Surgical repair of an iatrogenic ureteral injury
- Colleen M Feltmate, MD
Colleen M Feltmate, MD
- Assistant Professor
- Harvard Medical School
- Graeme S Steele, MBBCh, FCS
Graeme S Steele, MBBCh, FCS
- Assistant Professor of Surgery
- Harvard Medical School
Intra-operative iatrogenic ureteral injuries, if recognized during the operation, should be repaired at that setting . Ureteral injuries identified in the postoperative period require a delayed operative repair.
Ureteral injuries can occur during open or laparoscopic intra-abdominal, vaginal, and endourological procedures. In a retrospective review of 165 patients with iatrogenic ureteral injuries over a 20-year span, endourologic procedures were responsible for most iatrogenic injuries . Urologic, gynecologic, and general surgical procedures were responsible for 42, 34, and 24 percent of injuries, respectively.
Injury to the ureter is the most common complication of pelvic surgery, ranging from less than 1 to 10 percent of procedures, depending on the complexity of the procedure [2-6]. Prevention is ideal, and early recognition is the next best approach. Nevertheless, despite preventive measures (eg, radiographic imaging, ureteral stents) to minimize injury to the ureter in high-risk clinical settings (eg, previous pelvic surgery, one functioning kidney), injuries still occur and a high level of intra-operative and postoperative vigilance is indicated .
The surgical management of iatrogenic ureteral injuries, whether identified early or late, is discussed here. The incidence, prevention, recognition, and evaluation of ureteral injuries following gynecologic and colorectal procedures are reviewed elsewhere. (See "Urinary tract injury in gynecologic surgery: Identification and management" and "Urinary tract injury in gynecologic surgery: Prevention" and "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery", section on 'Ureteral injury'.)
Most ureteral injuries are not identified intra-operatively, but rather in the postoperative period [3-5,8]. The general principles of recognizing an iatrogenic injury to the ureter are the same, regardless of the indications of the operative procedure.
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- GENERAL APPROACH
- MANAGEMENT OF CONTUSION
- MANAGEMENT OF A LIGATION
- SURGICAL REPAIR
- Lower ureter
- - Ureteroureterostomy
- - Ureteroneocystostomy
- - Psoas hitch ureteral reimplantation
- Middle ureter
- - Boari flap
- - Transureteroureterostomy
- Upper ureter
- - Autotransplantation
- - Ileal or appendiceal interposition graft
- - Nephrostomy
- - Nephrectomy
- ROLE OF MINIMALLY INVASIVE REPAIR
- POSTOPERATIVE CARE AND FOLLOW UP
- POSTOPERATIVE COMPLICATIONS
- LONG-TERM OUTCOMES
- SUMMARY AND RECOMMENDATIONS