Immediate and late management of iatrogenic ureteric injuries: 28 years of experience

Abstract

ObjectiveTo evaluate the long-term results after managing intraoperative and late-diagnosed cases of iatrogenic ureteric injury (IUI), treated endoscopically or by open surgery.Patients and methodsPatients immediately diagnosed with IUI were managed under the same anaesthetic, while those referred late had a radiological assessment of the site of injury, and endoscopic management. Open surgical procedures were used only for the failed cases with previous diversion.ResultsIn all, 98 patients who were followed had IUI after gynaecological, abdominopelvic and ureteroscopic procedures in 60.2%, 14.3% and 25.5%, respectively. The 27 patients diagnosed during surgery were managed immediately, while in the late-referred 71 patients ureteroscopic ureteric realignment with stenting was successful in 26 (36.6%). Complex open reconstruction with re-implantation or ureteric substitution, using bladder-tube or intestinal-loop procedures, was used in 27 (60%), 16 (35.5%) and two (4.5%) patients of the late group, respectively. A long-term radiological follow-up with a mean (range) of 46.6 (24.5–144) months showed recurrent obstruction in 16 (16.3%) patients managed endoscopically and reflux in six (8.3%) patients. Three renal units only (3%) were lost in the late-presenting patients.ConclusionPatients managed immediately had better long-term results. More than a third of the late-diagnosed patients were successfully managed endoscopically with minimal morbidity. Open reconstruction by an experienced urologist who can perform a complex substitutional procedure was mandatory to preserve renal units in the long-term.

Post Abdominal Hysterectomy Ureterovaginal Fistula

“…Iatrogenic ureteric injury is an uncommon complication of obstetric and gynecological surgery and almost 70% of cases are unrecognized during surgery. 5 Although the prevalence of iatrogenic ureteric injury following gynecological cancer surgery is high, total abdominal hysterectomy for benign condition account for most of the cases. 6 Unrecognized ureteral injury increases postoperative morbidity leading to Þ stula formation, urinoma, fever, septicemia, sepsis, or renal functional loss.…”

“…And in cases of partial ureteric injury DJ stenting can be done and removed after 6-12 weeks. 4,5 CONCLUSION Iatrogenic ureteric injury is an uncommon, yet serious complication of obstetric and gynecologic surgery that deteriorates women's quality of life. Therefore a good knowledge of pelvic anatomy, good surgical skills, anticipation and intraoperative vigilance during pelvic surgery helps to avoid ureteric injury.…”

Complications of Endourologic Procedures: A Review on Iatrogenic Ureteral Perforation

“…Patients with undiagnosed perforations in the long term present with strictures and non-functional nephroureteral units. Ureteral perforation must be suspected in patients referred with recurrent fever, flank pain or urinary fistula [34] .…”

“…Their incidence is 1.35% [14] although this is probably underestimated as it is not usual to perform a routinary retrograde ureteropyelography after finishing the procedure unless a lesion is suspected [7] . Nevertheless, it is possible that only the extravasation of large amounts of fluids leads to clinical symptoms [7,34] . When this occurs, it results in urinomas [36] .…”

“…However, it has been experimentally observed that 3-weeks provide the same results regarding ureteral healing, which is an advantage, as reducing stenting duration decreases the adverse effects associated with double-J stents [45] . When lesions are diagnosed late, the placement of a double-J stent for 8-12 weeks is the first therapeutic option [34] . If perforation appears during retrieval of ureteral access sheath, Traxer et al recommend double-J for 3-6 weeks [19] .…”