Surgical ureteral injuries

T i!~ii

SURGICAL URETERAL INJURIES MARK A. ST. LEZIN, M.D. MARSHALL L. STOLLER, M.D. From the Department of Urology, University of California School of Medicine, San Francisco, California

~urgical procedures. While some injuries are hofieed intraoperatively, most are missed and ilpresent later with pain, sepsis, u r i n a r y i~rMnage, or renal loss resulting from obstruc!ilion, strictures, ureteral fistulas, urinomas, or Management can be particularly difle early postoperative period in debilients, especially after major oncologic or radiation therapy. A flexible ap!!proach and early intervention after complete !~ini~y assessment is the key to a successful out!if'come.The choice of treatment is based on the iiloeation, type and extent of ureteral injury as ~iwell as the patient s medical history, current ondition, and survival prognosis. An gic approach is ideal for injuries recostoperatively. The morbidity of de~ir and an open re-exploration often oided.

superior vesical vessels. Before entering the bladder, the ureter passes under the vas deferens. The female ureter courses posterior to the infudibulopelvic ligament containing the ovarian vessels. It continues anterior to the obturator structures, superior vesical vessels, uterine artery, and the ovary. As the ureter turns medially toward the bladder it lies in the base of the broad ligament and 2 cm lateral to the cervix. The ureter is again crossed by the uterine artery before entering the bladder. 1 The ureteral arteries lie between the ureteral adventitia and muscle wall. It is supplied by small arterial branches of the renal, aorta, gonadal, vesical, and iliac vessels. However, the ureteral "artery" may be discontinuous in 20 percent of ureters with incomplete anastomoses of the supplying vessels. Above the pelvic brim the ureter's arterial supply is derived medially. Below the pelvic brim it arrives laterally.2

Anatomy

Risk Factors

T h e ureter is frequently inadvertently iniiured because of its close proximity to impor!tant pelvic structures, its relatively long course !:inthe retroperitoneum, and tenuous blood suplily, Knowledge of the course of the ureter is the ii.,irststep toward preventing ureteral injuries. The ureters descend in the retroperitoneum ant¢rior to the psoas muscle, closely adherent to the peritoneum. The left ureter is crossed anteriorly by the left colic or inferior mesenteric and Sigrnoidal vessels. The right colic and ileocolic Vessels and the root of the mesentery containing the superior mesenteric vessels cross the right ureter. Before entering the pelvis, the ureter passes under the gonadal vessels before crossing OVerthe iliac vessels. In the pelvis, the male ureter continues anterior to the obturator nerve and vessels and the

Most patients suffering from iatrogenic injuries have no risk factors.

can occur during a variety of U rinjuries eurologic, t evascular, r aand lgeneral !i~eeologic,

UROLOGy /

DECEMBER 1991

/

Open surgical factors Ureters are frequently injured during difficult abdominal and pelvic operations when the normal anatomy and tissue planes are distorted. Bulky or invasive tumors, previous operations, ureteral duplication, and ectopic kidneys may change the expected course of the ureter. Endometriosis, retroperitoneal fibrosis, and inflammatory processes such as abscesses, pelvic inflammatory disease, diverticulitis, and inflammatory bowel disease may change the course of the ureter and make ureteral dissection and mobilization difficult. Ureteral laceration, devascularization, or occlusion may resuit. Radiation therapy can make dissection

VOLUME XXXVIII, NUMBER 6

497

Types of surgical ureteral injuries Open surgery Transection Suture ligation Crush Devascularization-ischemic necrosis Kink obstruction Circatrical fibrotic stricture Cautery thermal injury Endourologic surgery Perforation Stricture formation A~ulsion Ischemic necrosis Mucosal false passage Intussusception Prolapse into bladder

TABLE 1.

more difficult and ureteral arterial supply more tenuous. After dissection, avascular necrosis and fistula formation may develop. Attempts to control major hemorrhage deep in the pelvis can result in inadvertent ureteral injury from improperly placed hemostats or ligatures. Large tumors may further obscure visualization of the ureters and vessels complicating efforts at dissection and hemostasis (Table I).

Endourologic factors Risk factors for endourologic injuries include those noted for open surgery such as radiation, tumor, and inflammation2 However, endourologic injuries are more dependent on intraluminal ureteral factors. Ureteral strictures, impacted, multiple or oversized stones are a few examples. Kinks and tortuosity, and poor visualization from bleeding are contributing factors. Instruments such as guide wires, ureteral catheters, ureteroscopes, stone baskets, and balloon dilators may injure the ureter. Use of electrohydraulic (EHL), ultrasonic, and laser lithotriptors are commonly involved as well. Surgical Procedures

Gynecologic surgery Gynecologic surgery accounts for many ureteral injuries because of the proximity of the ureter in the pelvis to key female structures such as the ovarian and uterine vessels. In large series of 1,093 and 3,185 patients undergoing major gynecologic procedures, the incidence of ureferal injury was 0.5-1.5 percent. 4,~ Abdominal hysterectomies are the most common open surgery associated with ureteral injury. It accounts for 38 percent of all the injuries combined from 498

eight series of iatrogenic inj Most injuries occur close to region of the infundibulopeb clamping and ligature plm hemorrhage is the most corn The incidence of ureteral : cal hysterectomy is 2.2 perce much more likely after pre¢ therapy. In a series of 122 x radical hysterectomy, only operative radiation. The cot gery was comparable for thq teral fistulas occurred in 5/i~ patients compared with 5/1] not receive radiation. The ou pair was dismal for both grc or ileal urinary diversion quired in 6/10 patients. 18 Diagnostic and therapeut casionally results in inju: Fulguration of the ureter is cause. The injury is usually traoperatively. Late preser tonitis, fistula, or ureteral rule. iv Other unusual cause, include cesarean section, vat and ovarian tumor resection

Colorectal surgery Following abdominal ant tomy, abdominal perineal re: most common open surge1 ureteral injury, accounting fq teral injuries in combined : dence of ureteral injury dur percent. 12,1aa9The left ureter injured due to its proximit moid.19 Division of the later rectum in the presence of 1 TABLEII. 312 operations re injuries/from combined ser Operation Abdominal hysterectomy Radical hysterectomy Abdominoperineal resection Vascular Ovarian tumor resection Miscellaneous colorectal Vaginal hysterectomy Suprapubic urethropexy Laminectomy/spinal fusion Appendectomy Cesarean section Miscellaneous

UROLOGY

/

DECEMBER

1991

/

VOLUI~

ureter at increased risk. t2 Division of -ior mesenteric artery and reperitoneaduring eotoreetal surgery may" injure er as well2 Most patients present with na ureteral obstruction. However, occafistula or peritonitis may develop.

~roscopw procedures he incidence of ureteral injuries varies ~I~ from 2-17 percent. 2°-27 Huffman ~8 rei ~ fifteen series totaling 1,696 ureteroscoirocedures and found an overall perforation o f 7 percent. Open operative repairs for ~r injuries occurred in 0.4 percent of cases; eral strictures resulted in 1.4 percent of proires.as Most injuries occur in the distal one i of the ureter, where most procedures take ~252~ However, the ureteropelvic junction D and the proximal ureter may be more ie to injury. The proximal ureter has less ~le support and contains a thinner lining of osal cells than the distal ureter. 28 iieteral stricture formation is probably ~dby several factors, including direct mui injury or pressure ischemia from impacted ~, i n t r a m u r a l hematomas, extravasated ant, a n d infected urine, and circumferential idecl mueosa. 3°-33 The UPJ and the distal er are frequent sites of strictures, possibly ruse of their relatively fixed nature. 2s Torof the ureter by the ureteroscope in these S may cause ischemic or mucosal injury reng in .strictures. reteral perforation may occur by forced ,~Ss w h e n resistance is encountered, espey w h e n negotiating kinks, tortuous segts, strictures, or the natural curve over the arteries. Complete avulsion or intussuscepOf the ureter may occur during extraction irge or impacted stones in the distal ure:~2.~4.2~.ao Capturing the wall of the ureter La stone basket during stone extraction also result i n significant tears, avulsion, or iniseeption. Sharp edges can develop on flat baskets which can injure the ureter during !ion of t h e basket to capture a stone. Small iharp wires or catheters may cause mueosal i:and false passages. Large ureteroscopes Cireumferentially denude the mucosa lead!0 strictures. [traSonic, electrohydraulie l i t h o t n p s y L), a n d laser ureteroscopic lithotripsy have ~s hf o w n to be effective methods of in situ ragrnentation in the ureter. However, c a n c a u s e direct thermal ureteral injury.

/

D E C E M B E R 199i

/

Lasers may cause the least direct injury because of superficial penetration, tow energy transmitted, and the benefit of using smaller, flexible ureteroscopes. 2a Thermal injury to the ureter is potentially greatest with EHL. Injury can be avoided if the probe is directed and discharged against the stone under vision. Small and flexible scopes can be used with EHL. a4 The ultrasonic lithotriptor can be eumbersome and bulky and may perforate the ureter with its rigid tip. 25,26,33,a~However, stone extraction and visualization are facilitated by continuous suction of blood, stone fragments, and debris, minimizing the need for a stone basket and multiple reentries of the ureteroscope. The UPJ may stenose after failed dismembered pyeloplasty, endopyelotomy, prolonged presence of a renal pelvis calculus or open pyelolithotomy26 Intramural and meatal strictures also occur after resection of the ureteral orifice during transurethral resection of prostate and bladder tumors, and after balloon dilation and ureteral catheterization. 2,Q,26av,a6Open ureterolithotomy may also cause stricture formation.~i.12.37

Vascular procedures Ureteral obstruction is common after aortoiliac and aortofemoral arterial bypass surgery. In their review of several studies focusing on ureteral injury from vascular surgery, Blasco and Saladie 38 found that the incidence of asymptomatic hydronephrosis after aortovascuIar bypass surgery was 20 percent. Only 2 percent were symptomatic. Seventy percent of rare ureteral fistulas were found to occur within the first month. Symptomatic ureteral obstruction presented late, 35 percent within two months, 50 percent within twelve months, and 18 percent after five years. Fifteen percent were bilateral. Risk factors included retroperitoneal fibrosis, radiation exposure, long-term ureteral stents, graft infections, and graft dilation or false aneurysms. Intramural ureteral fibrosis may be caused by arterial pulsation injury to an immobilized ureter. Ureteral devaseularization during retroperitoneal dissection also may oeeur. In most cases, the ureteral dilatation is mild and asymptomatie. Hydronephrosis usually resolves within three months, a9,4° In a prospective study of 93 patients undergoing aortofemoral bypass surgery followed pre- and postoperatively at one week, three months, and one year, hydronephrosis was found in 12 percent of 18I kidneys. Asymptomatie ureteral

VOLUME XXXVIII, NUMBER 6

499

dilatation persisted in only 1/93 patients (1%) after one year. 3° In a series of 35 patients with ureteral obstruction following vascular surgery, "fibrosis" was cited as the cause in 90 percent of cases. Graft pseudoaneurysm and direct operative injury were causal in the remaining eases. 41 Graft position anterior to the ureters may be important in some cases of ureteral injury, z°-4~ An anterior graft position was found in 70 percent of patients with ureteral fistula, but in only 30 percent with obstruction alone. ~9,41

Miscellaneous Spinal surgery for disk disease or fusion has been reported as rare causes of ureteral injury. Risk factors are a prone position and L4/5 disk repair, when the ureter is in close proximity to the herniated disk. ~,9,11A2,43,44Uncommon causes of ureteral injury include suprapubie and vaginal bladder neck suspension procedures,~°-~3 appendectomy, v,1°,~3 eysteetomy, 2,°,45 and inguinal herniorrhaphy. 6 Presentation Seventy to 80 percent of ureteral injuries present postoperatively. 6,7,°-12 Flank pain from obstruction occurs in 36-90 percent. °,~°,4~Sepsis with fever is associated with obstruction in at least 10 percent. 7,11 Renal failure from bilateral obstruction is found in less than 10 percent of cases. 7,°-~2 Ureterovaginal or ureterocutaneous fistulas present in 20-64 percent of cases with watery discharges seven to ten days after surgery. 7,°-x2 A mass, urinoma, abscess, malaise, vague gastrointestinal symptoms, or ileus are often found. Diagnosis The goals of the diagnostic workup inelude determination of the site, extent, cause, and complications of the ureteral injury. Careful physical examination may disclose abdominal or flank tenderness from ureteral obstruetion, an aeute condition of the abdomen from peritonitis, a mass from a urine collection or hematoma, or fluid drainage from the w o u n d or vagina. Occasionally, a ureterovaginal fistula will be mistaken for a vesieovaginal fistula, or both may present. Presence of one or both fistulas can often be determined by placing a pack in the vagina and instilling the bladder with methylene blue.If methylene blue is seen on the vaginal pack, a vesieovaginal fistula is probably present. ~ Laboratory workup should include cultures of urine, fluid collections, and blood w h e n sep500

sis is suspected. Cre."*'~ . . . . . . serum and urinary dr~ firm the presence of u low global renal func Radiologic evaluati travenous pyelogram to evaluate gross rena] struetion, urinary ext tion and extent of inju tralateral kidney for pathology or coexistir fore treatment optio: and transureterouret~ In a series of 23 patier in all patients. 11 Hyd: eolumnation, nonvis of contrast media, an terial in the vagina ai ings.7.10.13 Cystoscopie retro: valuable to delineate eially when the IVP d ize the kidney or uret catheterization, a ure Dangerous bacterial ureter or urinoma dm tion may lead to infec not established via a neous nephrostomy. also provide excellent the extent of urinary and severity. Postrel~ lowed with serial exa Voiding cystoureth utilized to evaluate a to determine the statl bladder psoas hitch a~ is considered. If drain continues despite ne]; eoureteral reflux shou loon occlusion of the Computed tomo I magnetic resonance: cially helpful to scare mas, and for staging MRI can be perform, poor and may show w e l l . D y n a m i c g~ triamine-penta- aceti, MRI may differential teral obstruction an kidney from an obstr Ultrasound's nonin to be performed at tl~ able study to assess s. . . . . . . . ~

UROLOGY

/ DECEMBER1991

/

.

VOLUME XXXVIIi;;N~~Tm

,sis of ureteral injury is being enter:rasound is also excellent for imaging tring percutaneous punctures of ob:idneys, urine collections, and abtrasonography may detect the pres)ris in the collecting system representbezoars or pyonephrosis. Obstructed •e safely followed by sonography sk of contrast nephropathy. scans may be necessary to determine ruction is worthy of salvage. Such establish that cortical blood flow and recovery is poor after long-term ob~tive assessment :atus of a ureter remains in question ~ring surgery, a limited intravenous pyelocan be done on patient on operating table. ~ith satisfactory renal function, hemo~amics, and hydrational status, 1-2 cc/kg of ~nografin may be given intravenously after a ~ain film of the abdomen is obtained. Five~ild fifteen-minute films may reveal the site of ~jury. Since radiographic hydronephrosis may ~ t be present early after obstruction, the presice of ureteral contrast eolumnation, extravaiiion, or asymmetry should raise suspicion of a ~teral injury. The relative function of the con~alateral kidney also should be evaluated bef0recomplex reconstruction is contemplated. :iThe ureter usually can be identified above !ihbsuspected injury site. Starting at the level of !fileiliac arteries, the ureters can be carefully followeddistally. Anterior dissection just to vis~;~ahzethe ureter s course should be done. Mobli!!tzati0nand overdisseetion should be avoided to !Preventureteral devaseularlzatlon. A ureterotii~0rayis usually not indicated to cheek the pat~n~yof the ureter. An IVP or eystostomy with il.retiogradeureteral catheterization and ureteroigram is safer for the ureter. Intravenous !~aethyleneblue, which turns urine blue, can be hSed to help identify a urinary leak. ; ~ystoseopm retrograde and percutaneous ~ep~ostomy antegrade ureterograms during eadourologic procedures will usually identify ~thesite and extent of ureteral injury. They are rarely indicated for injury assessment during :~Pea surger3~

Treatment The treatment of surgical ureteral injuries depends on the site and length of damaged seg:ment:Presence of cancer, infection, retroperito4'~OLoGy

/

r~cv~aR~R

1~1

/

neal fibrosis, vascular graft, and previous radiation exposure to involved areas are important factors which impact upon the choice of repair. The function and condition of the affected and contralateral kidney must be considered. The patient's over-all medical condition and life-expectancy, as well as patient preferences regarding treatment options are of equal importance. Injuries recognized during open surgery Once the injury is fully delineated and assessed, treatment can be chosen. Several concepts for successful open ureteral repair should be followed. (1) Debride questionably viable tissue. Necrosis of nonviable ureter may result in delayed fistula, urinoma, or stricture formation. A ureteral stent is advised to help prevent complications if viability of the ureter is still questionable. (2) Strive for a tension-free and watertight anastomosis. Too many interrupted sutures at the ureteral anastomosis may compromise ureteral blood supply and healing. A spatulated repair for ureteroureterostomy will create an open anastomosis. (3) Isolate the repair from infection, retroperitoneal fibrosis, and cancer if possible. Omental pedicle sleeves based on the gastroepiploic vessels can isolate the anastomosis. The omentum can decrease the risk of eicatrical fibrotic reaction, increase the blood supply, and improve the mobility of the ureter for allowing normal peristalsis.l~ (4) Avoid cancer and irradiated ureters at the anastomosis. Fistula and obstruction will often resuit. (5) Minimize ureter mobilization. Ureteral devascularization is possible. (6) Temporary urinary diversion with percutaneous nephrostomy drainage should be considered until an experienced specialist is consulted if unfamiliar or complex reconstruction is entertained. Nephectomy generally should be reserved for nonfunctional kidneys and for patients with reasonable contralateral function. For ureters trapped within a ligature, release is usually sufficient. Occasionally debridement of the involved segment is necessary if viability is uncertain. Clamp crush injuries are more likely to result in more significant ureteral injury. Ureteral reanastomosis or ureteroneocystostomy after resection of the involved segment of ureter is safest. Distal ureter. For a ureteral injury involving the distal 5 em, an antireflux ureteroneocystostomy such as the Politano-Leadbetter procedure is simple and effective. If the injury does

VOLUME XXXVIII. NUMBER 6

501

not permit a tension-free reimplantation with modest ureteral mobilization, a vesieopsoas hitch can be performed. The psoas hitch brings the bladder to the ureter and facilitates tensionfree antireflux ureteral implantation. A 6-em ureteral defect can be bridged. *s Pathologic small, neurogenie, tuberculous, or irradiated bladders should not be used. Bladder outlet obs t r u c t i o n is also a relative e o n t r a i n d i e a tion.46.48-5° The Boari bladder flap is excellent when a psoas hitch will not suffice to bridge the ureferal shortage. Because of increased blood loss, possible bladder pedicle ischemia and necrosis, and the increased complexity of the procedure, a psoas hitch should be considered first. W h e n combined with a psoas hitch, a long ureteral deficit can be overcome. 51'~2 An 18-era defect has been bridged by this method. 49 Kronigsberg, Blunt, and Mueeke 53 found that 15 of 21 patients with distal ureteral injuries obtained good results from Boari flaps. Asymptomatie vesieoureteral reflux may be common despite antireflux ureteral bladder implantation. 52,~3 Boari flaps are contraindicated in small, irradiated, and neuropathie bladders and when the blood supply to the pediele via the superior vesical artery is inadequate. 4~,49,~4 Bladder transitional cell carcinoma is a relative eontraindieation since routine eystoseopie follow-up of the bladder flap is difficult. 5° M i d d l e ureter. For simple transection, ureteroureterostomy is satisfactory. If a large segment of ureter is lost, a Boari flap with psoas hitch may repair the defect. In more extensive injuries a transureteroureterostomy (TUU) may be used. 5~'56 Hodges et al. 56 reported a 92 percent success rate for 100 patients undergoing TUU, mostly for iatrogenie injury. The TUU is also indicated if previous operations, infection, or radiation precludes safe pelvic ureteral dissection and reconstruction. However, TUU jeopardizes the contralateral ureter and kidney.57 Angulation of the donor ureter can occur in its retroperitoneal course to the recipient ureter. Obstruction of the donor ureter by placement between the aorta and inferior mesenteric artery should be prevented. 56 Contraindieations for TUU include previous radiation exposure, r e t r o p e r i t o n e a l processes such as fibrosis, adenopathy, and infection, and presence of stones, renal tuberculosis, or urothelial tumors. Recipient distal ureteral obstruction is also a contraindication. 12 Anastomotie tension and poor ureteral blood supply account for many

502

transureteroureterostomy failu cations.49. 57 Proximal ureter. Most i managed by ureteroureterosto situations when most of the ur, or inaccessible for repair and tl~ too short for TUU, autotranspl~ final interposition should be c procedures are complex and re. tient selection for a suceessfl traoperative decisions are oft some instances p e r c u t a n e o u drainage should be performed t liberate workup, and consult leagues, the patient, and their : tomy may be the safest option f when renal preservation is not Autotransplantation is a re for low-risk, y o u n g patiew without aortoiliac atheroselero renal disease. Retroperitoneal tive contraindication because venous blood flow obstruction vena cava, or iliac veins. Per: marion and scarring from prey tion and infection may preve t o m y prior to transplantati described excellent results in treated after ureteral injury of renal function. Hypertensic obstruction w e r e avoided. corenal reflux was present in Intestinal ureteral substituti~ partial replacement of a dam~ bowel, usually terminal ileu~ complications include hyperct and hyperkalemia from resort ileal mucosa. If drainage of ileal ureter and renal functior compensation will prevent sit lyte abnormalities. Ureteral c obstruction, especially in eoml testinal mucus can cause uri~ absorption in the intestinal se~ points out that the intestinal s, to dilate and create high pc leading to acidosis, infection, and worsening upper tract dra Goodwin and others described when patients were chosen ca1 those p a t i e n t s w i t h p o o r (creatinine > 2 mg/dL), bla struction and neurogenic bla emptying and high intravesic With follow-up of six months

UROLOGY

/

D E C E M B E R 1991

/

VOLUME XXXVIII,

:::~

trgical repairs o] ureteral ined series 1961-19866-11,13

:omy

Percent 30.0 19.0 15.0 8.9 7.0 5.4 3.4 3.1 8.2

84 patients were reviewed. vere successfully treated by ldged by preservation of reP appearance, and normal ~erative mortality rate was ileal reflux was universal, common. Symptomatic int. Chronic bacteriuria in asts, a poorly draining and/or r, and high post-void residecurrent or chronic pyelodeterioration. 58,6° The ap~n used for right proximal with success. 62 postoperatively presenting postoperatively with sepsis or fistulas in deth cancer or radiation expooptions often are not clearmany medically stable paureteral segmental injury, y as described earlier is indierns about the difficulty of i seven to twenty-one days inflammation is maximal, 2 described equally good reand lower morbidity and early open repair, v,12,~3,~3,~4 7 of patients with delayed injuries, an initial endouroa excellent alternative. Peromy (PNS) and retrograde nent can stabilize the septic with ureteral obstruction. ~ral stent or PNS can be peranesthesia for the critically i not tolerate general or reOccasionally, PNS or stent Jw resolution of the injury ttervention. 2~,~4'2v'45'"5-~8 For sation of the ureter can be

~l/0LOGY

managed conservatively with PNS until suture dissolution restores ureteral continuity. 68 However, stents and PNS are also useful to temporize until more definitive therapy can be performed safely. Cystoscopic retrograde ureteral stent placement is usually the initial endourologic approach. Keys to successful stent placement include proper patient positioning and an initial retrograde ureterogram to define the anatomy. Dilute contrast material and fluoroscopy are also indispensable for difficult retrograde manipulations. A floppy or coaxial guide wire used in combination with ureteral catheters can be used to negotiate tortuous, kinked, strictured, and perforated ureters. However, retrograde stent placement can be difficult or impossible. In one series by Dowling 11 only 1/20 injured ureters was successfully stented. Similarly, Hoch and Persky 1° succeeded to place stents in 1/10 obstructed ureters after injury. W h e n retrograde manipulation fails, PNS should be performed to establish drainage. PNS can be performed under ultrasound guidance with fluoroscopic confirmation. Nephrostoureterography, Whitaker pressure-flow studies, creatinine clearance, and antegrade renal and ureteral manipulations are possible once the nephrostomy tube is placed. Antegrade ureteral stent placement may succeed when retrograde attempts fail. 66,~v In 11/15 ureters managed by PNS for ureteral obstruction or with antegrade stent for fistula the injury resolved. The remaining 4 required open surgical repair, n Chang, Marshall, and Mitchell 66 reported successful resolution of 10/12 ureteral fistulas managed four to six weeks with antegrade placed ureteral stents. Failures were long-term fistulas which were present greater than four months. Epithelialization may prevent spontaneous closure of old fistulas. ~8 Balloon dilation of ureteral strictures can be p e r f o r m e d in a r e t r o g r a d e or a n t e g r a d e fashion, s° Kramolowsky, Tucker, and Nelson 2° reported successful dilation of 9/14 (64 %) ureteral strictures initially managed endoscopically. There were no complications. Strictures which were successfully dilated were short (< 2 cm) and recently formed. If stricture intubation could be performed, dilation was possible in 82 percent of cases, n° Netto et al. v° had a similar success rate (57 % ) and problems with long and impassable strictures. O'Brien, Maxted, and Pahira 37 achieved a 50 percent success rate with balloon dilation of ureteral strictures overall,

/ DECEMBER 1991 / VOLUME XXXVIII, NUMBER 6

503

and succeeded in 6/10 balloon-dilated ureteral strictures after iatrogenic injury. Lang 3~ expects a 90 percent success rate for all fresh strictures when inflammation, radiation, or devascularization are not main features of the ureteral injury. Unfortunately, inflammation and devascularization probably are important in most iatrogenic injuries. UPJ obstruction from primary congenital stenosis, renal pelvic stones, or iatrogenic strictures following pyelolithotomy or failed pyeloplasty can be treated by endoscopic incision, i.e. endopyelotomy. Both antegrade nephroseopic and retrograde ureteroscopic endopyelotomy have a success rate of 80-90 percent, compared with 90-100 percent success w i t h pyeloplasty. 7~-74 Endopyelotomy is ideal for strictures following pyeloplasty when a repeat open repair is difficult. The shorter hospitalization, fast recovery, low morbidity, and infrequent serious complication rate make endopyelotomy appealing despite a slightly higher chance of failure. 7~'75 However, Hulbert, Hunter, and Castaneda-Zuniga TM found only a 47 percent success rate for acquired strictures treated by endopyelotomy. Strictures resulting from open or endoscopic stone surgery improved in only 17 percent, compared with 70 percent for failed pyeloplasty. Long and complete strictures were most difficult to treat. Stricture recurrence occurred within four weeks for treatment failures. TM Karlin, Badlani, and Smith 'r2 suggest that patient selection is key to success. Relative contraindications for endopyelotomy includes long stricture length, a large redundant renal pelvis, and a high inserting UPJ. An aberrant anterior lower pole vessel is present in 30 percent of patients. It can be avoided by careful endoscopy and a posteriorlateral incision. Strictures elsewhere in the ureter also have been treated by endoscopic incision less fr'equently. 6°'77

following TUU may result in sis, and retroperitoneal uril Boari flap and psoas hitch m by vesicoureteral reflux or ( struction. Renal loss from per or elective nephrectomy may Percutaneous nephrostom: rarely causes liver, splenic, ol nificant renal hemorrhage or also uncommon. Chronic ba¢ onization of the long-term r may predispose to pyelone: lodgement and obstruction] quire replacement. Balloon ¢ pyelotomy can result in t disruption, and retroperiton Retrograde endopyelotomy i risk for distal ureteral stricture. 73 Vreteral stents are well tolerated, but : ~ quently cause irritative voiding s y m p t ~ ! i which usually respond to anticholinergic m ~ cations. They should be removed or ch every four months to prevent e n c r u s t a t i ~ Stent obstruction, migration, and erosiofi~!::~:~:: tula are rare problems. 78'79 Follow-up Careful follow-up is import repair. Intravenous pyelogl and/or antegrade ureterogrm tained one month after repail thereafter if abnormalities rer study at six months or one 3 asymptomatic ureteral strict treatment or close follow-up. may be an excellent adjunct struction is of concern. Final by serum creatinine should [ cially after bilateral injury, b be necessary if the function of remains in doubt. Prevention

Complications of Repair The most common complications of repairs include recurrent fistula or urinoma, strictures, ureteral kinks, and infection. Open reoperation may be required if endourologie management fails. Infection of vascular grafts is a dreaded complication of ureteral repair after aortic bypass surgery. Progressive renal failure, acidosis, sepsis, and upper tract decompensation can complicate ileal ureter substitution. Recipient ureteral obstruction or anastomotie stricture 504

Many ureteral injuries oct open dissection or endosco r may not be preventable eve: are followed by the most skilled surgeon. An attempt ties is the goal. An adeq workup is required before o]~ surgery. If the ureter is inv( tumor resection or vascular or eonrast-enhaneed CT are the course of the ureter. Hox . . . . . ,

UROLOGY

/ DECEMBER 1991 / VOLUME XXXVIII, NU i , ~ N , ~

~ a s not been shown to prevent ureteral in~!during routine hysterectomy.14'8° Routine ~ n g studies for unselected patients are not ~d~ctive and carry potential risks of cone!ated anaphylaxis and nephrotoxicity. ~ging studies cannot replace a well-planned ~ery and careful dissection. eases when the ureter is at risk, such as ~0minal hysterectomy, careful identification ~ e ureter and its course is advised. When ~fification is difficult, the ureter can be it crosses the iliac vessels and then ffully distally. Furosemide and hyenhance visualization of the periHemostasis and optimal exposure during difficult ureteral exploraection. aetie ureteral catheter has been ,r identification of the ureter, espeduring pelvic surgery for malignancy. feral catheters may cause more problems they solve. Small 5F catheters may be dirt0 palpate, giving the surgeon a false sense .,urity, despite continued risk of ureteral inFiberoptic catheters are also available to in ureter visualization. However, stent ement may cause ureteral edema, which icause temporary ureteral obstruction after s ~ e removed shortly after surgery. Bilatobstruction leading to renal failure has reported.S1 Finally, retrograde manipulaadd to operative time and have inherent of ureteral injury and upper urinary tract

~ii

~ti0n. Conclusion reteral injuries occur during a variety of ab!nal~ pelvic, and endourologic procedures. surgeon should be aware of riskr f~:t:~si, iandsiteof potential ureteral inju y o "s !toire of proeedures. When injury oeeurs ioperatively, complete assessment of the inand consideration of salient individual pafactors should lead to successful repair and ~ery in most eases. For injuries presenting ~!peratively, immediate endourologic ma~!ation is often the best initial management ~Use of its low morbidity during the early

E0 o,o ,vo ex,ens,vo ,oju,e,,m~atg open repair may be indicated. Careful _

~W.up is encouraged due to the high inci~ce of repair failures, fistulas, and strictures. San Francisco, California 94143-0738 (DR. STOLLER)

~L(}(~y / DECEMBER 1991

/

References 1. Netter F: In Shapter RK (Ed): The CIBA Collection of Medical Illustration, Kidneys, Ureters, and Urinary Bladder, New Jersey, CIBA Pharmaceutical Company, p 23. 2. Guerrierro WG: Ureteral injury, Urol Clin North Am 16: 237 (1989). 3. Chang R, and Marshall FF: Management of ureteroscopic injuries, J Urol 137:1132 (1987). 4. Mann WJ, et al: Ureteral injuries in an obstetrics and gynecology training program: etiology and management, Obstet Gynecol 72:82 (1988). 5. Daly J, and Higgins KA: Injury to the ureter during gynecologic surgical procedures, Surg Gynecol Obstet 167:19 (1988). 6. Spence HM, and Boone T: Surgical injuries to the ureter, JAMA 176:1070 (1961). 7. Witters S, Cornelissen M, and Vereecken R: Iatrogenic ureteral injury: aggressive or conservative treatment, Am J Obstet Gynecol 155:582 (1986). 8. Fry DE, Milholen L, and Harbrecht PJ: Iatrogenic ureteral injury, options in management, Arch Surg 118:454 (1983). 9. Higgins CC: Ureteral injuries during surgery, JAMA 199:82 (1967). 10. Hoch WH, Kursh ED, and Persky L: Early aggressive management of intraoperative ureteral injuries, J Urol 144:530 (1975). 11. Dowling RA, Corriere JN Jr, and Sandler CM: Iatrogenie ureteral injury, J Urol 135:912 (1986). 12. Zinman LM, Libertino JA, and Roth RA: Management of operative ureteral injury, Urology 12:290 (1978). 13. Bright TC III, and Peters PC: Ureteral injuries seeondary to operative procedures, Urology 9:22 (1977). 14. Larson DM, et al: Ureteral assessmentafter radical hysterectomy, Obstet Gynecol 69:612 (1987). 15. Riss P, Koelbl H, Neunteufel W, and Janiseh H: Wertheim radical hysterectomy 1921-1986: changes in urologie eomplicat.ions, Gyneeol Obstet 241:249 (1988). 16. Underwood PB Jr, et al: Radical hysterectomy: a critical review of twenty-two years' experience, Am J Obstet Gynecol 134:889 (1979). 17. Grainger DA, et al: Ureteral injuries at laparoscopy: insights into diagnosis, management and prevention, Obstet Gynecol 75:839 (1990). 18. Hughes ESR, McDermott FT, Polglase AL, and Johnson WR: Ureterie damage in surgery for cancer of the large bowel, Dis Colon Rectum 27:293 (1984). 19. Andersson A, and Bergdahl L: Urologic complications following abdominoperineal resection of the rectum, Arch Surg 111: 969 (1976). 20. Shultz A, Kristensen JK, Bride T, and Eldrup J: Ureteroscopy: results and complications, J Urol 137:865 (1987). 21. Blute ML, Segura M, and Patterson DE: Ureteroscopy, J Urol 139:510 (1988). 22. Weinberg JJ, Kwabena A, and Smith AD: Complications of ureteroscopy in relation to experience: report of survey and author experience, J Urol 137:384 (1987). 23. Dretler SP: An evaluation of ureteral laser lithotripsy: 225 consecutive patients, J Urol 143:267 (1990). 24. Carter S StC, Cox R, and Wiekham JEA: Complications associated with ureteroscopy, Br J Urol 58:625 (1986). 25. Kramolowsky EV: Ureteral perforation during ureterorenoseopy: treatment and management, J Urol 138:36 (1987). 26. Ono Y, et al: Long-term results of transurethral lithotripsy with the rigid ureteroscope: injury of intramural ureter, J Urol 142:958 (1989). 27. Lytton B, WeissRM, and Green DF: Complications of ureteral endoscopy, J Urol 137:649 (1987). 28. Huffman JL: Ureteroscopie injuries to the upper urinary tract, Urol Clin North Am 16:249 (1989). 29. Kramolowsky EV, Tucker RD, and Nelson CMK: Management of benign ureteral strictures: open surgical repair or endoscopic dilation?, J Urol 141:285 (1989). 30. Biester R, and Gillenwater JY: Complications following

VOLUME x x x v n i , NUMBER 6

505

ureteroscopy, ~ Urol 136:380 (1986). 31. Lang EK: Transluminal dilatation of ureteropelvic junction strictures, ureteral strictures, and strictures at ureteroneocystostomy sites, Radiol Clin North Am 24:601 (1986). 32. Boddy S-AM, et al: Irrigation and acute ureteric dilatation-as for ureteroscopy, Br ] Urol 63:11 (1989). 33. Boddy S-AM, et ah Acute ureteric dilatation for ureteroscopy, an experimental study, Br J Urol 61:27 (1988). 34. Willseher MK, et al: Safety and efficacy of electrohydraulic lithotripsy by ureteroscopy, J Urol 140:957 (1988). 35. Chaussy C, et at: Transurethral ultrasonic ureterolithotripsy using a solid-wire probe, Urology 29:531 (1987). 36. Smith AD: Management of iatrogenic ureteral strictures after urological procedures~ J Urol 140:1372 (1988). 37. O'Brien WM, Maxted WC, and Pahira JJ: Ureteral stricture: experience with 31 cases, J Urol 140:737 (1988). 38. Blaseo F-J, and Saladie J-M: Ureteral obstruction and ureteral fistulas after aortofemoral or aortoiliae bypass surgery, J Urol 145:237 (1991). 39. Goldenberg SL, Gordon PB, Cooperberg PL, and MeLoughlin MG: Early hydronephrosis following aortic bifurcation graft surgery: a prospective study, J Urol 140:1367 (1988). 40. Spirnak ]P, Hampel N, and Resnik MI: Ureteral injuries complicating vascular surgery: is repair indicated?, J Uro1141:13 (1989). 41. Sant GR, Heaney ]A, Parkhurst EC, and Blaivas JG: Obstructive uropathy~a potentially serious complication of reconstructive vascular surgery, J Urol 129:16 (1983). 42. Schapira HE, et al: Ureteral injuries daring vascular surgery, ] Urol 125:293 (1981). 43. Gangal MP: Ureteral injury incident to lumbar disc surgery, J Neurosurg 36:90 (1972). 44. Delay P, et ah An unusual ureteric injury, Br J Uro158:567 (1986), 45. Persky L, Hampel N, and Kedia K: Percutaneous nephrostomy and ureteral injury, J Urol 125:298 (1981). 46. Silverstein ]I, Libby C, and Smith AD: Management of ureteroscopic ureteral injuries, Urol Clin North Am 15:515 (1988). 47, Seme]ka RC, et ah Obstructive nephropathy: evaluation with dynamic Gd-DTPA-enhanced MR imaging, Radiology 175: 797 (1990). 48. Kishev S: Psoas-bladder hitch procedure: our experience with repair of the iniured ureter in men, J Urol 113:772 (1975). 49. Boxer RJ, Johnson SF, and Ehrlich RM: Ureteral substitution, Urology 12:269 (1978). 50. Warwick RT, and Worth PHL: The psoas bladder-hitch procedure for the replacement of the lower third of the ureter, Br ] Urol 41:701 (1968). 51. Gross M, Peng B, and Waterhouse K: Use of the mobilized bladder to replace the pelvic ureter, J Urol 101:40 (1969). 52. Williams JL, and Porter RW: The Boari bladder flap in lower ureteric injuries, Br ][ Urol 38:528 (1966). 53. Konigsberg H, Blunt K], and Muceke ED: Use of Boari flap in lower ureteral injuries, Urology 5:751 (1975). 54. Symmonds RE: Ureteral injuries associated with gynecologic surgery: prevention and management, Clin Obstet Gynecol 19:623 (19'76). 55. Hendren WH, and Hensle TW: Transureteroureterostomy: experience with 75 cases, J Urol 123:826 (1980). 56. Hedges CV, et al: Transureteroureterostomy: 25-year experience with 100 patients, J Urol 123:834 (1980). 57. Ehrlich RM, and Skinner DG: Complications of transureteroureterostomy, J Urol 113:467 (1975). 58. Preut GR Jr, Stuart WT, and Witus WS: Utilization of ileal

506

segments to substitute for extensive ureteral loss, J Urol 90i (1963). 59. Rodie B, Novick AC, Rose M, and Straffon RA: Long-t results with renal autotransplantation for ureteral replaCertiet Urol 136:1187 (1986). ~ 60. Tanagho EA: A case against incorporation of bowel':: ments into the closed urinary system, J Urol 113, 796 (1975): 61. Boxer RJ, et ah Replacement of the ureter by small~r tine: clinical application and results of the ileal ureter in ~9 tients, ] Urol 121:728 (1979). \ 62. Komatz Y,, and ltoh H: A ease of ureteral injury re,;: Ewith appendix, J Urol 144:132 (1990). 63. Badenoch DF, et al: Early repair of accidental injur~)t~ ureter or bladder following gyuaecological surgery, Br J U~0[ 516 (1987). 64. Reland C: Early treatment of ureteral injuries foundii gynecological surgery, ] Urol 118:25 (1977) . . . . 65. Pocoek RD, et al: Double J stents a review of 100 pa~ii~ Br ] Urol 58:629 (1986). 66. Chang R, Marshall FF, and Mitchell S: Percut~:fi management of benign ureteral strictures and fistulas, J U(0i 1126 (1987). . . . . . . 67. Lang EK, et al: The management of urinary fistuli~ strictures with pereutaneous ureteral stent catheters, ] Urb!::

736 (1979).

!~i

68. Harshman MW, Pollack HM, Banner MP, and V~g~ Conservative management of ureteral obstruction seeond~i suture entrapment, J Urol 127:121 (1982). 69. Kiewiet de Jonge M, van der beek C, Well EHJ, anai saet BLRA: Antegrade ureteroseopy: a new tool in mana~ of severe ureteral strictures, Urology 27:49 (1986). 70. Net-to NR Jr, Ferreira U, Lemos GC, and Clar0 JF/~ dourological management of ureteral strictures, ] Urol 1~ (1990). ~ 71. Brannen GE, Bash WH, and Lewis GP: Endopyd~ for primary repair of ureteropelvic ~unction obstruction, ] 139- 29 (1988). ~ 72. Karlin GS, Badlani GH, and Smith A: Endopyd~ versus open pyeloplasty: comparison in 88 patients, J uir0~ 476 (1988). 73. Clayman RV, Raster JW, Kavonssi L, and Picas D~ teronephroscopie endopyelotomy, J Urol 144:246 (1990).:i; 74. O'Flynn K, et al: EndobaUoon rupture and sten~ pelviureteric junction obstruction: technique and early r~] J Urol 64:572 (1989). 75. Badlani G, Karlin G, and Smith AD: Complicatio~ dopyelotomy and analysis of slides of 64 patients, J Urol ] d (1988). 76. Hulbert ]C, Hunter D, and Castaneda-Zuniga Wi cation of and techniques for the reconstitution of acqmr~i tures in the region of the ureteropelvic junction, J Uroi :[~ (1988). 77. Selikowitz SM: New coaxial ureteral stricture knife Clin North Am 17:83 (1990). ~'~ 78. Saltzman B: Ureteral stents, Urol Clin North Am :!~,i

(1988).

!:~:~:

79. Bhargava A, and Yusef R: Ureterovenous fistulaij~L.iii usual complication of ureterle catheterization, J (1987). ~]:~:80. Piscitelli JT, Simel DL, and Addison WA: Who sho,ll intravenous pyelograms before hysterectomy for benign ~t~ Obstet Gynecol 69:541 (1987). ~ 81. Sheikh FA, and Khubchanaui IT: Prophylactic ~ catheters in colon surgery--how safe are they? Report ofi~ Dis Colon Rectum 33:508 (1990).

UROLOGY

/ DECEMBER 1991 / VOLUME XXXVIII,