Ureteral Avulsion during Semirigid Ureteroscopy: A Single-Centre Experience

Abstract

Aims. The aim of the study is to present our experience with the management of ureteral avulsions following semirigid ureteroscopy for ureteral stones. This is one of the largest series reported so far. Methods and Materials. It is a retrospective and observational study done at Sri Ramachandra Institute of Higher Education and Research over the last 18 years. Results. There were seven cases of ureteral avulsion following semirigid ureteroscopy. All patients were males with a mean age of 35.7 years. All had impacted stones, with proximal ureteric location in 6 patients and distal ureteric location in 1 patient. Five cases had two-point avulsions with loss of entire ureter. Two cases had one-point avulsion: one distal ureteric and the other mid-ureteric. Of the five cases with whole length ureteral avulsion, four were managed by classical ileal replacement of ureter and the the fifth case was managed by ileal replacement of ureter by the Yang–Monti technique. Of the two cases with one-point avulsion, one was managed by uretero-neocystostomy and the other by uretero-ureterostomy. All the patients had successful outcome. Conclusions. Even though rare, ureteral avulsion can potentially happen especially when dealing with impacted ureteric stones. Being conscious of the possible occurrence of this serious complication during any difficult ureteroscopy and exercising utmost care during the procedure are important preventive measures. However, this catastrophe can be successfully managed by either immediate definitive repair or in a staged manner.

The Predictive Factors of Renal Loss After Iatrogenic Ureteral Avulsion in The Medicolegal Perspective

“…In addition, large impacted stones at this location lead to the formation of a weak or unhealthy ureter, causing avulsion to develop more easily in the proximal ureter where muscle support is weak, and the absence of little or no remaining ureter further reduces the success of end-to-end anastomosis. [ 2 , 10 ]…”

“…The repair of ureteral avulsions should preferably be undertaken immediately in stable cases because delayed repair may result in the loss of ureteral length due to fibrosis. [ 2 ] However, considering surgical experience, hospital conditions, or general state of the patient, s/he can be referred to a more experienced higher center after providing proper urinary drainage and discussing this option with the patient. [ 13 ] While delayed repair is recommended after approximately four to 8 weeks in experienced clinics, it has also been suggested that repair performed within the week of injury may cause fewer complications.…”

“…[ 5 ] The classical ileal replacement of the ureter for complete ureteral avulsion is another rescue option with high reliability, especially in case of emergency repair performed in experienced centers. [ 2 ]…”

“…These injuries are listed as various complications ranging from simple mucosal damage to catastrophic ureteral avulsions. [ 2 ] Although ureteral injury rates have decreased with the increase in surgical experience and technological developments in URS devices since the 1990s, studies conducted with large series report the incidence of ureteral perforation as 0–18% and that of ureteral avulsions as 0–0.5%. [ 1 , 3 ] Conventionally, the term ureteral avulsion refers to an upper urinary tract injury associated with the loss of full-thickness continuity of the ureter due to blunt trauma, especially as a result of acute deceleration/acceleration movement that occurs during traffic accidents.…”