Simultaneous percutaneous nephrolithotomy and early endoscopic ureteric realignment for iatrogenic ureteropelvic junction avulsion during ureteroscopy

Abstract

E882Cite as: Can Urol Assoc J 2015;9(11-12):E882-5 http://dx.doi.org/10.5489/cuaj.2830 Published online December 14, 2015. AbstractWe present a case report of successful management of ureteropelvice junction avulsion during ureteroscopy successfully managed with simultaneous percutaneous nephrolithotomy and early endoscopic ureteral realignment. IntroductionThe incidence of ureteral injury and overall complications during ureteroscopy ranges from 0 to 28%. [1][2][3][4][5] Iatrogenic ureteral injury varies from minor mucosal petechiae to erosion, perforation, and rarely complete ureteral avulsion. 6 Factors associated with higher complication rates during ureteroscopy are longer surgery times, treatment of renal calculi, surgeon inexperience, and previous irradiation. 1,3,7 Ureteral stents are the cornerstone in the management of ureteral injury. If stent placement is not possible following ureteral injury, placement of a percutaneous nephrostomy tube is required for renal drainage until elective repair can be accomplished. 1,[8][9][10] Several authors have reported reasonable rates of success with ureteroscopic ureteral realignment for iatrogenic ureteral injury during gynecologic and general surgical procedures.9-13 However, to our knowledge, there has not been a previous report of successful endoscopic ureteral realignment following avulsion of the ureter at the level of the ureteropelvic junction. Case reportA 59-year-old female with a long history of nephrolithiasis had a 7-mm right renal pelvic calculus. Ureteroscopic treatment was performed at an outside institution. There was some difficulty with ureteral dilatation and UPJ avulsion of the ureter was suspected associated with insertion of the ureteral access sheath. A safety guide wire was not used during the procedure. Subsequently, a guide wire was not able to be passed beyond the injury into the renal collecting system and, therefore, a stent could not be placed. A 5F ureteral catheter was placed through the avulsed proximal ureter projecting into the retroperitoneum. The patient was transferred to Indiana University Health Methodist Hospital for subsequent management.The patient has a history of cirrhosis, splenomegaly, and thrombocytopenia with a platelet count of 52,000 and an INR of 1.5. Ureteroscopy was performed confirming complete avulsion of the ureter (Fig. 1). A stent could not be placed and a ureteral catheter was replaced into the retroperitoneum near the kidney. The following day a percutaneous nephrostomy was inserted by Interventional Radiology (Fig. 2). The patient was then returned to the operating room and placed in a prone split-leg position to allow for simultaneous antegrade and retrograde access to the ureter. The percutaneous access was dilated to 30F and an Amplatz sheath was positioned into the kidney (Fig. 3). Nephroscopy identified the stone in the renal pelvis which was removed. The UPJ was identified and noted to be very small in caliber. A flexible ureteroscope was passed antegradely through the UPJ confirming that the avu...

Management of ureteric avulsion during ureteroscopy: a systematic review and our experience

“…Primary open approach was used in the majority of cases (38/43) with laparoscopic assistance used in 3 cases [7,8]. Endoscopic approach in the form of retrograde and antegrade realignment was used primarily for 4 patients [9][10][11]. (8) and ureteropyelostomy with ureterovesicostomy (7) were the common procedures used for proximal avulsions.…”

“…Though this procedure looked tempting as it can be done immediately and easily, our analysis shows that this temptation should be avoided as the long-term results are not good due to the poor vascularity of the avulsed ureter, which ultimately fibrosed and, if not detected early, leads to silent loss of the renal unit. Endoscopic management in the form of antegrade and retrograde realignment of distracted segments has been described in literature; however, as we have already mentioned, the concern continues to be vascularity which depends on the extent of displacement of the avulsed segments [9][10][11]. These patients have to be followed up rigorously for development of strictures and may require secondary reconstructive procedure for salvaging renal function [9][10][11].…”

“…Endoscopic management in the form of antegrade and retrograde realignment of distracted segments has been described in literature; however, as we have already mentioned, the concern continues to be vascularity which depends on the extent of displacement of the avulsed segments [9][10][11]. These patients have to be followed up rigorously for development of strictures and may require secondary reconstructive procedure for salvaging renal function [9][10][11]. Finally, nephrectomy is also an immediate option where the function of concerned kidney is already deranged and sometimes as a last resort following failed reconstructions especially in older patients.…”