Ureteral Injury Research Articles

Effect of preoperative Silodosin on facilitating access sheath placement in retrograde intrarenal surgery. A randomized controlled studys

ABSTRACT Introduction to evaluate the effect of preoperative Silodosin on ureteric dilatation to facilitate ureteral access sheath (UAS) placement and reduction of ureteral wall injury in retrograde intrarenal surgery (RIRS). Methods one hundred and twenty patients with renal or ureteric stones were randomly allocated into 2 equal groups. Group A represents patients who received a 7-day preoperative single dose Silodosin before RIRS while Group B represents patients who received a placebo for the same regimen. Our primary outcome was to assess the success rate of (UAS) placement. Our secondary outcomes were to evaluate the perioperative complication rate, stone-free rate, hospital stay, and cost analysis. Results In our study, Silodosin showed a higher success rate for (UAS) insertion compared to placebo with a statistically significant difference (p-value = 0.04). Spontaneous UAS insertion in the Silodosin group was 58.3%, which was increased with active ureteric dilatation to 98.3%. Preoperative Silodosin led to less postoperative pain and analgesics requirements without impacting postoperative hospital stay or stone-free rate. There was less ureteric injury incidence in the Silodosin group compared to placebo with a statistically significant difference (p-value = 0.002). Conclusion Preoperative Silodosin facilitates UAS insertion with a protective role against ureteric injury compared to placebo.

Prophylactic ureteral stent in colorectal surgery: a meta-analysis and systematic review.

Accidental ureteric injury during colorectal surgery is a rare but dreadful event. It is associated with a higher risk of urinary tract infection (UTI) and acute kidney injury (AKI). Prophylactic placement of double J stents could improve ureteral identification and decrease the chance of accidental ureteral injury. We searched MEDLINE, Cochrane, Central Register of Clinical Trials, and Web of Science for studies published until March 2024. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled with a random-effects model. Statistical significance was defined as p < 0.05. Heterogeneity was assessed using the Cochran Q test and I2 statistics, with p-values inferior to 0.10 and I2 > 25% considered significant. Statistical analysis was conducted in RStudio version 4.4.1. Eleven observational studies were included, comprising 71,784 patients. Among them, 11,723 (16.4%) were submitted to a prophylactic ureteral stent while 59,961 (83.6%) were not. There was no significant difference in ureteral injury between the groups (0.66% vs 0.8%; OR 1.45; 95% CI 0.43-4.87; p = 0.552; I2 = 56%). Prophylactic stent placement was associated with an increase in AKI (1.7% vs. 0.56%; OR 1.54; 95% CI 1.24-1.91; p < 0.001; I2 = 44%), operative time (MD 24.8min; 95% CI 4.9-44.8; p = 0.01; I2 = 91%), and a decrease in mortality (OR 0.11; 95% CI 0.05-0.23; p < 0.001; I2 = 42%). No differences were observed in UTI, hematuria, length of hospital stays, and reoperation. In colorectal surgery, prophylactic ureteral stents were associated with increased AKI and operative time. No significant difference was observed in ureteral injury, UTI, hematuria, length of hospital stays, and reoperation.

Predictors and potential risk factors of iatrogenic ureteral injury following common obstetric and gynecological surgeries: A single-center retrospective study

Objectives: As iatrogenic ureteral injury carries a high burden and is associated with increased postoperative morbidity and mortality, the purpose of this study is to determine the incidence and potential risk factors of iatrogenic ureteral injury following common obstetric and gynecological surgeries in King Abdulaziz Medical City. Methods: This was a single-center retrospective cohort study based on data extracted from an electronic hospital information system conducted in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Three thousand four hundred and sixty-four cases of cesarean section (C-section) and hysterectomy from January 1, 2021, to December 31, 2022, were reviewed. All cases of C-section and hysterectomy in which the urology department was consulted for suspected iatrogenic ureteric injuries were included in the study. All cases other than C-sections and hysterectomy in which the urology department was consulted for suspected iatrogenic ureteric injuries were excluded from the study. Results: A total of 45 patients for whom urology was consulted for suspected ureteral injury were included in this study. Approximately (35.6%) one-third of the patients had positive findings of ureteral injury following common obstetric and gynecological surgeries. About 41.2% of these patients had previous gynecological surgeries. Other potential risk factors were tested such as age and body mass index. Older patients were slightly at higher risk of iatrogenic ureteral injury (P &lt; 0.05). Conclusion: Ureteral injury in obstetric and gynecological surgeries is rare yet serious complication. The findings of this study suggest that the incidence of iatrogenic ureteral injury was relatively associated with older age.

A Presacral Fixation Simulation Surgical Training Model for Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) Sacrocolpopexy

ObjectiveThe number of sacrocolpopexies performed with transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is increasing, and presacral fixation is the most dangerous step. Therefore, the training opportunities for trainees to become competent in performing vNOTES sacrocolpopexy are very important. Simulation-based training is ideal for filling this gap. The objective of this video article is to demonstrate a simulation surgical training model in vNOTES presacral fixation. SettingThe Department of Gynecology at a university hospital. ParticipantsA urogynecological surgeon. Interventions(1) Establish presacral model (Fig. 1) and pelvic model (Fig. 2). (2) Establish vNOTES single-port platform. (3) Steps of vNOTES presacral fixation: (a) Identify the sacral promontory and right hypogastric nerve (rHN), and incise the right pelvic peritoneum. (b) Expose and open the presacral fascia to expose the middle sacral vessels and anterior longitudinal ligament (ALL). (c) Complete mesh fixation. (d) Close the pelvic peritoneum. This study is exempt from IRB approval. Model materials and corresponding costs are given in Table 1. ConclusionWe present a presacral fixation simulation model during vNOTES sacrocolpopexy. A piece of rubber tissue is attached to pelvic model to accurately simulate the vagina, thus achieving the establishment of the vNOTES single-port platform. The presacral model displays the anatomic hierarchy of presacral exposure: pelvic peritoneum, presacral fascia, presacral space, as well as the ALL, rHN, ureter, and presacral vessels, which are embedded in these layers. Presacral slope design enables realistic presacral suture and mesh fixation. In case of nerve, blood vessel, or ureteral injury during dissection, this model simulates the manifestation through the leakage of different colored liquids. This new model allows the next generation of urogynecological surgeons to acquire adequate training to make them more prepared to perform their initial vNOTES sacrocolpopexy on a patient, possibly increasing future safety and effectiveness.

Collecting Duct Pro(Renin) Receptor Contributes to Unilateral Ureteral Obstruction-Induced Kidney Injury via Activation of the Intrarenal RAS.

Although the concept of the intrarenal renin-angiotensin system (RAS) in renal disease is well-described in the literature, the precise pathogenic role and mechanism of this local system have not been directly assessed in the absence of confounding influence from the systemic RAS. The present study used novel mouse models of collecting duct (CD)-specific deletion of (pro)renin receptor (PRR) or renin together with pharmacological inhibition of soluble PRR production to unravel the precise contribution of the intrarenal RAS to renal injury induced by unilateral ureteral obstruction. We examined the impact of CD-specific deletion of PRR, CD-specific deletion of renin, and S1P (site-1 protease) inhibitor PF429242 treatment on renal fibrosis and inflammation and the indices of the intrarenal RAS in a mouse model of unilateral ureteral obstruction. After 3 days of unilateral ureteral obstruction, the indices of the intrarenal RAS including the renal medullary renin content, activity and mRNA expression, and Ang (angiotensin) II content in obstructed kidneys of floxed mice were all increased. That effect was reversed with CD-specific deletion of PRR, CD-specific deletion of renin, and PF429242 treatment, accompanied by consistent improvement in renal fibrosis and inflammation. On the other hand, renal cortical renin levels were unaffected by unilateral ureteral obstruction, irrespective of the genotype. Similar results were obtained via pharmacological inhibition of S1P, the key protease for the generation of soluble PRR. Our results reveal that PRR-dependent/soluble PRR-dependent activation of CD renin represents a key determinant of the intrarenal RAS and, thus, obstruction-induced renal inflammation and fibrosis.

Identifying risk factors for urologic complications in placenta accreta spectrum surgical management.

To describe urologic complications associated with the surgical management of placenta accreta spectrum and determine their risk factors. A retrospective study was conducted on all patients diagnosed with abnormal invasive placentation who underwent surgery and delivered between 2002 and 2023 at a single expert maternity centre. Intra-operative and post-operative complications were described, with a special focus on urologic intra-operative injuries, including vesical or ureteral injuries. Univariate and multivariate analyses were performed to determine risk factors of intra-operative urologic injuries associated with placenta accreta spectrum surgical management. Additionally, using the Clavien-Dindo classification, the effects of intra-operative urologic injury and ureteral stent placement on post-operative outcome were evaluated. A total of 216 patients were included, of which 47 (21.48%) had an intra-operative bladder and/or ureteral injury. Placenta percreta was associated with a higher rate of intra-operative urologic injury than placenta accreta (72.34% vs. 6.38%, p < 0.001). Multivariate analyses showed that patients who had placenta percreta and bladder invasion or emergency hysterectomy were associated with more intra-operative urologic injuries (OR = 8.07, 95% CI [2.44-26.75] and OR = 3.87, 95% CI [1.09-13.72], respectively). Patients with intra-operative urologic injuries had significantly more severe post-operative complications, which corresponds to a Clavien-Dindo score of 3 or more, at 90 days (21.28% vs. 5.92%, p = 0.004). Surgical management of placenta accreta spectrum is associated with significant urologic morbidity, with a major impact on post-operative outcomes. Urologic complications seem to be correlated with the depth of invasion and the emergency of the hysterectomy.

A rare case of early abdominal pregnancy (EAP)

Introduction: Abdominal pregnancy comprises 1% of ectopic pregnancies and is challenging to manage due to the associated significant morbidity and mortality. Abdominal pregnancy may be classified according to gestation and implantation site. Ultrasound imaging is the mainstay of diagnosis. Confirmatory tests include magnetic resonance imaging (MRI) and diagnostic laparoscopy. Case Report: A 36-year-old patient, amenorrheic for 9–10 weeks, presented to the early pregnancy unit complaining of a one-day history of abdominal pain associated with an episode of vomiting. She denied vaginal bleeding and examination revealed left lower quadrant tenderness. Ultrasound imaging demonstrated a live abdominal pregnancy around 12 weeks’ gestation implanted on the left uterine surface. Following appropriate counselling, she opted for surgical management and consented to the termination of pregnancy. She underwent diagnostic laparoscopy which confirmed that the gestational sac was arising from the left lateral uterine angle and was densely adherent to the omentum and bowel. The procedure was converted to laparotomy to enable safe adhesiolysis and excision of the entire gestational sac. Postoperatively, she represented on day 12 with abdominal pain, fever and bleeding. Computed tomography of abdomen and pelvis (CT-AP) suggested left ureteric injury and she underwent retrograde double J urethral stent (JJ stenting) of the left ureter. Fortunately, the same healed with conservative management. Conclusion: Abdominal pregnancy is rare and poses challenges in diagnosis and management. Once diagnosed, urgent surgical management is recommended given the high risk of complications including intra-abdominal bleeding and visceral injury. Therefore, each case requires a careful and considered treatment approach by a multi-disciplinary team.

The efficacy of flexible ureteroscopy for large volume stones and hazards of ureteral access sheath usage: A prospective randomized study

ABSTRACT Objectives We aimed to assess the stone free rate of flexible ureteroscopy and laser lithotripsy (FURL) in upper urinary tract stones (UUTS) >20 mm and the risk of complications from ureteral access sheath (UAS) usage. Methods This is a prospective randomized clinical trial that included patients with UUTS larger than 20 mm who underwent FURL after randomization into two groups: group A (UAS) and group B (non-UAS). Data were collected for patients’ demographics, stone parameters, operative and postoperative complications, and the outcome of FURL regarding stone-free rate (SFR) and perioperative complications, with a 6-month follow-up. Stone clearance was defined as the absence of fragments or the presence of fragments smaller than 2 mm on follow-up CT scans of the urinary tract (CTUT). Results One hundred and fifty-nine patients were evaluated. The mean stone size was 27.08 ± 6.185 mm. Complete stone-free status was achieved in 84.9% of the patients. No significant difference was detected between both groups regarding operative time or SFR. The ureteric injury was identified in 13 (8.1%) patients (10 in group A and 3 in group B, p: 0.0481). Five of them, from group A, revealed hydronephrosis after stent removal. Postoperative pain and fever were documented in 50 and 22 patients, respectively, without significant differences between both groups. Postoperative sepsis occurred in 7 patients (2 in group A, 5 in group B, p: 0.380) who required supportive care. Conclusion FURL without UAS is a safe and efficient treatment for upper urinary tract stones larger than 20 mm in the form of lower risk of ureteric injury.

Utility and challenges of ureteral visualization using a fluorescent ureteral catheter in high risk surgeries for colorectal cancer.

Ureteral injury occurs in 0.3-1.5% of colorectal cancer surgeries. Devices to visualize the ureteral course and avoid ureteral injury are required for minimally invasive surgery (MIS). The NIRC™ fluorescent ureteral catheter (FUC) is a versatile ureteral visualization device currently available in Japan that can be used in combination with a variety of laparoscopic and robotic systems. In this study, we examined the outcomes of high-risk patients who underwent colorectal cancer surgery with FUC insertion. One hundred forty-one patients who underwent MIS for colorectal cancer and colorectal cancer recurrence at our institute between January 2021 and May 2024 underwent preoperative FUC insertion because of the high risk of ureteral injury and surgical difficulty. For these patients, patient background data and short-term outcomes were examined. The results are expressed as the median and interquartile range. Age, 70 [60-78]; M:F(n), 84:57; BMI, 22.1 [19.7-24.7]; T4 (TNM classification), 52 cases (36.9%); preoperative intestinal obstruction, 45 cases (31.9%); abscess formation, 30 cases (21%); surgical history, 70 cases (50%); recurrent cancer, 14 cases (9.9%); preoperative chemo-radiotherapy, 28 cases (19.9%); time required for FUC insertion, 12 [9-19] minutes; operation time, 412 [309-552] minutes; blood loss, 10 [5-30]ml; open conversion, 0 cases; postoperative hospitalization, 12 [9-17.5]; circumferential resection margins < 1mm (rectal surgery), 4/87 cases (4.6%); comorbidities, 0 ureteral injury, 1 urethral injury during FUC insertion (0.7%) and 16 CD Grade 3 or higher cases (11%). FUC may improve the safety of MIS and reduce blood loss in addition to preventing ureteral injury and is expected to have oncological advantages for ensuring the margin of the tumor without fear of ureteral injury. However, the time required for and complications associated with FUC are challenging. New methods for less invasive and easier ureteral visualization may be needed.

WP6.9 - Essential Surgery Skills Course: A One Week Training Program to Prepare Surgeons for Humanitarian Deployment

Abstract Background Medical students, surgical trainees, and surgical faculty are increasingly interested in incorporating global surgery into their clinical practices and professional careers. However, many concerns remain about the preparation of surgeons for operating in resource-limited settings and their exposure to critical procedures such as cesarean sections, hysterectomies, or fracture reductions. In an attempt to address these concerns, academic institutions have developed advanced professional training programs for the global surgeon. Methods A six-day essential surgery skills conference was created at a large academic institution that provides trainees and surgeons with an overview of common surgical scenarios across orthopedics, urology, obstetrics, gynecology, general surgery, anesthesia and ultrasound in the form of didactics, simulations, and wet labs. Results 11 surgical trainees from four large academic institutions attended the essential surgery skills conference. Trainees attended sessions on point of care ultrasound, regional anesthesia, general anesthesia, hysterectomies, cesarean sections, post-partum hemorrhage, fracture reduction and fixation, ureteral injuries, and humanitarian deployment. A pre and post-test was administered. Improvement was noted in the trainees scores on the post-test in their knowledge of surgical subspecialty care. Trainees also reported feeling better prepared for humanitarian deployment. Conclusion Global surgery conferences can be designed to provide a networking and collaboration forum for improving access to surgical services worldwide. One-week predeparture conferences that discuss essential technical skills and relevant global surgery knowledge may better prepare surgeons to operate in resource-limited settings.

Assessment of Holmium:YAG, Pulsed-Thulium:YAG and Thulium Fiber Lasers for Urinary Stone Ablation. In Vitro Study.

Objective: To evaluate the ablation speed (AS), laser efficiency and direct thermal lesions during urinary stone lithotripsy with the current available laser technologies: Holmium:YAG (Ho:YAG), pulsed-Thulium:YAG (p-Tm:YAG) and thulium fiber laser (TFL) in vitro using different laser settings. Materials and Methods: Ho:YAG, p-Tm:YAG, and TFL laser system were used in an in vitro ureteral model with a volume of 125 mm3 Begostone. The following parameters were tested across all laser devices: 0.6J/10 Hz (6 W), 0.6 J/20 Hz (12 W), 1.5 J/10 Hz (15 W), and 1.5 J/20 Hz (30 W), employing short pulse width for all lasers and long pulse width for Ho:YAG and p-Tm:YAG. Ten participants conducted the experimental setup during 3-minutes laser on time, combining the laser technology, settings, and pulse widths, with a total of 20 different combinations. The efficiency, AS and ureteral damage resulting from each intervention were analyzed. Results: p-Tm:YAG and TFL demonstrated significantly higher efficiency compared with Ho:YAG (0.049 ± 0.02 Δgr/KJ and 0.042 ± 0.01 Δgr/KJ vs 0.029 ± 0.01 Δgr/KJ; p < 0.05). In all laser sources, as the power increases, the AS also increases (p < 0.05). Furthermore, only at high-energy settings (1.5 J) higher frequency led to increase AS (p < 0.05). Both, p-Tm:YAG and TFL exhibited higher AS compared to Ho:YAG (0.64 ± 0.33 Δgr/s and 0.62 ± 0.31 Δgr/s vs 0.44 ± 0.22 Δgr/s; p < 0.05). Regarding ureteral injuries, as the power increases, there is a higher chance of ureteral damage (p = 0.031). No differences were observed between laser technologies (p = 0.828). Conclusions: Both, p-Tm:YAG and TFL exhibited superior performances during laser lithotripsy compared with Ho:YAG, as they demonstrated higher efficiency and ablation speed. Thermal damage did not appear to be associated with specific laser equipment, but higher grades of lesions are described by increasing power.

Total laparoscopic hysterectomy with posterior cul-de-sac obliteration: step-by-step procedures based on precise anatomical landmarks.

Dense adhesion due to severe endometriosis between the posterior cervical peritoneum and the anterior sigmoid or rectum obliterates the cul-de-sac and distorts normal anatomic landmarks. Surgery for endometriosis is associated with severe complications, including ureteral and rectal injuries, as well as voiding dysfunction. It is important to develop the retroperitoneal avascular space based on precise anatomical landmarks to minimize the risk of ureteral, rectal, and hypogastric nerve injuries. We herein report the anatomical highlights and standardized and reproducible surgical steps of total laparoscopic hysterectomy for posterior cul-de-sac obliteration. We approach the patient with posterior cul-de-sac obliteration using the following five steps. Step 1: Preparation (Mobilization of the sigmoid colon and bladder separation from the uterus). Step 2: Development of the lateral pararectal space and identification of the ureter. Step 3: Isolation of the ureter. Step 4: Development of the medial pararectal space and separation of the hypogastric nerve plane. Step 5: Reopening of the pouch of Douglas. Surgeons should recognize the importance of developing the retroperitoneal avascular space based on precise anatomical landmarks, and each surgical step must be reproducible.

VE12 Ureteroplasty with robotic graft for ureteral injury

VE12 Ureteroplasty with robotic graft for ureteral injury

VE21 Robotic approach to complex ureteral injuries

VE21 Robotic approach to complex ureteral injuries

VNOTES versus Laparoscopic Uterosacral Ligament Suspension for Apical Pelvic Organ Prolapse: Perioperative and Short-Term Outcomes.

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a novel approach in gynecological surgery. This study was aimed at comparing perioperative and short-term postoperative outcomes of vNOTES versus laparoscopic approaches to uterosacral ligament suspension (USLS) for apical pelvic organ prolapse. A retrospective cohort study included all women who underwent vNOTES versus laparoscopic USLS at two university-affiliated centers between 2017 and 2023. The relationships between variables were tested using Fisher's exact test or t test, including a sub-analysis comparing hysterectomy and hysteropexy outcomes within the groups. Logistic regression assessed the influence of baseline factors and operative factors on the primary and main secondary outcomes of interest. This study comprised 47 vNOTES and 54 laparoscopic USLS cases (including 11 and 15 hysteropexies respectively). Baseline demographics in the two groups were similar. There were no differences in operative outcomes and no instances of ureteral injury. The vNOTES technique allowed for the use of significantly more sutures per side (2.0 [2.0-4.0] vs 1.0 [1.0-1.0], p = 0.001). Postoperative complications within 6 weeks demonstrated no significant differences. Both groups exhibited comparable rates of baseline subjective POP symptoms (100% vs 96.2%, p = 1.00) which improved significantly at 6 weeks (4.3% vs 11.1%, p = 0.282). At 6 weeks, anatomical success was achieved by significantly more patients with vNOTES (93.5% vs 78.6%, p = 0.042). Baseline and 6-week POP symptoms in the hysterectomy and hysteropexy subgroups were similar. Both vNOTES and laparoscopic USLS demonstrated comparable subjective success rates at 6 weeks postoperatively. The vNOTES approach demonstrated improved anatomical success at 6 weeks, but the difference was not significant after adjusting for operative factors.

Can Radiological Imaging Accurately Predict the Length of the Ureteral Defect/Stricture Following Ureteral Injury?

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.

Application of 11/13Fr suctioning ureteral access sheath and 8.55Fr single-use digital flexible ureteroscope in one-stage flexible ureteroscopic lithotripsy: an initial experience of 900 cases.

To report our initial experience of one-stage flexible ureteroscopic lithotripsy(FURL) with 11/13Fr suctioning ureteral access sheath(UAS) and 8.55Fr single-use digital flexible ureteroscope(SDFU) in upper ureteral or renal calculi. We retrospectively collected the clinical data of 900 adult patients with upper ureteral or renal calculi treated by FURL with 11/13Fr suctioning UAS and 8.55Fr SDFU from January 2022 to April 2024. Demographics, peri- and postoperative outcomes were assessed. In all, 40 of 940 cases(4.26%) failed to introduce UAS and required second-stage FURL because of ureterostenosis and were excluded. Mean stones size of the remaining 900 eligible cases was 1.68 ± 0.58cm in greatest diameter. There were 228 cases of upper ureteral stone, 456 cases of renal stone and 216 cases of concomitant ureteral and renal calculi. The mean operation time was 52.20 ± 20.21min and the postoperative hospital stay was 2.87 ± 1.37 days. The stone-free rate of 1 month postoperatively was 89.56% and only 2.44% of patients with residue underwent additional reoperation. The rate of postoperative fever, postoperative pain needing analgesic and slight ureteral mucosal injury were 5.11%, 8.22% and 7.78%, respectively. None of patient suffered from severe complications, such as sepsis or ureteral perforation. It's practical and suitable for the vast majority of adult patients to undergo FURL in single session with 11/13Fr suctioning UAS without preoperative stenting. FURL with 11/13Fr suctioning UAS and 8.55Fr SDFU is feasible, reliable, safe, and efficient in the management of renal stone and upper ureteral stone.

Intraoperative Fluorescent Navigation of the Ureters, Vessels, and Nerves during Robot-Assisted Sacrocolpopexy.

In this study, we aimed to demonstrate the feasibility and safety of navigating the ureters, middle sacral artery (MSA), and superior hypogastric nerve (SHN) using indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during robot-assisted sacrocolpopexy (RSCP). Overall, 15 patients who underwent RSCP for apical vaginal prolapse were retrospectively enrolled. All patients underwent cystoscopic intraureteric instillation of 5 cc ICG (2.5 mg/mL) before RSCP and intravenous injection of 3 cc ICG during presacral dissection and mesh fixation. In all patients, the fluorescent right ureter was clearly identified in real time. The MSA was visualized on ICG-NIRF images in 80% (13/15) of patients. The mean time from ICG injection to MSA visualization was 43.7 s; the mean duration of the arterial phase was 104.3 s. Fluorescent SHN was detected in 73.3% (11/15) of patients. The time from ICG injection to SHN fluorescence was 48.4 s; the duration of fluorescence was 177.2 s. There was no transfusion, iatrogenic ureteral injury, or bowel or urinary dysfunction. Our results indicated that intraoperative ureter, MSA, and SHN mapping using ICG-NIRF images during RSCP is a valuable and safe technique to avoid iatrogenic ureteral, vascular, and neural injuries and to simplify surgical procedures. Nonetheless, further studies are required.

Meta-analysis reveals higher intraoperative urologic complication rates in minimally invasive radical hysterectomy compared to abdominal radical hysterectomy.

Minimally invasive radical hysterectomy (MIRH) has been increasingly adopted for its benefits of reduced blood loss and shorter hospital stays. This study aims to conduct a meta-analysis to compare the incidence of intraoperative urologic complications, including bladder and ureteral injuries, between MIRH and abdominal radical hysterectomy (ARH). We systematically searched PubMed, EMBASE, and the Cochrane Library for studies published up to April 2024. A total of 35 studies were analyzed to compute odds ratios (ORs) for intraoperative urologic complications, bladder injuries, and ureteral injuries, focusing on subgroup evaluations by publication year, study quality, body mass index (BMI), geographic region, and surgical method. The meta-analysis demonstrates that MIRH is associated with higher risks of intraoperative urologic complications (OR=2.412, 95% CI: 1.995-2.916, P<0.001), bladder injuries (OR=2.109, 95% CI: 1.567-2.839, P<0.01), and ureteral injuries (OR=2.549, 95% CI: 1.992-3.262, P<0.001). No publication bias was detected across the studies, ensuring the robustness of the findings. Significant differences in complication rates were also observed across geographic and procedural subgroups. The findings confirm that MIRH has a higher rate of intraoperative urologic complications, including bladder and ureteral injuries, compared to ARH. These results provide essential insights that could guide clinical decision-making and influence surgical practice guidelines.

Urologic Morbidity in Surgery of Placenta Accreta Spectrum in Universitas Andalas Hospital

Background: Hysterectomy for placenta accreta spectrum disorders is known to be associated with urologic morbidity, including intentional or unintentional cystostomy, ureteral injury, and bladder fistula. Case: A 32year old woman with urine retention post total hysterectomy on indications placenta accreta spectrum Grade 3 type 4 S2 segment- 9 days ago, referred to Universitas Andalas Hospital. The patient complained difficulty to urinate, hematuria and supra pubic pain. Physical examination sign of acute abdomen unclear. A Pelvic abdominal ultrasound was performed, the result were Acites and complex acites, left renal hydronefrosis, cystitis and sludge gallblader. From the laboratory result found anemia, leucocytosis, trombositosis, ureum, creatinine and albumin were in normal limit, hyponatremia, hypokalemia, hypocalsemia. The patient were given antibiotics, blood transfusion and natrium, kalium and calcium correction. Cystoscopy was performed to explore the bladder, the result were found adhesion and ruptured at the posterior wall of the bladder a long 3 cm then proceed with laparotomy to repair the bladder and adhesiolisis. During hospitalization, the patient’s condition was good, hemodynamics was stable with sufficient diuresis. The patient was discharged on day 4 after laparotomy of bladder repair with temporary urine catheter installed. Discussion: This patient diagnose previously is placenta accreta spectrum with percreta graded so had a high risk of urologic morbidity. The bladder ruptured occurred after 9th day of hysterectomy. This can occur because the injury during dissection of the uterine vesicular fold undergoes necrosis and then become opens on the 9th day after hysterectomy. A multidisciplinary team should be made in management of placenta accreta spectrum. A team comprising a consultant maternal fetal medicine with pelvic surgery experienced, a blood bank team, an anesthesiologist, a urologist skilled, an interventional radiologist and an experienced neonatologist is advised. Keywords: urologic complication, placenta accreta, urologic morbidity