Ureteric injury: a challenging condition to diagnose and manage

Abstract

Although ureteric injury is relatively uncommon, it is a serious event that can result in intra-abdominal sepsis, renal failure, and loss of the ipsilateral renal unit. Most injuries are iatrogenic and remain undiagnosed until the patient presents with symptoms postoperatively. In addition to compromising patient safety, missed ureteric injuries frequently result in litigation. Over the past 20 years, there has been a rapid uptake of laparoscopic and robotic techniques within urology and other surgical specialties. This trend, coupled with increased use of ureteroscopy, has increased the risk of injury to the ureter. The key to diagnosing and managing a ureteric injury is to have a low threshold for suspecting its presence. Diagnosis can be achieved using retrograde pyelography, ureteroscopy, CT, or intravenous urography. Initial management should involve ureteric stent placement or percutaneous nephrostomy drainage. In selected patients, surgical reconstruction might be the optimal approach. Decisions regarding surgical technique (open, laparoscopic, or robotic) are guided by the clinical situation and surgical expertise available.

Laparoscopic dissection of the intramural ureter to repair a complete transection of the distal ureter: Initial experience with a new minimally invasive technique that preserves the anatomy of the urinary tract

“…2 When there is complete injury of the distal ureter, direct ureteral reimplantation or a psoas-bladder or Boari-flap hitch procedure is usually performed to ensure ureterovesical continuity. 1,5 This type of surgical treatment with ureteroneocystostomy often requires ureteral re-implantation to control the physiological function of the ureterovesical junction, 5 a procedure that extends the operating time and increases morbidity. In general, when complete injury of the ureter occurs, a repair is performed to spatulate the ureter by placing a ureteral stent and suturing end-to-end, providing there is a ureteral stump that can be used for reanastomosis.…”

“…Distal ureteral injury is more common than injuries affecting the proximal ureter; in some cases, ureteral injury goes unnoticed and later presents as stenosis and hydronephrosis. 1,2 Gynecological and urological procedures are most often associated with a ureteral injury. In gynecologic surgery, ureteral injury occurs in 0.1% to 1.5% of procedures for benign pathological conditions and up to 5% of oncologic procedures.…”

“…Ureteral injuries from gynecological procedures account for up to 64% of the injuries, with the remaining injuries due to laparoscopic general surgery and laparoscopic urologic surgery. 1 The treatment of ureteral injuries differs depending on the location of the injury. 3 In the distal ureter, where most injuries occur during gynecologic procedures, 4 treatment depends on the diameter of the injury.…”

“…If the injury is greater than 50% of the diameter, or if there is devascularization, surgery is then indicated. 1 If surgery is needed, a ureteral reimplant is recommended as the first-line treatment for lower ureteral injuries.…”

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

“…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][10][11][12][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.…”