Complete ureteropelvic-junction disruption following renal trauma: conservative management. / Avulsión completa de la unión pieloureteral tras traumatismo renal: manejo conservador.

INTRODUCTION: Surgical exploration in complete ureteropelvic-junction disruption (CUPJD) is still recommended by many authors. Conservative approach to pediatric renal trauma (RT) includes minimally invasive techniques such as nephrostomy, angioembolization or double-J stent placement. CASE REPORT: A 14-year-old patient with CUPJD was treated conservatively. CT-scan revealed active bleeding of the renal artery and significant urine extravasation. Coil angioembolization and nephrostomy placement were performed. An attempt to place a double-J stent was unsuccessful and surgical reconstruction was scheduled. Before surgery, methylene-blue was injected through the nephrostomy observing blue urine output through urethra. Antegrade pyelogram revealed drainage from the urinoma to the ureter. A new attempt to place an internal-external double-J-stent was successful. After 5 weeks, it was removed with total restoration of the urinary tract. CONCLUSION: Complete urinary tract restoration in some cases of CUPJD following RT is possible through a nonoperative approach. It can be safe and effective, reducing the risk of complications associated with complex surgeries.

INTRODUCCION: Muchos autores siguen recomendando la exploración quirúrgica en casos de avulsión completa de la unión pieloureteral (ACUPU). El abordaje conservador del traumatismo renal (TR) pediátrico incluye técnicas mínimamente invasivas como la nefrostomía, la angioembolización o el catéter doble J. CASO CLINICO: Paciente de 14 años con ACUPU tratada de forma conservadora. El escáner reveló la presencia de una hemorragia activa en la arteria renal, además de una importante extravasación urinaria. Se practicó angioembolización con bobinas y nefrostomía. Se intentó colocar un catéter doble J, sin éxito, por lo que se programó reconstrucción quirúrgica. Antes de la cirugía, se inyectó azul de metileno a través de la nefrostomía, observándose salida de orina azul a través de la uretra. La realización de una pielografía anterógrada reveló la presencia de drenaje desde el urinoma hacia el uréter. El segundo intento de colocar un catéter doble J interno-externo sí resultó fructífero, retirándose al cabo de 5 semanas, con restauración total del tracto urinario. CONCLUSION: La restauración completa del tracto urinario en algunos casos de ACUPU tras TR es factible sin necesidad de recurrir al abordaje quirúrgico. Se trata de un proceso seguro y eficaz que disminuye el riesgo de las complicaciones propias de las cirugías complejas.

The role of ureteric indocyanine green fluorescence in colorectal surgery: a retrospective cohort study.

BACKGROUND: Ureteric injury (UI) is an infrequent but serious complication of colorectal surgery. Prophylactic ureteric stenting is employed to avoid UI, yet its efficacy remains debated. Intraoperative indocyanine green fluorescence imaging (ICG-FI) has been used to facilitate ureter detection. This study aimed to investigate the role of ICG-FI in identification of ureters during colorectal surgery and its impact on the incidence of UI. METHODS: A retrospective cohort study involving 556 consecutive patients who underwent colorectal surgery between 2018 and 2023 assessed the utility of routine prophylactic ureteric stenting with adjunctive ICG-FI. Patients with ICG-FI were compared to those without ICG-FI. Demographic data, operative details, and postoperative morbidity were analyzed. Statistical analysis included univariable regression. RESULTS: Ureteric ICG-FI was used in 312 (56.1%) patients, whereas 43.9% were controls. Both groups were comparable in terms of demographics except for a higher prevalence of prior abdominal surgeries in the ICG-FI group. Although intraoperative visualization was significantly higher in the ICG-FI group (95.3% vs 89.1%; p = 0.011), the incidence of UI was similar between groups (0.3% vs 0.8%; p = 0.585). Postoperative complications were similar between the two groups. Median stent insertion time was longer in the ICG-FI group (32 vs 25 min; p = 0.001). CONCLUSION: Ureteric ICG-FI improved intraoperative visualization of the ureters but was not associated with a reduced UI rate. Median stent insertion time increased with use of ureteric ICG-FI, but total operative time did not. Despite its limitations, this study is the largest of its kind suggesting that ureteric ICG-FI may be a valuable adjunct to facilitate  ureteric visualization during colorectal surgery.

A delayed diagnosis of iatrogenic ureteral injury results in increased morbidity.

This study aimed to register and analyse outcomes after iatrogenic ureteral injuries (IUI) with special emphasis on potential consequences of a delayed diagnosis, and further to analyse if the incidence of IUI has changed during the study period. 108 patients treated for an IUI during 2001-2021 were included. Injuries due to endourological procedures, planned tumour resection and traumatic injuries were excluded. All relevant information to answer the research questions were entered into a database. Chi-square and t-tests were used for categorical and continuous variables respectively. Regression analysis was used to evaluate potential change of incidence in IUIs over time. Our results showed that most IUIs (74, 69%) were caused by gynaecological surgery. 49 (45%) had a delayed diagnosis (not diagnosed intraoperatively). Younger age (mean 50 vs 62 years, p < 0.001) and benign indication for laparoscopic hysterectomy (OR 8.0, p < 0.001) predisposed for a delayed diagnosis. Patients with a delayed diagnosis had a higher number of secondary injury related procedures (mean 4.6 vs 1.7, p < 0.001), hospital admissions (mean 3.0 vs 0.8, p < 0.001) and longer hospital stays (mean 20.6 vs 3.9 days p < 0.001) compared to patients with an intraoperative diagnosis. There was complete recovery for 91% of the patients. We did not observe any changes in IUI incidence during the study period. In conclusion, our study underlines that IUI can cause major morbidity for the patient affected if not diagnosed intraoperatively. Benign indication and younger age are predictors for a delayed diagnosis. The prognosis is good, with 91% full recovery. No significant changes in incidence of IUIs were observed.

Acute kidney injury after colorectal surgery with prophylactic ureteral stents.

BACKGROUND: After colorectal surgery, acute kidney injury (AKI) results from a complex interplay of multiple independent causes and preventive measures that occur during the hospitalization. Prophylactic stenting for ureter identification has been identified as a potential cause, but the evidence is conflicting, possibly because of differing baseline characteristics and procedure-related approaches. OBJECTIVE: This retrospective cohort study assesses the role of stents in the etiology of AKI after determining the independent predictors of AKI. METHODS: From a population of 1224 consecutive colorectal patients (from 8/1/2016 through 12/31/2021), 382 (31.2%) received ureteral stents, and propensity score matching was used to create stented and control groups. Emergent cases and patients with sepsis were excluded from the analysis. Previously identified independent predictors of AKI, minimally invasive procedures, and a history of diabetes mellitus were used as criteria to create two balanced groups. RESULTS: Baseline demographic characteristics and procedure-related factors baseline factors were similar between the groups. There was no difference in the rate of AKI between stented patients and controls (P = 0.82), nor was there any difference in postoperative complications, such as chronic renal insufficiency (CRI, P = 0.49), average postoperative creatinine (P = 0.67), urinary tract infections (UTI, P = 0.82), any postoperative infection (P = 0.48), in-hospital complications (P = 1.00), length of stay (LOS, P = 0.15), and 30-day readmissions (P = 0.79). CONCLUSIONS: In a population of patients where stenting was frequently employed, ureter stents placed for identification did not appear to cause AKI or AKI-related complications.

The relationship between the force applied and perceived by the surgeon during ureteral access sheath placement: ex-vivo experimental model.

PURPOSE: To define a peak force of insertion (PFOI) threshold for ureteral damage during ureteral access sheath (UAS) placement on an experimental ureteral orifice model. METHODS: A specially designed water tank using 2 laparoscopic 5 mm ports and 2 different size (10 Fr and 8 Fr) sealing cap adaptors (SCA) as ureteral orifices was used to perform the test. A 10-12 Fr UAS was fixed to a load cell and the force of insertion (FOI) was continuously recorded with a digital force gauge.13 experts in the field of endourology who participated performed 3 UAS insertions. The FOI was recorded initially with 10 Fr followed by 8 Fr SCA. On the final insertion, the orifice was obstructed, leaving a 5 cm length to insert the UAS. The experts were asked to "Stop at the point they anticipate ureteral damage, and they would not proceed in real life". RESULTS: Using 10 Fr SCA the PFOI was 2.12 ± 0.58 Newton (N) (range:1.48-3.48) while 8 Fr SCA showed a PFOI 5.76 ± 0.96 N (range:4.05-7.35). Six of the experts, said they would stop proceeding when they reached above 5.1 N. Three experts had PFOI < 5.1 N and the other 4 stated they would go with PFOIs of 5.88, 6.16, 6.69 and 7.35 N when using SCA of 8 Fr.The highest load they would stop proceeding had a PFOI of 6.09 ± 1.87 N (range: 2.53-10.74). CONCLUSION: The PFOI threshold for ureteral damage inserting UAS of the experts is variable. Although FOI is a subjective perception, experience suggests that ureteral injury may occur at an average of 6.05 N perceived by surgeons' tactile feedback. In-vivo measurement of UAS PFOI may confirm a threshold.

Keep your attention closer to the ureters: Ureterolysis in deep endometriosis surgery.

Endometriosis surgery involving the ureter poses significant challenges requiring meticulous surgical techniques and vigilant postoperative care. This chapter addresses key aspects of ureterolysis techniques, intraoperative management of ureteral injuries, and postoperative care in the context of endometriosis surgery. Ureterolysis methods aim to isolate and mobilize the ureter while preserving its vascularity. Cold instruments and careful dissection are recommended to prevent thermal injury during surgery. Intraoperative tools such as indocyanine green (ICG) show promise in assessing for vascular compromise. Over half of ureteral injuries are detected postoperatively, necessitating a high index of suspicion. Optimal postoperative care in the case of ureteral injury involves Foley catheterization for decompression, ureteral stenting, and meticulous follow-ups to monitor healing and renal function. While advances have been made in surgical techniques and diagnostic tools, gaps persist in preoperative imaging optimization and predictive models for identifying at-risk patients. This chapter aims to bridge existing knowledge gaps, optimize surgical practices, and enhance the overall care and outcomes of patients undergoing endometriosis surgery involving the ureter.

Prophylactic ureteric catheterisation during complex gynaecological surgery: A systematic review and meta-analysis.

BACKGROUND: There is a lack of robust evidence to recommend the use of perioperative ureteric catheterisation or stenting in complex gynaecological surgery. OBJECTIVES: To evaluate the evidence on the benefits and risks of perioperative ureteric catheterisation or stenting in complex gynaecological surgery. SEARCH STRATEGY: A literature search was performed in CINAHL, the Cochrane Library, Embase and MEDLINE, from 1946 to January 2024, using a combination of keywords and Medical Subject Headings (MeSH) terminology. SELECTION CRITERIA: Randomised controlled trials (RCTs) and observational studies were included. DATA COLLECTION AND ANALYSIS: Meta-analysis of the RCTs and observational studies were performed separately. Cochrane RevMan 6.5.1 was used to undertake meta-analysis. Risk ratios with 95% CIs were calculated for the outcome measures. MAIN RESULTS: Ten studies were included: three RCTs and seven observational studies, comprising 8661 patients. The three RCTs, comprising a total of 3277 patients, showed no difference in the risk of immediate complications in the form of ureteric injury between the ureteric stent and the control groups (RR 0.9, 95% CI 0.49-1.65). The observational studies included 5384 patients. Four studies that explored the ureteric injury as an outcome did not show any difference between the two groups (RR 0.76, 95% CI 0.27-2.16). One case-control study with 862 participants found that the rate of ureteric injury was higher in the non-stented group, although this was observed in only three patients. The risk of urinary tract infection (UTI) was increased in the stent group, although not with statistical significance (RR 1.84, 95% CI 0.47-7.17). There was no significant difference in the risk of ureteric fistulae (RR 1.91, 95% CI 0.62-5.83), although the number of studies was limited. CONCLUSIONS: Prophylactic ureteric catheterisation or stenting for complex gynaecological surgery is not associated with a lower risk of ureteric injury.

Can preoperative ureteral stent placement help in the intraoperative identification of iatrogenic ureteral injury?

BACKGROUND: The benefits of prophylactic ureteral stent placement during colorectal surgery remain controversial. This study aimed to determine the incidence of ureteral injury in colorectal operations, assess the complications associated with stent usage, and determine whether their use leads to earlier identification and treatment of injury. METHODS: This was a retrospective study of patients undergoing colorectal abdominal operations between 2015 and 2021. Variables were examined for possible association with ureteral stent placement. The primary study endpoint was ureteral injury identified within 30 days postoperatively. RESULTS: Of 6481 patients who underwent colorectal surgery, 970 (15%) underwent preoperative ureteral stent placement. The use of stents was significantly associated with a higher American Society of Anesthesiologists classification, wound classification, and longer duration of surgery. A ureteral injury was identified in 28 patients (0.4%). Of these patients, 13 had no stent, and 15 had preoperative stents placed. After propensity matching, stent use was associated with an increased risk of hematuria and urinary tract infection. Ureteral injury was identified intraoperatively in 14 of 28 patients (50.0%) and was not associated with ureteral stent use (P = .45). CONCLUSION: Iatrogenic ureteral injury was uncommon, whereas preoperative stent placement was relatively frequent. Earlier recognition of iatrogenic ureteral injury is not an expected advantage of preoperative ureteral stent placement.

Lesión duodeno-ureteral compleja por herida de arma de fuego: diagnóstico y resolución quirúrgica / COMPLEX DUODENAL-URETERAL LESION DUE TO FIREARM INJURY, DIAGNOSIS AND SURGICAL RESOLUTION

Las lesiones traumáticas duodenales son infrecuentes pero producen una tasa de morbi-mortalidad significativa. Se debe tener presente la elevada frecuencia de lesiones asociadas, siendo las de uréter superior las más frecuentes. Masculino de 50 años ingresa por HAF paravertebral derecha. Al ingreso OTE, lucido, vigil, con dolor y defensa abdominal generalizada. En la TC toracobdominal con cte EV y VO se objetiva extravasación de contraste oral a nivel duodenal y en fase excretora renal derecha.Se decide Laparotomía de urgencia objetivando lesión transfixiante de 2da porción de duodeno de < 50% de su circunferencia y sección de uréter derecho proximal. Se realiza rafia en dos planos de duodeno, colocación de pig tail y anastomosis T-T de uréter derecho mas drenaje. Buena evolución postquirúrgica con control tomográfico a las 72 hs sin objetivar fuga. Alta hospitalaria al 6to día. El traumatismo duodenal es una patología rara que se asocia con una tasa considerable de morbimortalidad, su localización retroperitoneal puede hacer que los clásicos signos de peritonismo no estén presentes en el momento de la evaluación, por lo que se recomienda la realización de exámenes clínicos seriados y de estudios complementarios con contraste VO y EV. Las lesiones ureterales asociadas son las más frecuentes. La mayoría tienen una pérdida mínima de tejido, siendo usualmente reparadas mediante desbridación y anastomosis.

Duodenal traumatic injuries are rare but produce a significant morbidity and mortality rate. The high frequency of associated lesions should be kept in mind, with those of the upper ureter being the most frequent. 50-year-old male enters for right paravertebral HAF. At hospital admission, lucid patient and vigil. Thoracoabdominal CT with intravenous and oral contrast show extravasation of oral contrast at the duodenal level and in the right renal excretory phase. Emergency laparotomy is decided by objectifying transfixing lesion of the 2nd portion of the duodenum of <50% of its circumference and proximal right ureter section. Raffia is performed in two planes of the duodenum, placement of pig tail and TT anastomosis of the right ureter plus drainage. Good post-surgical evolution with tomographic control at 72 hours without objectifying leakage. Hospital discharge on the 6th day. Duodenal trauma is a rare pathology that is associated with a considerable morbidity and mortality rate, its retroperitoneal location may make the classic signs of peritonism not present at the time of the evaluation, so clinical exams are recommended series and complementary studies with VO and EV contrast. Associated ureteral lesions are the most frequent, Most have minimal tissue loss, usually repaired by debridement and anastomosis.

Iatrogenic ureteral obstruction during transvaginal ocyte retrieval

ABSTRACT Transvaginal oocyte retrieval is a crucial step in assisted reproductive technology. Various complications may arise during this procedure. Ureteral injury is a rare, but a serious complication in gynecological practice. During oocyte retrieval, ureteral injuries, detachment and obstruction can be seen, though rare. In this study, we will present ureteral obstruction that develops secondary to small hematoma, which mimics ovarian cyst torsion or ruptured ovarian cyst.

Management of full-length complete ureteral avulsion

ABSTRACT Introduction Complete ureteral avulsion is one of the most serious complications of ureteroscopy. The aim of this report was to look for a good solution to full-length complete ureteral avulsion. Case presentation A 40-year-old man underwent ureteroscopic management. Full-length complete avulsion of ureter occurred during ureteroscopy. Pyeloureterostomy plus greater omentum investment outside the avulsed ureter and ureterovesical anastomosis were performed 6 hours after ureteral avulsion. The patient was followed-up during 34 months. Double-J tube was removed at 3 months after operation. Twenty three months after the first operation, the patient developed hydronephrosis because of a new ureter upside stone, then rigid ureteroscopy and holmium laser lithotripsy were used successfully. Conclusion Pyeloureterostomy plus greater omentum investment outside the avulsed ureter and ureterovesical anastomosis may be a good choice for full-length complete ureteral avulsion.

Robotic repair of vesicovaginal fistula - initial experience

ABSTRACT Objective The most common acquired fistula of the urinary tract is Vesicovaginal fistulae (VVF) (1) posing social stigmata for the patient as well as a surgical challenge for the urologist. Here we present our initial experience with Robotic assisted laparoscopic repair of VVF, its safety and efficacy. Materials and Methods Seven out of eight fistulas were post hysterectomy; five had undergone abdominal while two had laparoscopic hysterectomy while one was due to prolonged labour. Two had associated ureteric injury. All underwent robotic assisted laparoscopic trans abdominal extravesical approach. Three 8 mm ports for robotic arms, one 12 mm port for camera and another 12 mm for assistant were used in a fan shaped manner. All had preoperative ureteric catheter placed. Bladder was closed in two layers and vagina in one layer. Omental flap placed in all cases except two where it was not possible. Drain and per urethral catheter placed in all cases. Double J stents were placed in two cases requiring ureteric implantation additionally. Results The mean age of presentation was 39.25 years (26-47 range) with mean BMI being 26.25 kg/m2 (21-32 range). Mean duration between insult and repair was 9.37 months (3-24 months). Only in single case there was history of previous repair attempt. On cystoscopy four had supratrigonal VVF and four were trigonal with mean size of 13.37 mm (7-20 mm). Mean operative time was 117.5 minutes (90-150). There were no intraoperative/postoperative complications or need for open conversion. Mean haemoglobin drop was 1.4 gm/dL (0.3-2 gm). Drain was removed once 24-48 hours output is negligible. One patient had post-operative urinary leak at 2 weeks which ceased with continuation of catheterisation for another 2 weeks. Catheter was removed after voiding cystourethrogram showed no leak at 2-3 weeks postoperatively. Mean duration of drain was 3.75 days (3-5) and per urethral catheterisation (which was removed after voiding cystourethrography) was 15.75 days (9-28). Mean hospital stay was 6.62 days (4-14). Post-operative bladder capacity was 324.28 cc (280-350) on voiding diary. Follow up ranged from 3-9 months. At 3 months of follow-up, these patients continued to void normally and there was no evidence of recurrence of VVF. Conclusion Robotic repair of VVF is safe and feasible and has additional advantages in the form of precise suturing under 3D vision and certainly a more striking and effective option especially in complex VVF repair associated with ureteric injuries (2).

Identificación de trauma ureteral en un hospital de tercer nivel / Ureteral trauma: report of five cases

Introduction: Ureteral trauma can result from various noxas the most frequent iatrogenic. Additional this, external causes: blunt trauma, sharp weapon and gunshot contributing to the overall incidence. Its early diagnosis although great importance to avoid complications is difficult so it is their suspect is essential when confronted with trauma patients. Case reports: We report five patients aged 15 to 46 years with ureteral trauma. Two patients had gross hematuria, one patient acute abdominal pain and two as hypovolemic shock. The lesions were found mainly to the left ureter and in smaller proportion in right ureter. Four patients the diagnosis was surgical exploration and one case was performed by scans. All were operated, had an uneventful postoperative period and are currently asymptomatic.

Introducción: El trauma de uréter puede ser resultado de diferentes noxas siendo la más frecuente la iatrogénica. Adicional a esto, las causas externas de trauma contuso, las causadas con arma cortopunzante y las realizadas por arma de fuego contribuyen a la incidencia global. Su diagnóstico temprano, aunque de gran importancia para evitar complicaciones, resulta difícil por lo que es primordial su sospecha cuando nos enfrentamos a pacientes politraumatizados. Casos clínicos: Se identificaron 5 casos de trauma ureteral en nuestro hospital desde septiembre de 2012 a agosto de 2013. La mediana de edad fue 24,5 años (15-46 años). Se manifestaron como hematuria macroscópica en dos casos, un caso como dolor abdominal agudo y dos como choque hipovolémico. Estas lesiones se encontraron principalmente localizadas hacia uréter izquierdo y en menor proporción en uréter derecho, todas de tipo penetrante, causadas por arma de fuego. En 4 pacientes el diagnóstico fue por exploración quirúrgica y un caso fue realizado a través de escanografía. Los pacientes fueron intervenidos quirúrgicamente, ninguno presentó complicaciones y se encuentran actualmente asintomáticos.

Sustitución ureteral bilateral con asa ileal / Bilateral ileal ureteral replacement

Introduction: Ureteral replacement by a loop of defunctionalized ileum was described more than 2 centuries ago and continues to be a therapeutic option at present. This series describes the technique of bilateral ureteral replacement with ileum. Aim: To report 4 cases of bilateral ileal ureteral replacement performed at our institution, its indications, the surgical technique, complications, and a review of the literature. Material and Method: We report 4 cases of extensive bilateral ureteral injury of different etiologies, whose treatment with curative intent was to replace the damaged ureter with a isoperistaltic small bowel segment. Results: The surgical technique used was standard in all cases. There were no intraoperative complications and only one patient had hyperchloremic acidosis. No patient has shown loss of renal function in the long-term follow up. Conclusion: Is an effective therapeutic, safe and reproducible technique to replacement of major bilateral ureteral injuries, independent of the original cause.

Introducción: La sustitución ureteral por un asa de íleon desfuncionalizada fue descrita hace más de 2 siglos y continúa siendo una alternativa terapéutica en la actualidad. Esta serie describe la técnica de sustitución ureteral bilateral con íleon. Objetivo: Presentar 4 casos de sustitución ureteral ileal bilateral realizados en nuestro centro, indicaciones de la técnica quirúrgica, complicaciones y revisión de la literatura. Material y Método: Presentamos 4 casos de lesión ureteral bilateral extensa, de etiologías diferentes, cuyo tratamiento con intención curativa fue la sustitución de la lesión ureteral por un segmento intestinal isoperis-táltico. Resultados: La técnica quirúrgica empleada fue estándar en todos los casos. No hubo complicaciones intraoperatorias, y sólo una paciente presentó descompensación metabólica por acidosis hiperclorémica. En ningún paciente se ha demostrado pérdida en la función renal. Conclusión: El segmento intestinal de íleon desfuncionalizado es una alternativa terapéutica eficaz, segura y reproducible, para el reemplazo de importantes lesiones ureterales bilaterales, independiente de la causa original.

Reemplazo ureteral con apéndice cecal / Ureteral replacement with cecal appendix

We report two cases with ureteral lesions. A 34 years male with a residual retroperitoneal mass caused by a testicular cancer, that persisted after chemotherapy. During the surgical excision of the mass, the involvement of the right ureter was discovered. A 43 years old female with a left ureteral lesion secondary to radiation therapy and with a non-functioning contralateral kidney. In both cases a ureteral replacement with the cecal appendix was performed, without surgical complications. After five years of follow up, the urinary tract of the male patient is normal. The female patient required an endoscopic incision of the connection between the appendix and the urinary bladder, eight years after the surgical procedure. Three years after the endoscopic procedure the repaired urinary tract is in good conditions.

Objetivo: Presentar dos casos de reemplazo ureteral con apéndice cecal y revisar la literatura relacionada al tema. Material y Método: Presentamos dos casos de lesión ureteral. Un paciente de 34 años con masa retroperitoneal residual post quimioterapia englobando el uréter derecho, secundaria a un tumor testicular, y una paciente de 43 años monorrena funcional con lesión ureteral izquierda actínica. Resultados: En ambos casos se realizó un reemplazo ureteral, derecho e izquierdo, sin complicaciones intraoperatorias. El seguimiento alejado a 5 y 11 años muestra indemnidad de la vía urinaria. Conclusión: Estos 2 casos, con seguimiento prolongado, apoyan la factibilidad del uso del apéndice cecal como variante para el reemplazo ureteral en lesiones extensas.

Ureteroscopy in patients with coagulopathies is associated with lower stone-free rate and increased risk of clinically significant hematuria

PURPOSE: Patients with coagulopathy are at increased risk of peri-operative hemorrhage. The aim of the present study was to compare ureteroscopy (URS) in these high risk patients to those with normal bleeding profile. MATERIALS AND METHODS: Twelve patients with coagulopathies (Group I) undergoing 17 URS were included in the study [3 for biopsy of ureteral lesions and 9 for Holmium Laser Lithotripsy (HLL)]. A patient had Child B (MELD 11) cirrhosis, 6 patients were on warfarin, 3 patients on ASA, 1 patient on ASA and clopidogrel, and the last patient was on heparin. URS in Group I was performed without correction of coagulopathy. Group II consisted of 32 patients with normal bleeding profile who underwent 34 URS concurrently. RESULTS: Group I included 4 ureteral biopsies in 3 patients with suspicious ureteral lesions and 13 URS for HLL in 9 patients with nephrolithiasis. There were no significant differences between the two groups in terms of patient age, sex, percent of renal stones, median operative and fluoroscopy times. When compared with Group II, Group I had significantly larger median stone size (9.2 vs. 14.0 mm, p = 0.01) and significantly lower stone-free rate after first URS (94.1% vs. 69.2%, p = 0.04). However, after second URS, stone-free rates were comparable in both groups (92.3% vs. 100%, p = 0.9). Two (16.7%) patients with coagulopathy were readmitted due to gross hematuria. There were no post-operative complications in Group II. CONCLUSIONS: Although URS in selected patients with coagulopathies is safe, it is associated with significantly lower stone-free rates and higher readmissions due to gross hematuria.

Extravasación urinaria postraumatismo abdominal cerrado: ¿es posible un diagnóstico precoz?: informe de dos casos / Urinary extravasation post blunt abdominal trauma: is it possible an early diagnosis?: report of two cases

La lesión de la vía urinaria superior con extravasación urinaria ocasionada por un traumatismo abdominal cerrado es infrecuente y, a menudo, no reconocida en una evaluación inicial.Un diagnóstico tardío de esta lesión aumenta significativamente la morbilidad. Se presentan dos casos, uno con avulsión de uréter superior derecho y el otro con laceración parenquimatosay de pelvis renal derecha con diagnóstico tardío y complicacionesgraves postraumatismo abdominal cerrado directo. El conocimiento del mecanismo del traumatismo y la evaluación de signos y síntomas locales son datos de importancia parasospechar una lesión pieloureteral, independientemente de la gravedad del traumatismo. La ausencia de hematuria inicial no es infrecuente y su presencia y grado no guarda relación con lagravedad de la lesión. Una tomografía computada abdominal con contraste endovenoso, evaluada en fase excretora tardía, permite la identificación precoz de una extravasación de orina.

An injury to the upper urinary tract with urinary extravasation caused by blunt abdominal trauma is uncommon and often unrecognized in an initial evaluation. A late diagnosis of this injury significantly increases morbidity. Two cases are discussed, one with avulsion of right upper ureter and the other one with parenchymal and right renal pelvis laceration with delayed diagnosis and severe complications subsequent to a direct blunt abdominal trauma. Knowledge of the mechanismof trauma and the assessment of local signs and symptoms are important data for suspecting ureteropelvic injury regardless of the trauma severity. The absence of initial hematuria is notuncommon and their presence and degree is unrelated to the severity of the injury. An abdominal computed tomography with IV contrast evaluated in delayed excretory phase allows an early detection of extravasation of urine.