Is endourological intervention a suitable treatment option in the management of iatrogenic thermal ureteral injury? A contemporary case series

Abstract

Background Iatrogenic ureteral injury (IUI) is relatively rare, however, can cause sepsis, kidney failure, and death. Most cases of IUI are not recognized until the patient presents with symptoms following pelvic surgery or radiotherapy. Recently, minimally invasive approaches have been used more frequently in the treatment of IUI. This study evaluates urological intervention success rates and long-term clinical outcomes according to the type of IUI following hysterectomy. Methods Twenty-seven patients who underwent surgery due to IUI in our clinic following hysterectomy were evaluated between January 2011 and April 2018. Patients were classified according to the time of diagnosis of IUI. The IUI cases diagnosed within the first 24 h following hysterectomy were designated as "immediate" IUI, while that diagnosed late period was considered 'delayed' IUI. The type of IUI was categorized as "cold transection" if it was due to surgical dissection or ligation without any thermal energy, and "thermal injury" if it was related to any energy-based surgical device. Patient information, laboratory and perioperative data, imaging studies, and complications were assessed retrospectively. Results All cases of delayed diagnosis IUI were secondary to laparoscopic hysterectomy (P = 0.041). Patients with thermal injury to the ureter were mostly diagnosed late (delayed) (P = 0.029). While 31% of the patients who underwent endourological intervention were diagnosed immediately, 69% of them were diagnosed as delayed. These rates were roughly reversed for open reconstructive surgery: 73% and 27% (P = 0.041), respectively. We detected eight ureteral complications in our patient cohort following the urological intervention. In all these failed cases, the cause of IUI was a thermal injury (P = 0.046) and the patients had received endourological treatment (P = 0.005). No complications were detected in patients who undergo open urological reconstructive surgery. While one of the patients who developed urological complications had an immediate diagnosis, seven were in the delayed group (P = 0.016). Conclusion Endourological intervention is performed more frequently in delayed diagnosed IUI following hysterectomy, however, the treatment success rate is low if thermal damage has developed in the ureter. Surgical reconstruction is should be preferred in these thermal injury cases to avoid further ureter-related complications.

Urological injuries following gynecologic surgery: clinical manifestations, diagnosis and management

“…However, it is important to note that cystoscopy is not sufficient for detecting all ureteral injuries, as partial ureteral obstructions, transections or thermal lesions might be overlooked. Particularly thermal injuries have been shown to be more challenging to detect than direct transections, which in turn delays the diagnosis 28 .…”

2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery

“…Ureteral injuries include a complete transection of the ureter, a partial transection of the ureter, or a complete occlusion of the ureter with no leakage. Thermal lesions may be more subtle and are harder to recognize as compared to direct transection, leading to delayed diagnosis [ 104 ]. Once identified, IUTI lesions should be classified according to the extent of the injury and its associated mechanism.…”

Optical coherence tomography for the detection of electrothermal ureteral injury in an ex-vivo porcine model

“…[6][7][8][9] Earlier detection is necessary to reduce morbidity, increase ease of repair, and improve patient outcomes. 10,11 A method to diagnose, localize, and define the severity of thermal injury could also facilitate targeted management and repair. 12 Microscopy can reveal early signs of coagulative injury not visible to the naked eye but requires tissue resection.…”