Ureteral Injury Research Articles (Page 1)

Anastomotic leakage and ureteral injury are serious complications in colorectal surgery, negatively impacting both short- and long-term outcomes. Indocyanine green (ICG) fluorescence has gained attention for intraoperative intestinal perfusion assessment and ureteral navigation. This study evaluated whether these ICG fluorescence-based techniques reduce surgeons' mental workload. We retrospectively assessed surgeons' workload using the NASA Task Load Index (TLX) during laparoscopic colorectal surgeries performed between January and December 2022. Anastomotic blood flow was assessed either using the ICG fluorescence method (n = 158) or the conventional method (n = 29). Moreover, patients undergoing left-sided colorectal surgery were divided into two groups based on the use of fluorescent ureteral navigation (n = 29) versus nonfluorescent navigation (n = 72). Surgeons using ICG fluorescence for blood flow assessment reported significantly lower TLX scores across all domains, including weighted workload (WWL): 12.3 (IQR: 10.5-17.3) vs. 46.8 (IQR: 21.6-54.4), P < 0.0001. Similarly, fluorescent ureteral navigation was associated with significantly lower frustration (20 [12.5-35] vs. 30 [20-55], P = 0.0093) and WWL (20.3 [17.2-36.5] vs. 29 [19.0-43.9], P = 0.0412) compared with the nonfluorescent group. Among surgeons not certified by the Japan Society for Endoscopic Surgery, fluorescent guidance resulted in lower frustration and WWL (P = 0.0053 and P = 0.0092, respectively). No significant differences were observed among certified surgeon. ICG fluorescence-based techniques for anastomotic perfusion and ureteral navigation effectively reduce mental workload for surgeons, especially for those without endoscopic surgical certification. These methods may serve as supportive tools in promoting safe and ergonomic colorectal surgery.

Analyzing relationship between ureter and lumbar vertebrae: insights from digital radiography.

ABSTRACT Objective To evaluate the peri-operative outcomes of retrograde intrarenal surgery (RIRS) using flexible and navigable suction (FANS) ureteral access sheath (UAS) in children less than 2 years age. The primary objective was to assess the single-stage stone free rate. The secondary objectives included the evaluation of operative time, intraoperative visibility, need for reintervention, complication rates and length of hospitalization. Materials and Methods A prospective single centre observational study was done in children less than 2 years age, who underwent RIRS using FANS UAS, from from October 2023 to November 2024. Demographic data, operative parameters were recorded. Intraoperative visibility was assessed using Likert’s scale (grade 1- excellent, grade 2 – average, grade 3 – poor). Complications were graded according to the Clavien-Dindo (CD) classification system. Results Twenty-one children were included and analysed. The median age was 12.00 (10.00–14.25) months and the median stone size was 11.00 (9.00–13.12) mm. The median operative time was 32.00 (25.75–37.25) min. Grade 1 intraoperative visibility was noted in 100% of patients and 3 out of 21 had grade 1 lower ureteric injury due to access sheath placement. 2 out of 21 (9.5%) patients had CD Grade 1 fever, 4 out of 21 (19%) patients had CD grade 1 hematuria. 95.2% were stone free in a single stage, at 4 weeks and none required re-intervention. The median follow-up period was 11.00 (8.75–12.00) months. Conclusion FANS UAS for RIRS in children ( < 24 months) improves single-stage SFR, reduces infections, and lowers re-interventions without serious complications. Its use, ideally by experienced urologists in tertiary centres, confirms its potential as a game-changer

Abstract Background: Iatrogenic ureteric injury is a serious surgical complication, leading to significant morbidity. Understanding its contemporary causes, diagnostic patterns, and management outcomes is crucial for improving patient care. Aim: This study aimed to identify the etiology, management, and outcomes of iatrogenic ureteric injuries in a clinical series of 44 patients. Methods: A retrospective, descriptive study was conducted on 44 patients with iatrogenic ureteric injuries treated between January 2020 and January 2024. Data on demographics, causative procedures, injury characteristics, diagnostic timing/modality, and treatment strategies were collected and analyzed using SPSS version 25.0. Statistical associations were assessed using Pearson's Chi-Squared test. Results: The cohort had a female predominance (61.4%). Gynecological surgeries were the most common cause of injury (40.9%), followed by urological procedures (38.6%, predominantly ureteroscopy) and general surgeries (20.5%). The lower ureter was the most frequently injured site (52.3%). The most common injury types were perforation (29.5%) and ligation (27.3%). A significant association was found between the cause and type of injury (p&lt;0.001), with ureteroscopy linked to perforations/avulsions and gynecological surgery to ligations. Diagnosis was immediate (intraoperative) in 47.7% of cases and delayed in 52.3%. Retrograde ureterography was the primary diagnostic modality (56.8%). Immediate diagnosis was significantly associated with less complex management (e.g., stenting), while delayed diagnosis necessitated more complex reconstruction (p=0.002). Treatment was tailored to the injury and included Double-J stenting (27.3%), ureteroureterostomy (13.6%), and ureteroneocystostomy (27.3%). A significant association was found between the site of injury and the type of surgical repair performed (p=0.015). Conclusion: Iatrogenic ureteric injuries remain a significant challenge, most commonly caused by gynecological and urological procedures. The timing of diagnosis is a critical determinant of management complexity, with intraoperative recognition allowing for simpler, more effective repair. Adherence to procedure-specific preventive strategies and a high index of suspicion are essential to mitigate these injuries and optimize patient outcomes.

Introduction: Prophylactic ureteral catheterization (PUC) is routinely performed during non-urologic procedures to avoid iatrogenic ureteral injury. However, evidence of its benefit is conflicting, as data suggest that the rate of ureteral injury is unchanged and there is lack of data reporting associated complications. The purpose of this study was to evaluate the outcomes of routine PUC in non-urologic surgeries. Methods: All consecutive patients who underwent PUC during non-urologic procedures between January 2019 and March 2024 were reviewed. Demographic, clinical, and perioperative characteristics, including ureteral injury rates, were reviewed. Complications within 90 days were divided into low-grade (urinary tract infection [UTI], gross hematuria, and flank pain) and high-grade (new or worsening hydronephrosis and need for nephrostomy or indwelling stent). Logistic regression was performed to identify predictors of PUC-related complications. Results: Among 233 patients, 63.5% were female. Median age and body mass index were 57 years and 28, respectively. Patient history included neoadjuvant chemotherapy in 54 (23%), pelvic radiation in 43 (18%), and pelvic surgery in 119 (51%). Surgery types included colorectal (75.1%), gynecological (14.2%), or both (10.7%). A total of 101 urologic complications affected 43% of patients, including UTI (22.3%), gross hematuria (24.4%), flank pain (10.7%), new/worsening hydronephrosis (9.9%), and need for nephrostomy tube/stent (1.3%). Intraoperative ureteral injury rate was 3.9%. On multivariate analysis, prior pelvic radiation was significantly associated with the occurrence of high-grade complications (odds ratio 3.29, 95% CI 1.04, 10.43). Conclusion: PUC during non-urologic procedures is associated with a small but significant risk of urologic complications and does not eliminate the risk of ureteral injury. Prior pelvic radiation is a significant risk factor for PUC-related complications.

The association between prophylactic ureteral stents (PUS) and postoperative complications was evaluated. Five electronic databases were searched to identify studies involving patients undergoing colorectal surgery (CRS) with PUS. Primary outcomes were acute kidney injury (AKI), ureteral injury (UI), urinary tract infection (UTI) and hematuria. Risk ratios (RR) and mean differences (MD) were calculated using a random-effects model. Seventeen retrospective cohort studies involving 104 162 patients were analyzed. AKI incidence was not significantly different between PUS and non-PUS (P = .06). Subgroup analysis revealed no significant increase in AKI (P = .08). UI was similar (P = .74); UTI (P < .01) and hematuria (P < .01) were significantly higher with PUS. Operative time was longer (P < .01). PUS in CRS did not significantly reduce UI or increase AKI risk but was associated with higher UTI and hematuria.

To compare operative and 30-day outcomes of dusting versus popcorning lithotripsy during flexible ureteroscopy (FURS) with flexible suction ureteral access sheaths (FANS) in a real-world multicenter study. This prospective analysis included 704 adults from 21 centers undergoing FURS for kidney stone with FANS between August 2023 and August 2024. Patients were stratified by lasing strategy into dusting (n = 281) or popcorning (n = 423). Operative parameters, complications, and stone-free status (SFS) at 30 days-assessed by 2mm slice non-contrast CT scan were compared. Multivariable logistic regression identified predictors of complete clearance (no fragment). Patients in the popcorning group presented with larger and denser stones (> 2cm: 20.7% vs. 10.7%, p = 0.007; median HU 1100 vs. 1051, p = 0.003). Operative times were consistently longer with popcorning, including lasing (17 vs. 14min), ureteroscopy (34 vs. 30min), and overall duration (50 vs. 44min, all p < 0.001). Safety outcomes were comparable, although ureteric injury related to sheath placement was observed exclusively in the dusting group (6.8% vs. 0%, p < 0.001). At 30 days, dusting demonstrated superior outcomes: complete clearance (69.4% vs. 53.9%, p < 0.001), and lower reintervention rates (2.1% vs. 5.7%, p = 0.037). Multivariable analysis using sequentially adjusted models confirmed stone volume as a negative predictor of clearance (OR 0.76-0.81, p ≤ 0.005), while use of Thulium fiber and pulsed Thulium: YAG lasers increased odds of achieving zero residual fragments. Dusting was associated with higher stone-free rates and fewer reinterventions compared with popcorning. However, laser technology, rather than lasing strategy, was the strongest predictor of outcomes, underscoring the need for individualized treatment planning.

Objective: The aim of this study was to establish an evidence base of teamworking and confidence in the provision of emergency urology in the United Kingdom. Methods: An online survey of members of The British Association of Urological Surgeons looked at individual’s confidence in out-of-hours support and its effect on teamworking, communication and the management of emergency urological conditions, or requiring emergency surgery. This was compared with hospital and rota types and occupational status. Confidence in support available was measured on a 5-point Likert-type scale, and on a 10-point visual analogue scale for the clinical management of emergency conditions. Results: In general, communication was bi-directionally good between team members out-of-hours, although this was less evident in district general hospitals. More than 30% of urologists had little confidence in the support provided by their emergency department or on-call managers. Consultants were more confident managing urological conditions than mid-grade and core trainees. However, &gt;60% of consultants had no confidence in providing emergency skin cover, nephrectomy, the management of acute haemorrhage and urgent laparotomy if required, while only 50% were confident in managing the injured ureter. Conclusion: Teamworking and infrastructural support are good for out-of-hours urology. There is an imperative to reconsider training in the management of ureteric injuries at all levels. Level of evidence: Not applicable

Native tissue repair surgery for pelvic organ prolapse is associated with a high recurrence rate, and accumulating evidence has highlighted adverse events related to mesh use. This study aimed to assess the efficacy and safety of a modified paravaginal repair technique combined with sacrospinous ligament suspension for treating pelvic organ prolapse. This randomized, non-inferiority, endpoint assessor-blinded study included patients with pelvic organ prolapse. Participants were assigned to either the intervention group, who underwent the modified paravaginal repair with sacrospinous ligament suspension (MPVR-SSL), or the control group, who received laparoscopic sacrocolpopexy (LSC). Postoperative follow-up continued for one year. Among 173 patients evaluated for eligibility, 160 were enrolled, while 13 were excluded. Of those enrolled, 80 were randomized to each group. At the 12-month follow-up, 5 patients in the MPVR-SSL group and 4 in the LSC group were lost to follow-up. Success rates at 12months were 98.7% (75/76) in the LSC group and 97.3% (73/75) in the MPVR-SSL group, and no significant difference was found between them (P=0.552). No cases of ureteral injury, cystotomy/urethral injury, bowel injury, vascular injury, nerve injury, deep vein thrombosis, or pulmonary embolism were identified in the MPVR-SSL group. A few cases of vaginal bleeding, granulation, or fallopian tube prolapse occurred. Neuromuscular pain was more frequent in the MPVR-SSL group than in the LSC group (13 vs. 3, P=0.008). However, all patients experienced symptom resolution within three months. The MPVR-SSL proved to be an effective and safe approach for treating pelvic organ prolapse.

Prostate size has traditionally been considered a determinant of surgical difficulty and postoperative outcomes in radical prostatectomy. Larger glands often present challenges in bladder neck dissection, with potential implications for continence and oncological safety. We describe the maximal anatomic bladder neck preservation at the prostatic origin (MANO) technique, designed to enable safe circumferential dissection at the true bladder neck origin irrespective of gland size. This retrospective study analyzed 341 patients undergoing nerve-sparing robotic-assisted radical prostatectomy (RALP) with the MANO technique between 2017 and 2023. Patients were stratified into three groups by MRI-estimated prostate volume: < 30cc (n = 83), 30-50cc (n = 147), and > 50cc (n = 111). Perioperative, pathological, functional, and oncological outcomes were compared. Continence was defined as 0-1 pad/day, assessed at 3, 12, and 24 months. Larger prostates were associated with older age and higher preoperative PSA (p < 0.05). Mean operative time increased with gland size (165.2 vs. 191.5min, p < 0.001), and hospital stay was longer for > 50cc prostates (p = 0.003). Blood loss showed a non-significant increase with prostate size. Pathological stage, Gleason grade, and margin status were comparable across groups. Early continence at 3 months was similar (≈71% across cohorts, p = 0.607), with > 85% continent at 12months in all groups. Biochemical recurrence rates did not differ significantly (p = 0.630). Complications were infrequent, with no ureteric injuries reported. The MANO technique enables safe bladder neck preservation across all prostate sizes. Despite increased operative complexity in larger glands, functional and oncological outcomes remain equivalent. This approach may standardize bladder neck management in RALP and support improved continence recovery irrespective of prostate volume.

Urinary tract calculi are highly prevalent worldwide. Vacuum-Assisted Dedusting Lithotripsy (VADL) integrates a Flexible and Navigable suction ureteral access Sheath (FANS) with active suction to overcome limitations of traditional methods. This retrospective cohort study analyzed 1267 patients with renal/proximal ureteral calculi (stratified by stone size: ≤ 2cm, 2-3cm, > 3cm) treated with VADL (2022-2024). Primary outcomes were stone-free rate (SFR) and complications. Overall 3-month SFR was 79.34% (941/1186), highest in ≤ 2cm group (85.96%, OR = 3.2, 95%CI 2.1-4.8). Clavien-Dindo ≥ III complications occurred in 0.34%. Ureteral injury (≥ Grade 2) was 9.61%, associated with sheath size (12/14F: 15.53% vs. 10/12F: 6.63%, P = 0.01). VADL achieves high SFR with minimal severe complications, particularly for stones ≤ 2cm.

Background/Objectives: Placenta accreta spectrum (PAS) is an obstetric condition with placental adherence to the underling myometrium characterized by significant surgical morbidity at time of delivery. PAS delivery is most commonly performed by cesarean hysterectomy. The most common morbidities associated with PAS cesarean hysterectomy are blood transfusion, intensive care unit admission and urinary tract injuries. This requires interdisciplinary team management including obstetricians and urologists. Our objective was to identify pre- and intra-operative risk factors for urologic injury in this high-risk condition. Methods: A retrospective cohort study was performed at a single tertiary center with the Center for the Management of Placenta Accreta Spectrum disorders from 2012 to 2022. Urologic injuries were considered as injury to either the bladder or ureters. Furthermore, bladder injuries were subdivided into those inherent to the procedure (intentional cystotomy) and those considered unplanned complications (incidental cystotomy). Inclusion criteria required complete antenatal documentation for assessment, and these were accessed by electronic medical records. Multivariate analysis was performed for significant variables on univariate analysis. Results: During the 11-year study period, 146 cases of PAS were managed by our team. Of these, 39 (26.7%) were complicated by urologic injury. Intentional cystotomies were performed in 28.2% (11/39) of cases. There were 28 (28/39, 71.8%) incidental cystotomies and 5 (5/39, 12.8%) ureteral injuries were encountered. Of note, all 5 patients with ureteral injuries also had cystotomies. Upon univariate analysis, anterior placentation (OR 2.96 [1.94, 4.67], p = 0.04), percreta by antenatal ultrasound (OR 2.59 [1.13, 5.9], p = 0.02) and >2 pre-delivery vaginal bleeding episodes (OR 4.27 [1.54, 12.16], p = 0.005) were associated with urologic injury. Multivariate analysis revealed the independent significance of these variables. Of note, the presence of zero, one, two, and all three risk factors were associated with urologic injury rates of 11.1%, 22.5%, 41.9%, and 71.4%, respectively. Conclusions: Urologic injury during cesarean hysterectomy occurs in almost one-third of cases. Pre-operative risk factors may be used to identify those at greater risk for this surgical complication. Determining patient risk allows for the use of resources such as formal urology consultation, surgical planning, and intraoperative assistance, as well as detailed patient counseling.

Introduction: Robotic-assisted surgery has transformed elective general surgery, offering well-documented benefits for both surgeons and patients. However, its application in emergency settings remains underexplored. This study aimed to evaluate the feasibility, safety, and perioperative outcomes of robotic surgery in emergency general surgical cases when performed by an experienced surgical team.Methods: This observational, single-center study included 12 patients who underwent emergency robotic surgery at a high-volume tertiary care institution. All procedures were performed by the same surgeon with extensive experience in minimally invasive and robotic techniques. Demographic data and perioperative outcomes were prospectively recorded. Given the small sample size and single-arm design, only descriptive statistics were reported. Continuous variables are presented as mean ± standard deviation (SD) and median (range), and categorical variables as counts and percentages. No inferential statistical testing was applied, as the study was not powered for comparative analysis.Results: The median patient age was 73 years (range 38-91), with a median BMI of 27 kg/m² (range 25-34). The most common indications were obstructing colon tumors (58.3%) and incarcerated hernias (16.7%). The median operative time was three hours (range, two to six hours). There were no conversions to open or laparoscopic surgery. Minor postoperative complications (Clavien-Dindo grade I-II) occurred in two patients (16.7%) and were managed conservatively. One intraoperative complication (ureteric injury) was identified and managed robotically without conversion. No patient required postoperative intensive care. The median time to first flatus and oral intake was two days (range, one to three days). The median hospital stay was two days (range, 1-11 days), with no 90-day readmissions or mortality.Conclusion: Robotic-assisted emergency general surgery may be a safe and feasible option in carefully selected patients when performed by an experienced surgical team with institutional support. While early results from this small cohort are favorable, further multicenter comparative studies are needed to validate these findings and define optimal patient selection.

ABSTRACTVaginally assisted natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy has been compared to conventional laparoscopic total hysterectomy in previous reports. Incidentally, the risk of ureteral injury during total hysterectomy is lower with vaginal hysterectomy than with laparotomy or laparoscopy. Therefore, vNOTES hysterectomy, similar to vaginal hysterectomy, may be a safe option for total resection of cervical myomas.

A Rare Case of Ureteral Injury: Fall from Standing

Outcome of supracervical compared to total hysterectomy for emergency peripartum hemorrhage: a systematic review and meta-analysis.

Calcium oxalate (CaOx) stones account for 90% of uroliths in cats and contribute to ureteral inflammation and fibrosis, although the underlying mechanism remains unclear. Apoptosis inhibitor of macrophage (AIM) is known to play a protective role against tubular injury in feline kidney disease. This study investigated whether AIM contributes to ureteral fibrosis by using AIM-felinized mice subjected to CaOx bead-induced ureteral injury. Male C57BL/6 mice (n = 54), including wild-type mice (mA), AIM-knockout (koA) mice, and AIM-felinized mice (fA), were assigned to either a unilateral ureteral obstruction (UUO; U) group or a UUO plus CaOx implantation (C) group. Ureters were collected 14 days after the procedure for histopathological analysis. The severity of ureteral injury followed the order of koA-C ≥ fA-C > mA-C, indicating AIM’s involvement in the injury process. Furthermore, fA exhibited more severe fibrosis than mA mice (p < 0.05), suggesting that mouse AIM may have stronger anti-fibrotic effects than feline AIM. These results suggest that AIM-felinized mice could serve as a useful model for investigating feline-specific ureteral pathology. To our knowledge, this is the first experimental study to explore the role of feline AIM in ureteral injury and fibrosis. Further studies are warranted to validate the utility of this model.

The incidence of ureteral injury is increasing due to extensive application of the endourological procedures. In the present study, we evaluated the accuracy of imaging studies in predicting length of defect in patients with ureteral injury. We reviewed data of all consecutive patients who underwent endourological management for ureteral injury in our institution from Jan 2020 to Jan 2023, to assess the accuracy of radiological evaluations in determining the length of ureteral defect. We compared the radiological imaging results with intraoperative findings to determine its diagnostic accuracy. We report data on accuracy of preoperative imaging and outcomes of endourological management in 5 patients who presented with apparently long ureteral defects in preoperative radiological evaluations following ureteral injury. The mean age was 42[30.5-42.5]. three of five were male. The mean time from injury to ureteroscopic management was 12.5±7.5 days. The mean follow up time was 7.3±2.2 months. Our experience showed that radiological evaluations have the potential to overestimate the length of defect. Radiological evaluations following ureteral injury have the potential to overestimate the length of defect and therefore endoscopic evaluations and intraoperative imaging studies are necessary to accurately determine the length of defect and appropriate management. However, endourological management is safe and efficient in treating patients with short segment ureteral defect/injury.

Analysis of the use of prophylactic ureteral stents in preventing iatrogenic ureteral injury during radical hysterectomy for cervical Cancer.

Ureteral complications during colorectal surgery.