What are the reported outcomes for iatrogenic ureteral injury repair?

Updated: Nov 12, 2020
  • Author: Sandip P Vasavada, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Few recent studies have addressed the outcome and prognosis of ureteral injury, but older studies show that all of the surgical treatments mentioned are effective in treating ureteral injury.

Ureteral stents have been shown repeatedly to act as an excellent scaffolding mechanism when a partial ureteral distraction has occurred, with excellent long-term patency rates. In fact, the Davis intubated ureterotomy, which is the basis for current endourologic treatment of ureteral stricture disease, is aimed at incising a full-thickness portion of ureteral wall, followed by ureteral stent placement. As the ureter heals around the stent, the ureteral lumen is larger than the pretreated ureteral lumen.

In a study of initially unrecognized iatrogenic ureteral injury, Chung et al reported that retrograde ureteral stenting with a double-J stent was achieved in 21 of 25 patients (81%). Nephrostomy followed by alternative procedures was performed in the four patients in whom stenting failed. In the 21 patients with successful stenting, follow-up at a median of 9.7 months showed normal anatomy in 12 patients (57%) and stricture in six patients (28%), three of whom required surgical intervention. [15]

The urologic literature comprehensively documents the data regarding the efficacy of ureteroureterostomy in the treatment of ureteral injury. Initial studies regarding ureteroureterostomy focused on the operative technique and asked what type of anastomosis was superior. End-to-end, side-to-side, end-to-side, spatulated, unspatulated, watertight, and loose approximation anastomoses were attempted. These efforts led to broad acceptance of spatulated watertight anastomoses, with or without stents, as the best ureteral reconstruction technique in terms of long-term outcome.

The literature also demonstrates the long-term efficacy of transureteroureterostomy. Hodges et al reported that, among 100 patients accrued over a 25-year period who had been treated with transureteroureterostomy for various conditions, including ureteral stricture and intraoperative ureteral injury, 77 patients had no complications postoperatively. Of the 23 patients with complications, 5 patients had acute pyelonephritis, 3 patients had tumor blockage at the anastomotic site, 2 patients had IMA syndrome, and 2 patients had subsequent reflux of the normal ureter. In this study, 97% of patients had normal bilateral kidneys after a follow-up period of 1-23 years. [16]

In a 1997 study by Mathews et al, the psoas hitch reimplantation was shown to be a successful technique for reestablishing ureteral continuity after distal ureteral injury. In their study of 20 patients who underwent psoas hitch reimplantation for various conditions, 13 patients had iatrogenic injuries during surgery, and 17 patients (85%) required no further intervention for urologic problems and retained normal renal function after an average follow-up period of 6 years (range: 1-14 years). The authors conclude that psoas hitch reimplantation is an excellent treatment option for distal ureteral injuries. [17]

In 1975, Konigsberg et al reported on a series of patients; 15 of 21 patients studied had fair or excellent results for an average of 27 months after Boari flap reconstruction. Of the patients who had poor results, 2 patients had previous pelvic radiation, 2 patients had bladder carcinoma that recurred in the flap, and 2 patients had a flap that was not fixed to the psoas muscle. [18] With the benefit of modern indications for the use of Boari flaps, fewer poor results have occurred, although increased risk exists for bladder necrosis, given the dissection needed to create the flap. As a result of this risk and other technical considerations, many urologists opt for the psoas hitch reimplant as their first choice in ureteral reconstruction after a distal ureteral injury.

In a review of 65 women treated for morbidly adherent placenta, use of a surgical protocol that included rigid ureteral catheters, retrovesical dissection prior to hysterectomy and less invasive surgeries in selected patients resulted in a reduced frequency of ureteral injuries. [19]


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