were successful and the operation time was 1 -2 hrs (average 1.5 hrs).Drainage tubes for four patients were removed three days after operation.IN the remaining case the drainage tube was removed 10 days after surgery due to urine leakage.All wounds healed uneventfully.Serum creatinine and blood urea nitrogen were normal two weeks after surgery.Double-J tubes were removed safely under cystoscope eight weeks after surgery.In following-up,one case was found to have mild hydronephrosis and ipsilateral ureter slight expansion six months after surgery,but renal function was normal.There was no abnomality found in the remaining four patients after 2 -4 years of follow-up.The IVU showed normal morphology and good developments in the ipsilateral ureter. Conclusions Spiral pedunculated bladder muscle flap ureteroplasty is an ideal treatment method in repairing long ureteral segment defects. Key words: Ureteroscopy; Complication; Bladder muscle flap; Ureteroplasty

Prevalence and management of complications of ureteroscopy: a seven-year experience with introduction of a new maneuver to prevent ureteral avulsion.

To evaluate the prevalence and type of rigid ureteroscopy complications and suggest a new method for ureteral avulsion prevention. Between March 2002 and March 2009, we retrospectively evaluated 2955 patients who had undergone diagnostic or therapeutic ureteroscopy for asymptomatic hematuria, migrated ureteral stent, or transurethral lithotripsy. They were enrolled from four hospitals in Ahvaz, Iran. Complications were encountered in 241 (8%) patients, including transient hematuria (4.2%), mucosal erosion (1.4%), stone migration (1.3%), ureteral perforation (1.2%), and fever and/or sepsis (1.0%). Ureteral avulsion occurred in 6 (0.2%) patients. Mostly, complications were managed conservatively, using ureteral stenting. Ureteral avulsions were managed using a new technique. In our series, the complication rate is comparable with the literature. A new technique was used in case of ureteroscope entrapment in the ureter, to lessen the occurrence of ureteral avulsion.

Endoscopic Management of Complete Ureteral Avulsion from Uretero-Vesical Junction: A Novel Endoscopic Technique (Azayem Technique)

Abstract Introduction: This video presents our novel endoscopic technique for management of complete ureteral avulsion from uretero-vesical junction (UVJ). Materials and Methods: A retrospective study of prospective data on 1934 ureteroscopic stone manipulation procedures performed at our Urology Department in Saudi German Hospital–Jeddah from January 2001 to January 2011 was conducted. The ureterorenoscope used was an 8F, Storz, semirigid ureterorenoscope. During this period, three cases of complete ureteral avulsion from UVJ were recorded. All these three cases were managed successfully by our novel endoscopic technique that we present in this video. Surgical Procedure: Postavulsion event, the ureteroscope is withdrawn outside the patient keeping the guidewire (GW) in place. A Double-J (DJ) stent is then applied along the GW up to the kidney. The ureteroscope is then reinserted into the bladder, and guided by the DJ through the avulsion site into the retro peritoneum up to the lower end of the avulsed u...

Ureteral avulsion during contemporary ureteroscopic stone management: "the scabbard avulsion"

Ureteral avulsion during contemporary ureteroscopic stone management: "the scabbard avulsion"

UP-03.095 Prevalence and Management of Complications of Ureteroscopy: A 7-Year Experience with Introduction of a New Maneuver for Prevention of Ureteral Avulsion

UP-03.095 Prevalence and Management of Complications of Ureteroscopy: A 7-Year Experience with Introduction of a New Maneuver for Prevention of Ureteral Avulsion

Ureteral Avulsion During Contemporary Ureteroscopic Stone Management: “The Scabbard Avulsion”

Ureteral avulsion during ureteroscopic stone management is extremely rare. To date, many publications reporting avulsion have been associated with "blind basket extraction" under fluoroscopy and the use of the Dormia stone basket. Fortunately, despite the significant rise in the numbers of ureteroscopic cases being performed, the rate of ureteral avulsion remains low. This is likely in part because of improvements in ureteroscope technology and stone manipulation devices. We present three recent cases of ureteral avulsion referred to our center for further management. To our knowledge, these cases represent the first published description of avulsion where the ureteroscope became wedged in the intramural ureter, resulting in full-length avulsion of the ureter. The avulsion occurs both proximally and distally with a resultant length of ureter left attached to the ureteroscope. We dub this mechanism the "scabbard" avulsion. We describe the most likely mechanism of this injury, with suggestions on how to prevent it and how to release the ureteroscope should it become wedged in the intramural ureter.

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

The aim of this study was to investigate the treatment modality of complete ureteral avulsion. This study retrospectively analyzed the data of four patients with complete ureteral avulsion who were treated between November 2003 and March 2008 in our hospital. Of the four patients, one had ureteropelvic junction avulsion, one had proximal ureteral avulsion, and the other two had distal ureteral avulsion. One patient underwent autotransplantation of kidney for treatment of severe proximal ureteral avulsion. Pyeloureterostomy plus greater omentum investment outside the native distal ipsilateral ureter was performed in the patient with ureteropelvic junction avulsion. The other two patients underwent ureterovesical anastomosis. All four patients were followed up for an average time of 29 months (16-45 months). Renal function recovered well in the patient who underwent autotransplantation of kidney and ureterovesical anastomosis and the two patients who underwent ureterovesical anastomosis. The other patient who underwent pyeloureterostomy developed hydronephrosis and nonfunctioning kidney. The patient then underwent nephrectomy. Complete ureteral avulsion is a rare but severe complication. Autotransplantation of kidney and ureterovesical anastomosis may result in positive outcomes in patients with proximal ureteral avulsion.

A Case of Ureteral Avulsion Secondary to an Abdominal Stab Wound

A Case of Ureteral Avulsion Secondary to an Abdominal Stab Wound

Use of NTrap® during Ureteroscopic Lithotripsy for Upper Ureteral Stones

PurposeThis study aimed to determine the value of the NTrap® (Cook Urological INC, USA), which was designed to block the upward movement of stones during ureteroscopic lithotripsy.Materials and MethodsWe reviewed the data of 144 patients who underwent ureteroscopic lithotripsy for an upper ureteral stone from June 2006 to May 2010. Sixty-eight patients who underwent ureteroscopic lithotripsy without the use of the NTrap® were assigned to Group I and 76 patients who underwent ureteroscopic lithotripsy with the NTrap® were assigned to Group II. The size of the stones, operation time, success rate, and pre- and postoperative complications were compared retrospectively between the two groups.ResultsThe mean age of the patients (Group I: 35.8 years; Group II: 32.6 years) and the sex ratios were not significantly different between the two groups. The mean size of the stones was 6.9 mm and 7.4 mm, which also was not significantly different between the two groups. The mean operation time was 82.7 minutes and 78.7 minutes. The operation time was shorter in Group II, but the difference was not significant. The success rate of stone removal was 89.7% and 98.7% in Groups I and II, respectively; Group II showed a significantly higher success rate. Two cases of ureteral perforation and one case of ureteral avulsion occurred in Group I, and one case of ureteral perforation occurred in Group II.ConclusionsNTrap®, which is an instrument used to assist during ureteroscopic lithotripsy, can be considered to be an effective tool that blocks the upward movement of the stone and aids in safe stone removal.

Outcome of Retrograde Ureteroscopy URS for the Management of Ureteric Calculi: Four Years Experience

Objectives: To ascertain the efficacy of transurethral Ureteroscopy (URS) and Pneumatic Lithoclasty for the management of ureteral stones. Place and duration of study: This retrospective study was conducted from December 2005 to December 2009 at the Department of Urology and Renal Transplantation, Allied Hospital/Punjab Medical College, Faisalabad and Hospitals in Private sector. Methods: Patients with stones of different sizes and at different levels in the ureter were included in the study. Patients of less than 12 years of age and also patients with ureteric stones more than 3 cm were not included in the study.Such stones were managed by open Ureterolithotomy Results: A total number of 540 patients with ureteric calculi were included in the study. Cause of ureteric obstruction was stones in all cases. Among these 450 patients, 209 (38.6%) patients presented with lower ureteric stones, 266 (49.20%) patients presented with stones in the mid ureter, 65 (12.2%) patients presented with stones in the upper ureter. Bilateral ureteric calculi were present in 95 (17.5%) cases. Out of 540 cases 57 (10.62%) patients presented with anuria and they were initially treated by Percutaneous Nephrostomy PCN to relieve the obstruction followed by URS and Lithoclasty Overall, ureteric stones at different levels and of different sizes were treated successfully in 480 (89.0%) patients and in remaining 60 (11.0%) patients stones could not be broken. Stones were successfully fragmented and cleared in the 198 (94.73%) of 209 patients with stones in the lower ureter, in 253 (95.11%) of 266 patients with stones in the mid ureter and in 29 (44.61%) of 65 patients with stones in the upper part of ureter. Stones were successfully fragmented in 347 (98.21%) out of 354, 92 (85.18%) out of 108 and 41 (52.56%) out of 78 patients with stone sizes of <1 cm, 1-2 cm and 2-3 cm respectively. DJ stents were inserted in 426 (78.81%) cases. Procedure was not successful in 60 (11.0%) patients. Stones were migrated up in to renal pelvis in 31 (5.73%) patients, stone fragmentation failure was in 13 (2.40%) patients, failure of URS insertion up to stone was in 6 (1.10%) patients and ureteric avulsion was in 1 (0.18%). Conclusion: Transurethral rigid Ureteroscopy is still an acceptable procedure in the treatment of ureteric calculi of different sizes at different levels and it can be used safely with very good results in expert hands.

Ureteroscopic management of lower ureteric calculi: a 15‐year single‐centre experience

To review our 15-year experience with ureteroscopic treatment of distal ureteric calculi and to determine the impact of improved technology and techniques on the efficacy, success and complications of the procedure. We retrospectively reviewed the medical records of 4512 patients who underwent 5133 ureteroscopic procedures for the treatment of distal ureteric calculi at our institution from January 1991 to December 2005. The patient and stone characteristics, treatment variables and clinical outcomes were assessed. Factors such as type of ureteroscope, procedure duration, procedure success, complication rate and hospital stay were evaluated. Data obtained from a cohort of patients that underwent the procedure from 1991 to 1995 (group 1) were statistical compared with those obtained from a cohort of patients from 1996 to 2005 (group 2). Logistic regression analysis was used to identify associated factors with the major complications of ureteroscopy. Overall, the stone-free rate after the procedure was 94.6%, the mean (sd; range) operative duration was 43 (15.0; 25-120) min, the intraoperative complication rate was 6.67%, the postoperative complication rate was 9.9%, and the mean (sd) hospital stay was 1.7 (1.1) days. The clinical and radiological follow-up (mean 36.8 months) for 71.3% of eligible patients detected only 12 ureteric strictures (0.23%). On comparing group 1 with group 2, the overall success of ureteroscopic stone extraction improved from 85.7% to 97.3% (P < 0.001), significant ureteric perforation decreased from 3.3% to 0.5% (P = 0.05), ureteric avulsion decreased from 1.3 to 0.1% (P < 0.05), ureteric stricture decreased from 0.7% to 0.1% (P < 0.007), the mean (sd) procedure time significantly decreased from 75 (42.9) min to 36.5 (12.5) min (P < 0.001), and the mean hospital stay significantly decreased from 2.5 (1.6) days to 0.5 (1.2) days, with a trend toward outpatient treatment. Logistic regression analysis showed a significant association of the major ureteroscopic complications with increased operative duration, type of ureteroscope used, stone impaction, stone size and surgeon experience. The present series shows the high success rate, with minor complications, that can be achieved with ureteroscopic treatment of distal ureteric calculi. Improvements in ureteroscope design, accessories, technique and experience have led to a significant increase in the success rate and decrease in the complication rate.

Predictive Factors for Intraoperative Complications in Semirigid Ureteroscopy: Analysis of 1235 Ballistic Ureterolithotripsies

To evaluate potential preoperative predictive factors for complications in ureteroscopic treatment of ureteral stones. One thousand two hundred thirty-five semirigid ureteroscopies for ureteral stones were prospectively inserted in our database and analyzed for complications. Preoperative variables evaluated were as follows: age, gender, length of symptoms, previous extracorporeal shock wave lithotripsy (ESWL), associated urinary tract infection (UTI), stone location, and degree of hydronephrosis. Univariate analysis and multivariate logistic regression were conducted. Fifty-five (4.4%) procedures had complications. There were 8 ureteral perforations, 5 paraureteral stones, 2 ureteral avulsions, 5 mucosal eversions, 1 urethral injury, and 34 mucosal tears. In univariate analysis, age (P = .000), gender (P = .002), previous ESWL (P = .047), stone size (P = .001), and location (P = .001) were predictors of complications. Gender (P = .012), previous in situ ESWL (P = .037), stone size (P = .025), and location (P = .019) remained predictors in multivariate logistic regression. Semirigid ureteroscopy is a safe procedure with few complications. Larger stones, proximally located (iliac vessels or above) with previous in situ ESWL in men are preoperative predictors for intraoperative complications.

Endovascular snare kit in the combined antegrade and retrograde management of ureteral avulsion: report of two cases

We report the feasible and safe use of the Amplatz Goose Neck Snare kit for avulsed ureter retrieval during ureteroscopy. A 49-year-old lady and a 61-year-old man complaining of urolithiasis underwent ureteroscopy; following stone fragmentation, and basketing avulsion of the ureter occurred. Using the Amplatz Goose Neck Snare kit it was possible to place an indwelling ureteral catheter in both cases aiming at restoring the urinary upper tract continuity. The snare-assisted endovascular technique may be an interesting tool even in endourology for the management of ureteral avulsion. This endoscopic mini-invasive procedure makes it possible to avoid an immediate invasive surgical approach often resulting in nephrectomy, having time for planning a possible durable conservative treatment.

Rigid Ureteroscopy for Ureteral Stones: Factors Associated with Intraoperative Adverse Events

To analyze some of the factors that may be associated with a higher incidence of complications during management of ureteral stones by rigid ureteroscopy. We reviewed all ureteroscopic interventions aimed at stone extraction and/or fragmentation in our institution from 2001 through 2005. A total of 442 interventions were eligible for inclusion. Our focus was concentrated on (1) patient characteristics (age, gender, duration of symptoms, history of urinary schistosomiasis, and history of surgery involving the affected ureter), (2) stone characteristics (number, length, width, and level of the ureter affected), (3) the affected reno-ureteral unit (which side was affected, the kidney's ability to excrete contrast medium, and the status of the ureter proximal and distal to the stone), and finally (4) experience level of the surgeon in charge (junior v senior). The occurrence of intraoperative adverse events was considered a dependent variable and was statistically related to each of the above factors as independent variables. Intraoperative adverse events were encountered in 121 interventions including stone migration in 54, minor mucosal injuries in 24, ureteral perforation in 12, ureteral avulsion in 2, and aborted procedure due to bleeding or edema in 29. Symptomatology present for more than 3 months, a negative history of schistosomiasis, a positive history of ureteral surgery, stones above the ischial spines, stones >5 mm in width, a dilated proximal ureter, kidneys that failed to excrete contrast medium, and involvement of a more junior urologist were factors that were associated with a statistically significantly higher incidence of intraoperative complications. Rigid ureteroscopic stone manipulation remains a procedure that should be handled cautiously. Existence of any of the above risk factors should alert urologists, particularly at training centers, to adopt all possible precautionary measures.