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 intra-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 intraabdominal, 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.
- Redan JA, McCarus SD. Protect the ureters. JSLS 2009; 13:139.
- Selzman AA, Spirnak JP. Iatrogenic ureteral injuries: a 20-year experience in treating 165 injuries. J Urol 1996; 155:878.
- Delacroix SE Jr, Winters JC. Urinary tract injures: recognition and management. Clin Colon Rectal Surg 2010; 23:104.
- Brummer TH, Jalkanen J, Fraser J, et al. FINHYST, a prospective study of 5279 hysterectomies: complications and their risk factors. Hum Reprod 2011; 26:1741.
- Rose J, Schneider C, Yildirim C, et al. Complications in laparoscopic colorectal surgery: results of a multicentre trial. Tech Coloproctol 2004; 8 Suppl 1:s25.
- Neuman M, Eidelman A, Langer R, et al. Iatrogenic injuries to the ureter during gynecologic and obstetric operations. Surg Gynecol Obstet 1991; 173:268.
- Bothwell WN, Bleicher RJ, Dent TL. Prophylactic ureteral catheterization in colon surgery. A five-year review. Dis Colon Rectum 1994; 37:330.
- Warwick RT, Worth PH. The psoas bladder-hitch procedure for the replacement of the lower third of the ureter. Br J Urol 1969; 41:701.
- Santucci RA, Doumanian LR. Section IX. Upper urinary traact obstruction and trauma. Chapter 42. Upper urinary tract trauma. In: Campbell-Walsh Urology, 10th, Wein AJ, Kavoussi, Novick AC, Partin AW,Peters CA. (Eds), Elsevier, Philadelphia 2007. Vol 2, p.1169.
- Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int 2004; 94:277.
- Liu C, Zhang X, Xue D, et al. Endoscopic realignment in the management of complete transected ureter. Int Urol Nephrol 2014; 46:335.
- Summerton DJ, Kitrey ND, Lumen N, et al. EAU guidelines on iatrogenic trauma. Eur Urol 2012; 62:628.
- Wu TP, Sa L, Lee CL. Laparoscopic repair of delayed-onset ureter injury. J Minim Invasive Gynecol 2007; 14:253.
- McAninch Jack W. Chapter 17. Injuries to the Genitourinary Tract, Injuries to the Ureter. Tanagho EA, McAninch JW: Smith's General Urology, 17th Edition. McGraw Hill COmpanies, INc. 2008. http://www.accesssurgery.com/content.aspx?aID=3127630. (Accessed on October 05, 2011).
- Shah S, Nath V, Gopalkrishnan G, et al. Evaluation of extravesical and Leadbetter-Politano ureteroneocystostomy in renal transplantation. Br J Urol 1988; 62:412.
- Thrasher JB, Temple DR, Spees EK. Extravesical versus Leadbetter-Politano ureteroneocystostomy: a comparison of urological complications in 320 renal transplants. J Urol 1990; 144:1105.
- Haberal M, Emiroglu R, Karakayali H, et al. A corner-saving ureteral reimplantation technique without stenting. Transplant Proc 2006; 38:548.
- Bruézière J. [Leadbetter-Politano operation in the treatment of vesico-ureteral reflux in children. Indications, technic and outcome]. Ann Chir Infant 1966; 7:67.
- Mellin P, Eickenberg HU. Ureteral reimplantation: Lich-Grégoire method. Urology 1978; 11:315.
- Gross M, Peng B, Waterhouse K. Use of the mobilized bladder to replace the pelvic ureter. J Urol 1969; 101:40.
- Zinman LM, Libertino JA, Roth RA. Management of operative ureteral injury. Urology 1978; 12:290.
- Ehrlich RM, Melman A, Skinner DG. The use of vesico-psoas hitch in urologic surgery. J Urol 1978; 119:322.
- Mathews R, Marshall FF. Versatility of the adult psoas hitch ureteral reimplantation. J Urol 1997; 158:2078.
- HODGES CV, MOORE RJ, LEHMAN TH, BEHNAM AM. CLINICAL EXPERIENCES WITH TRANSURETEROURETEROSTOMY. J Urol 1963; 90:552.
- Ahn M, Loughlin KR. Psoas hitch ureteral reimplantation in adults--analysis of a modified technique and timing of repair. Urology 2001; 58:184.
- Konigsberg H, Blunt KJ, Muecke EC. Use of Boari flap in lower ureteral injuries. Urology 1975; 5:751.
- Golimbu M, Block N, Morales PA. Ureterovesical flap operation for middle and upper ureteral repair. Invest Urol 1973; 10:313.
- Benson MC, Ring KS, Olsson CA. Ureteral reconstruction and bypass: experience with ileal interposition, the Boari flap-psoas hitch and renal autotransplantation. J Urol 1990; 143:20.
- Bright TC 3rd, Peters PC. Ureteral injuries secondary to operative procedures. Report of 24 cases. Urology 1977; 9:22.
- Simmons MN, Gill IS, Fergany AF, et al. Technical modifications to laparoscopic Boari flap. Urology 2007; 69:175.
- Smith IB, Smith JC. Trans-uretero-ureterostomy: British experience. Br J Urol 1975; 47:519.
- Ehrlich RM, Skinner DG. Complications of transureteroureterostomy. J Urol 1975; 113:467.
- Sandoz IL, Paull DP, MacFarlane CA. Complications with transureteroureterostomy. J Urol 1977; 117:39.
- HARDY JD. High ureteral injuries. Management by autotransplantation of the kidney. JAMA 1963; 184:97.
- Novick AC, Straffon RA, Stewart BH. Experience with extracorporeal renal operations and autotransplantation in the management of complicated urologic disorders. Surg Gynecol Obstet 1981; 153:10.
- Armatys SA, Mellon MJ, Beck SD, et al. Use of ileum as ureteral replacement in urological reconstruction. J Urol 2009; 181:177.
- Wolff B, Chartier-Kastler E, Mozer P, et al. Long-term functional outcomes after ileal ureter substitution: a single-center experience. Urology 2011; 78:692.
- Goldwasser B, Leibovitch I, Avigad I. Ureteral substitution using the isolated interposed vermiform appendix in a patient with a single kidney and transitional cell carcinoma of the ureter. Urology 1994; 44:437.
- Verduyckt FJ, Heesakkers JP, Debruyne FM. Long-term results of ileum interposition for ureteral obstruction. Eur Urol 2002; 42:181.
- McCullough DL, McLaughlin AP, Gittes RF, Kerr WS Jr. Replacement of the damaged or neoplastic ureter by ileum. J Urol 1977; 118:375.
- Dowling RA, Corriere JN Jr, Sandler CM. Iatrogenic ureteral injury. J Urol 1986; 135:912.
- Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation. JAMA 2010; 303:959.
- Koukouras D, Petsas T, Liatsikos E, et al. Percutaneous minimally invasive management of iatrogenic ureteral injuries. J Endourol 2010; 24:1921.
- Dos Santos Abreu Lde A, Tanaka M, de Abreu SC, et al. Laparoscopic management of iatrogenic lesions. J Endourol 2008; 22:1279.
- De Cicco C, Ret Dávalos ML, Van Cleynenbreugel B, et al. Iatrogenic ureteral lesions and repair: a review for gynecologists. J Minim Invasive Gynecol 2007; 14:428.
- Thiel DD, Leroy TJ, Winfield HN, Igel TC. Robotic-assisted laparoscopic reconstruction of the upper urinary tract: tips and tricks. Urology 2010; 76:488.
- Patil NN, Mottrie A, Sundaram B, Patel VR. Robotic-assisted laparoscopic ureteral reimplantation with psoas hitch: a multi-institutional, multinational evaluation. Urology 2008; 72:47.
- Kamat N, Khandelwal P. Laparoscopic extravesical ureteral reimplantation in adults using intracorporeal freehand suturing: report of two cases. J Endourol 2005; 19:486.
- Puntambekar S, Palep RJ, Gurjar AM, et al. Laparoscopic ureteroneocystostomy with psoas hitch. J Minim Invasive Gynecol 2006; 13:302.
- Chung H, Jeong BC, Kim HH. Laparoscopic ureteroneocystostomy with vesicopsoas hitch: nonrefluxing ureteral reimplantation using cystoscopy-assisted submucosal tunneling. J Endourol 2006; 20:632.
- Laungani R, Patil N, Krane LS, et al. Robotic-assisted ureterovaginal fistula repair: report of efficacy and feasiblity. J Laparoendosc Adv Surg Tech A 2008; 18:731.
- Kalisvaart JF, Finley DS, Ornstein DK. Robotic-assisted repair of iatrogenic ureteral ligation following robotic-assisted hysterectomy. JSLS 2008; 12:414.
- Routh JC, Tollefson MK, Ashley RA, Husmann DA. Iatrogenic ureteral injury: can adult repair techniques be used on children? J Pediatr Urol 2009; 5:53.
- Neo EN, Zulkifli Z, Sritharan S, et al. Renal autotransplantation after an latrogenic left ureteric injury. Med J Malaysia 2007; 62:164.
- Paick JS, Hong SK, Park MS, Kim SW. Management of postoperatively detected iatrogenic lower ureteral injury: should ureteroureterostomy really be abandoned? Urology 2006; 67:237.
- 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