A 6-year retrospective clinical review of iatrogenic ureteric injuries repaired in a resource-deprived setting

Abstract

Background Seventy percent of ureteric injuries result from iatrogenic causes with about 75% of these diagnosed in the postoperative period. It may have fatal complications such as sepsis and or renal functional damage increasing morbidity and treatment cost. Objective The study aimed to identify the risk factors for iatrogenic ureteric injuries from open surgical procedures and the intervention outcome in a resource-poor setting. Patients and methods This was a multi-centre study. The clinical records of patients with iatrogenic ureteric injuries seen between 2015–2021 who were managed at the urology units of the Margaret Marquart Catholic Hospital, and the Ho Teaching Hospital, in the Volta region of Ghana, were retrieved. The data extracted included patients’ demographic factors, the clinical presentation, the primary surgery details, the time from surgery to presentation, the intervention offered, and the outcomes. The data were analysed using the Statistical Package for Social Scientists (SPSS) version 24.0. Results Twelve patients aged between 24–54 years with a total of 19 ureteric injuries were managed. The injuries resulted from a hysterectomy in 10 cases (83.3%), and one each from emergency caesarean section and inguinal hernia repair with traction and transection injuries respectively (16.7%). Seven out of 12 cases were diagnosed 48 h after surgery. Bilateral injuries occurred in 7 cases (14/19 injuries). Intraoperative recognition was common in unilateral injuries and surgeries performed by specialist surgeons. Ureteroneocystostomy (14/19), uretero-ureterostomy (1/19), and open suture release were the management procedures performed as in the intervention. Conclusion Open hysterectomy (83.7%) was the most common procedure leading to iatrogenic ureteric injuries in this study. Intra-operative recognition occurred when trained specialist surgeons performed the surgery. Late presentation with more severe morbidity was found amongst non-specialist surgeons. Thus, improvement in training to allow intra-operative diagnosis should be encouraged in general practitioners to reduce morbidity and improve outcomes.

A delayed diagnosis of iatrogenic ureteral injury results in increased morbidity

“…They did not find any other predictors regarding previous surgery, previous radiation, diagnosis, type of surgery or demographics. Wei et al 8 found that surgeon inexperience was the main prime risk for these injuries, and Ali et al 6 found that late diagnosis of IUIs were more common amongst non-specialist surgeons.…”

“…The reason why younger age and benign indication for hysterectomy predispose for a delayed diagnosis is not clear to us, but one theory that already has been mentioned is surgeon experience 6 , 8 . Our theory is that the more experienced surgeons perform surgery on malignant indication, due to the importance of radical tumour resection.…”

“…They did not find any other predictors regarding previous surgery, previous radiation, diagnosis, www.nature.com/scientificreports/ type of surgery or demographics. Wei et al 8 found that surgeon inexperience was the main prime risk for these injuries, and Ali et al 6 found that late diagnosis of IUIs were more common amongst non-specialist surgeons. We found a non-significantly increased risk of delayed diagnosis when the IUI occurred during laparoscopic or robot-assisted surgery.…”

“…Previous publications indicate potentially severe consequences of IUIs with a delayed diagnosis, compared to injuries diagnosed intraoperatively. Patients with a delayed diagnosis may sustain severe morbidities needing hospital readmissions and several secondary medical procedures awaiting definite treatment, and some may also experience life threatening complications due to the injury 4 – 6 . There is also the matter of increased costs to the healthcare system related to IUIs.…”

Management strategies and root causes of missed iatrogenic intraoperative ureteral injuries with delayed diagnosis: a retrospective cohort study of 40 cases

“…However, most ureteral injuries are diagnosed postoperatively with variable delays and clinical presentations, making management challenging [ 4 ]. Indeed, management of missed intraoperative ureteral injuries varies widely, from endoscopic treatment allowing cicatrisation of the ureter to more aggressive surgical management ranging from repair of the affected ureter (ureteroneocystostomy, ureteroureterostomy, transureteroureterostomy, ureteral substitution…) to nephrectomy in case of impossible surgical repair or in case of a destroyed kidney [ 5 , 6 ].…”