Ureteral injury during abdominal and pelvic surgery: immediate versus deferred repair

Abstract

IntroductionThe incidence of ureteral damage during abdominal surgery is <1%. Repair of these lesions can be performed immediately when the injury is detected or deferred when it has been missed.Material and methodsWe retrospectively reviewed ureteral injuries that required surgical repair and were made during gynaecological and general surgery procedures between the years 2004 and 2016. We compared the clinical and functional outcomes between immediate and deferred repair.ResultsWe registered 84 lesions after 4000 abdominal procedures (2.1%). A total of 20 injuries were noted during general surgery interventions (24%) and 64 during gynaecological procedures (76%). The approach was laparoscopic in 66 of these cases and open in the other 18. Mean time of follow-up was 24 months. Immediate repair was accomplished in 35 cases (41%) and deferred in 49 (59%), with a median time to repair of 5.7 months. The laparoscopic approach was more frequent in deferred repairs (76% vs. 16%), while the open approach was more common in immediate repairs (54% vs. 40%). Procedures used for ureteral repair included 62 ureteral reimplantations using a psoas hitch technique, 8 end-to-end ureteral anastomoses, 6 ureterorraphies and 6 ureteral catheterisations. Two nephrectomies were also performed. Success rates and complications were similar for both immediate and deferred procedures (68% vs. 73% and 26% vs. 23% respectively, both p >0.05).ConclusionsThe occurrence of ureteral injury during abdominal surgery is low. Immediate repair is preferred when feasible, but delayed recognition of the injury is more common. We found no difference between immediate and deferred repair in terms of success rates.

2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery

“…In general, immediate repair of IUTIs can be achieved with good results [ 17 ]. Three factors influence the outcome of an IUTI that is amenable to immediate repair: (1) the characteristics of the lesion (the nature, the location, the extent, the mechanism), (2) the patient’s conditions, and (3) the available urological expertise [ 1 , 2 ].…”

“…The majority of IUTI (50–70%) are recognized postoperatively with a median delay of 10 days from the primary procedure [ 15 , 16 ]. Unrecognized IUTIs or delayed management can lead to potentially severe postoperative sequelae such as urinoma and abscess formation, ureteral stricture, renal autotransplantation, and kidney loss [ 17 ]. IUTI can additionally contribute to the development or worsening of acute kidney injury (AKI), which is reported in 17.4% of patients undergoing major emergency abdominal surgery [ 18 ].…”

Initial experience of ureteric visualization using methylene blue during laparoscopy for gynecological surgery

“…The distal segment of the ureter is the most vulnerable, with over 80% of surgical injuries occurring in this anatomical region ( 3 ). In gynecological surgeries, ureteral injuries primarily occur during procedures such as hysterectomy and pelvic tumor surgeries ( 4 ) This is especially risky in complex and challenging pelvic surgeries involving conditions like deep Infiltrating endometriosis (DIE)-induced adhesions, large tumors, cervical fixation, and tumor infiltration. If ureteral injury is not promptly identified and repaired during surgery, the consequences are patient morbidity which could include ureteral obstruction, fistulas and irreversible kidney damage.…”