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Iatrogenic ureteral injury after laparoscopic cholecystectomy in a 13-year-old boy
Journal of Pediatric Urology (2008) 4, 322e324
CASE REPORT
Iatrogenic ureteral injury after laparoscopic cholecystectomy in a 13-year-old boy Job K. Chacko*, Paul S. Noh, Julia S. Barthold, T. Ernesto Figueroa, Ricardo Gonzalez A.I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA Received 24 November 2007; accepted 22 December 2007 Available online 25 February 2008
KEYWORDS Laparoscopic ureteral injury; Access injury
Abstract We present a report of a delayed ureteral injury after a laparoscopic cholecystectomy. The patient presented with one episode of gross hematuria after surgery. He was treated with ureteral stent drainage and did well with no long-term sequelae. ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Pediatric laparoscopy in children has been shown to be safe, but there is a small risk of access injuries [1]. We describe a previously unreported complication of ureteral injury after laparoscopic cholecystectomy.
Case report A 13-year-old male with chronic abdominal pain underwent laparoscopic cholecystectomy for a 0.6-cm gallstone and biliary dyskinesis. A 10-mm umbilical camera port with Hasson entry technique was used and three 5-mm ports were visually placed (two right, one left). The gallbladder was removed by clipping the cystic artery and cystic duct.
* Corresponding author. Tel.: þ1 302 651 5898; fax: þ1 302 651 6410. E-mail address: [email protected] (J.K. Chacko).
On postoperative day 1 the patient had one episode of gross hematuria, but was otherwise stable with no abdominal/flank pain. Laboratory evaluation was normal. A CT of abdomen/pelvis with delayed imaging (Fig. 1) showed medial extravasation from the right ureter near the level of the umbilicus. Intraoperative retrograde ureteropyelogram (Fig. 2) confirmed the medial extravasation. A double-J stent was placed and left for 1 month. Renal ultrasound obtained 5 months postoperatively was normal.
Discussion Iatrogenic ureteral injuries have been associated with intra-abdominal and pelvic surgery in open surgery in the past. With the increased use of laparoscopy and robotassisted surgery, there have been ureteral injuries associated with these newer techniques as well. Elliot and McAnnich [2] reviewed iatrogenic ureteral injuries and found that 50e70% were not recognized
1477-5131/$34 ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2007.12.009
Iatrogenic ureteral injury
323 Unrecognized electrosurgical injury has been reported to occur during laparoscopic surgery. The phenomenon of capacitative coupling has been reviewed by Wu et al. [4] where the injury from electric current from an active element can be transmitted without direct contact to the organ. Although not reported, this is a potential cause of ureteral injury also. Access injuries during laparoscopy have been investigated as well. Scha ¨fer and colleagues [5], in a review of over 14,000 laparoscopic cases over a 2-year period, identified 22 trocar injuries and four needle injuries (0.18%). Interestingly, 11 of the injuries occurred on the right side lateral to the umbilicus, which correlated with the right ureteral injury described in this report. To our knowledge, injury to the ureter during laparoscopic cholecystectomy has not been previously reported. We assume that the injury occurred unrecognized during access and trocar placement in the right abdomen.
Conclusion
Figure 1
CT abdomen/pelvis.
immediately. The greatest risk of injury was during gynecologic surgery, with 52e82% of operative injuries seen associated with these lower pelvis procedures. Urologic injuries were highest during ureteroscopy with a 0.3% avulsion rate and a 3e6% perforation rate. Ostrzenski and associates [3] reviewed laparoscopic ureteral injuries in the gynecology literature and found a 1e2% incidence during laparoscopic surgery. Of the 70 reported injuries, 20% of the laparoscopic ureteral injuries occurred during laparoscopically assisted vaginal hysterectomy. In addition, they confirmed the delayed presentation of iatrogenic ureteral injuries at 70%.
Figure 2
Although ureteral injury during laparoscopic cholecystectomy has not been reported previously, this case demonstrates that the ureter is potentially at risk during laparoscopic access. Since access is necessary in any laparoscopic case, signs and symptoms of hematuria, flank pain or peritonitis could be a delayed presentation of ureteral injury. Although most injuries are recognized postoperatively, they can usually be managed with ureteral stent drainage.
Conflict of Interest The authors have no conflict of interest.
Funding None.
Intraoperative retrograde ureteropyelogram.
324
Ethical approval Not applicable.
References [1] Peters CA. Complications in pediatric urological laparoscopy: results of a survey. J Urol 1996;155:1070e3.
J.K. Chacko et al. [2] Elliot SP, McAnnich JW. Ureteral injuries: external and iatrogenic. Urol Clin North Am 2006;33:55e66. [3] Ostrzenski A, Radolinski B, Ostrzenska KM. A review of laparoscopic ureteral injury in pelvic surgery. Obstet Gynecol Surv 2003;58:794e9. [4] Wu MP, Ou CS, Chen SL, Yen EYT, Rowbotham R. Complications and recommended practices for electrosurgery in laparoscopy. Am J Surg 2000;179:67e73. [5] Scha ¨fer M, Lauper M, Kra ¨henbu ¨hl L. Trocar and Veress needle injuries during laparoscopy. Surg Endosc 2001;15:275e80.
CASE REPORT
Iatrogenic ureteral injury after laparoscopic cholecystectomy in a 13-year-old boy Job K. Chacko*, Paul S. Noh, Julia S. Barthold, T. Ernesto Figueroa, Ricardo Gonzalez A.I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA Received 24 November 2007; accepted 22 December 2007 Available online 25 February 2008
KEYWORDS Laparoscopic ureteral injury; Access injury
Abstract We present a report of a delayed ureteral injury after a laparoscopic cholecystectomy. The patient presented with one episode of gross hematuria after surgery. He was treated with ureteral stent drainage and did well with no long-term sequelae. ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Pediatric laparoscopy in children has been shown to be safe, but there is a small risk of access injuries [1]. We describe a previously unreported complication of ureteral injury after laparoscopic cholecystectomy.
Case report A 13-year-old male with chronic abdominal pain underwent laparoscopic cholecystectomy for a 0.6-cm gallstone and biliary dyskinesis. A 10-mm umbilical camera port with Hasson entry technique was used and three 5-mm ports were visually placed (two right, one left). The gallbladder was removed by clipping the cystic artery and cystic duct.
* Corresponding author. Tel.: þ1 302 651 5898; fax: þ1 302 651 6410. E-mail address: [email protected] (J.K. Chacko).
On postoperative day 1 the patient had one episode of gross hematuria, but was otherwise stable with no abdominal/flank pain. Laboratory evaluation was normal. A CT of abdomen/pelvis with delayed imaging (Fig. 1) showed medial extravasation from the right ureter near the level of the umbilicus. Intraoperative retrograde ureteropyelogram (Fig. 2) confirmed the medial extravasation. A double-J stent was placed and left for 1 month. Renal ultrasound obtained 5 months postoperatively was normal.
Discussion Iatrogenic ureteral injuries have been associated with intra-abdominal and pelvic surgery in open surgery in the past. With the increased use of laparoscopy and robotassisted surgery, there have been ureteral injuries associated with these newer techniques as well. Elliot and McAnnich [2] reviewed iatrogenic ureteral injuries and found that 50e70% were not recognized
1477-5131/$34 ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2007.12.009
Iatrogenic ureteral injury
323 Unrecognized electrosurgical injury has been reported to occur during laparoscopic surgery. The phenomenon of capacitative coupling has been reviewed by Wu et al. [4] where the injury from electric current from an active element can be transmitted without direct contact to the organ. Although not reported, this is a potential cause of ureteral injury also. Access injuries during laparoscopy have been investigated as well. Scha ¨fer and colleagues [5], in a review of over 14,000 laparoscopic cases over a 2-year period, identified 22 trocar injuries and four needle injuries (0.18%). Interestingly, 11 of the injuries occurred on the right side lateral to the umbilicus, which correlated with the right ureteral injury described in this report. To our knowledge, injury to the ureter during laparoscopic cholecystectomy has not been previously reported. We assume that the injury occurred unrecognized during access and trocar placement in the right abdomen.
Conclusion
Figure 1
CT abdomen/pelvis.
immediately. The greatest risk of injury was during gynecologic surgery, with 52e82% of operative injuries seen associated with these lower pelvis procedures. Urologic injuries were highest during ureteroscopy with a 0.3% avulsion rate and a 3e6% perforation rate. Ostrzenski and associates [3] reviewed laparoscopic ureteral injuries in the gynecology literature and found a 1e2% incidence during laparoscopic surgery. Of the 70 reported injuries, 20% of the laparoscopic ureteral injuries occurred during laparoscopically assisted vaginal hysterectomy. In addition, they confirmed the delayed presentation of iatrogenic ureteral injuries at 70%.
Figure 2
Although ureteral injury during laparoscopic cholecystectomy has not been reported previously, this case demonstrates that the ureter is potentially at risk during laparoscopic access. Since access is necessary in any laparoscopic case, signs and symptoms of hematuria, flank pain or peritonitis could be a delayed presentation of ureteral injury. Although most injuries are recognized postoperatively, they can usually be managed with ureteral stent drainage.
Conflict of Interest The authors have no conflict of interest.
Funding None.
Intraoperative retrograde ureteropyelogram.
324
Ethical approval Not applicable.
References [1] Peters CA. Complications in pediatric urological laparoscopy: results of a survey. J Urol 1996;155:1070e3.
J.K. Chacko et al. [2] Elliot SP, McAnnich JW. Ureteral injuries: external and iatrogenic. Urol Clin North Am 2006;33:55e66. [3] Ostrzenski A, Radolinski B, Ostrzenska KM. A review of laparoscopic ureteral injury in pelvic surgery. Obstet Gynecol Surv 2003;58:794e9. [4] Wu MP, Ou CS, Chen SL, Yen EYT, Rowbotham R. Complications and recommended practices for electrosurgery in laparoscopy. Am J Surg 2000;179:67e73. [5] Scha ¨fer M, Lauper M, Kra ¨henbu ¨hl L. Trocar and Veress needle injuries during laparoscopy. Surg Endosc 2001;15:275e80.