Effectiveness and Cost of Stenting in Ureteral Injury in Colorectal Surgeries in the US: 2015 - 2019.

Background: Intraoperative ureteral injury (IUI) during colorectal surgery can have devastating consequences. This study aimed to assess the clinical and economic impact of pre-operative ureteral stenting in colorectal surgeries. Methods: A retrospective cohort study was conducted using United States hospital data (October 2015 - December 2019). IUI incidence was examined across selected inpatient surgery types (elective colectomy, enterectomy, proctectomy, enterostomy, other colorectal procedures; emergency colectomy). Stenting effectiveness was evaluated as the difference in IUI and intraoperative detection rates between propensity score-matched groups. The additional hospital cost for stenting was also estimated considering the savings from IUIs that were potentially avoidable or detected by stenting. Results: In total, 283,549 colorectal surgeries were analyzed. Across surgery types, stent use and IUI incidence ranged from 1.47% - 8.86% and from 0.91% - 2.90%, respectively. Stents were used in 6.75% of elective colectomy cases, where they were associated with an absolute reduction of 1.14 percentage points (95% CI: -1.85 to -1.03) in IUI rate and a 21.6 percentage point reduction in the intraoperative detection rate. Additional hospital costs for stenting ranged from $1,464 - $4,436 across surgery types. Additional results varied by case but were consistent with the colectomy example. Conclusions: While effective in limited settings, the IUI reduction attributed to stenting and ability to shift IUI detection to the intraoperative setting could not offset the hospital cost of stent placement during colectomy (and colorectal surgery, in general). There thus remains an ongoing need in colorectal surgery for a universal, cost-effective solution to prevent IUI.

Ureteric injuries during hysterectomy-A Norwegian retrospective study of occurrence and claims for compensation over an 11-year period.

INTRODUCTION: Ureteric injury is a rare but serious, iatrogenic complication of hysterectomy. The risk depends on indication for surgery, predisposing risk factors, and peroperative conditions. Our aims were to evaluate and learn from compensation claims to The Norwegian System of Patient Injury Compensation (NPE) for ureteric injury occurring during hysterectomies to predict risk factors, time of identification, symptoms, and consequences, and to relate these cases to injuries registered in The Norwegian Patient Registry. MATERIAL AND METHODS: A retrospective study of ureteric injuries occurring during hysterectomies, reported to NPE and the Norwegian Patient Registry from 2009 through 2019. RESULTS: During the study period, 53 096 hysterectomies were registered in The Norwegian Patient Registry, of which ureteric injury was documented in 643 (1.2%). More ureteric injuries were registered in large hospital trusts than in small trusts (1.3% vs. 0.7%, p < 0.05). NPE received 69 claims due to ureteric injury occurring during hysterectomy, comprising 11% of all injuries in the study period. Compensation was approved for 15%. Women who claimed compensation were younger (48.1 ± 8.9 years vs. 55.1 ± 13.6 years, p < 0.01), more likely to have had a benign diagnosis (89.9% vs. 52.1%, p < 0.01), and more likely to have had the ureteric injury recognized after discharge (58.0% vs. 33.0%, p < 0.001) compared with non-complainants. Identification of the ureters during the hysterectomy was documented in 30% of the NPE patient files. Additional information for the NPE cases included the following. The most common symptoms of unidentified injury were pain (77%), fever (12%), urinary leakage (13%), and anuria (8%). Re-operation was necessary in 77% of the cases, and 10% of the women lost one kidney. Long-term consequences after repair, such as loss of a kidney or persistent pain, were seen in 17%. No women died because of the injury. CONCLUSIONS: The incidence of ureteric injury occurring during hysterectomy in Norway was 1.2%; 11% involved a claim for compensation, and 15% of these had their case approved. Most ureteric injuries were not recognized during the hysterectomy. Documentation of peroperative identification of the ureters during hysterectomy was often missing. Vigilance to pain as a postoperative symptom of peroperative unrecognized ureteric injury may result in earlier diagnosis and treatment.

Incidence, type and management of ureteric injury associated with vesicovaginal fistulas: Report of a series from a specialized center.

OBJECTIVES: To report a large series of vesicovaginal fistula, and to assess the incidence of ureteric injury in association with vesicovaginal fistula. METHODS: We retrospectively reviewed a prospective database of patients with vesicovaginal fistula referred to our center between 2004 and 2016. Data on patient demographics, fistula etiology, mode of repair, and any associated ureteric injury and its treatment were noted. RESULTS: Overall, 116 patients (median age 49 years, range 23-88 years) were referred for management of vesicovaginal fistula during the study period. Four of these patients (3.4%) had associated ureteric injury, one of whom had bilateral injury. Ureteric obstruction alone was noted in two patients, ureterovaginal fistula alone in one patient, and bilateral ureteric obstruction and ureterovaginal fistula in one patient. All ureteric injuries were managed with simultaneous reimplantation into the bladder at the time of vesicovaginal fistula repair. Five patients had post-radiotherapy vesicovaginal fistula, and the remainder were post-surgical. Three patients with post-radiotherapy vesicovaginal fistula proceeded to primary diversion. CONCLUSIONS: Ureteric injury is far less common than previously reported, occurring in <5% of patients presenting with vesicovaginal fistula. It can be successfully managed, and it remains the major indication for abdominal repair of vesicovaginal fistula.

The sentinel stent? A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections.

PURPOSE: 'Prophylactic' ureteric stents potentially reduce rates, and facilitate intraoperative recognition, of iatrogenic ureteric injury (IUI) during colorectal resections. A lack of consensus surrounds the risk-benefit equation of this practice, and we aimed to assess the evidence base. METHODS: A systematic review was performed according to PRISMA guidelines. MEDLINE, Scopus, EMBASE and Cochrane databases were searched using terms 'ureteric/ureteral/JJ/Double J stent' or 'ureteric/ureteral catheter' and 'colorectal/prophylactic/resection/diverticular disease/diverticulitis/iatrogenic injury'. Primary outcomes were rates of ureteric injuries and their intraoperative identification. Secondary outcomes included stent complication rates. RESULTS: We identified 987 publications; 22 papers met the inclusion criteria. No randomised controlled trials were found. The total number of patients pooled for evaluation was 869,603 (102,370 with ureteric stents/catheters, 767,233 controls). The most frequent indications for prophylactic stents were diverticular disease (45.38%), neoplasia (33.45%) and inflammatory bowel disease (9.37%). Pooled results saw IUI in 1521/102,370 (1.49%) with, and in 1333/767,233 (0.17%) without, prophylactic ureteric stents. Intraoperative recognition of IUIs occurred in 10/16 injuries (62.5%) with prophylactic stents, versus 9/17 (52.94%) without stents (p = 0.579). The most serious complications of prophylactic stent use were ureteric injury (2/1716, 0.12%) and transient ureteric obstruction following stent removal (13/666, 1.95%). CONCLUSIONS: Placement of prophylactic ureteric stents has a low complication rate. There is insufficient evidence to conclude that stents decrease ureteric injury or increase intraoperative detection of IUIs. Apparently higher rates of IUI in stented patients likely reflect use in higher risk resections. A prospective registry with harmonised data collection points and stratification of intraoperative risk is needed.

Cystoscopy at the time of benign hysterectomy: a decision analysis.

BACKGROUND: Gynecologists debate the optimal use for intraoperative cystoscopy at the time of benign hysterectomy. Although adding cystoscopy leads to additional up-front cost, it may also enable intraoperative detection of a urinary tract injury that may otherwise go unnoticed. Prompt injury detection and intraoperative repair decreases morbidity and is less costly than postoperative diagnosis and treatment. Because urinary tract injury is rare and not easily studied in a prospective fashion, decision analysis provides a method for evaluating the cost associated with varying strategies for use of cystoscopy. OBJECTIVE: The objective of the study was to quantify costs of routine cystoscopy, selective cystoscopy, or no cystoscopy with benign hysterectomy. STUDY DESIGN: We created a decision analysis model using TreeAge Pro. Separate models evaluated cystoscopy following abdominal, laparoscopic/robotic, and vaginal hysterectomy from the perspective of a third-party payer. We modeled bladder and ureteral injuries detected intraoperatively and postoperatively. Ureteral injury detection included false-positive and false-negative results. Potential costs included diagnostics (imaging, repeat cystoscopy) and treatment (office/emergency room visits, readmission, ureteral stenting, cystotomy closure, ureteral reimplantation). Our model included costs of peritonitis, urinoma, and vesicovaginal/ureterovaginal fistula. Complication rates were determined from published literature. Costs were gathered from Medicare reimbursement as well as published literature when procedure codes could not accurately capture additional length of stay or work-up related to complications. RESULTS: From prior studies, bladder injury incidence was 1.75%, 0.93%, and 2.91% for abdominal, laparoscopic/robotic, and vaginal hysterectomy, respectively. Ureteral injury incidence was 1.61%, 0.46%, and 0.46%, respectively. Hysterectomy costs without cystoscopy varied from $884.89 to $1121.91. Selective cystoscopy added $13.20-26.13 compared with no cystoscopy. Routine cystoscopy added $51.39-57.86 compared with selective cystoscopy. With the increasing risk of injury, selective cystoscopy becomes cost saving. When bladder injury exceeds 4.48-11.44% (based on surgical route) or ureteral injury exceeds 3.96-8.95%, selective cystoscopy costs less than no cystoscopy. Therefore, if surgeons estimate the risk of injury has exceeded these thresholds, cystoscopy may be cost saving. However, for routine cystoscopy to be cost saving, the risk of bladder injury would need to exceed 20.59-47.24% and ureteral injury 27.22-37.72%. Model robustness was checked with multiple 1-way sensitivity analyses, and no relevant thresholds for model variables other than injury rates were identified. CONCLUSION: While routine cystoscopy increased the cost $64.59-83.99, selective cystoscopy had lower increases ($13.20-26.13). These costs are reduced/eliminated with increasing risk of injury. Even a modest increase in suspicion for injury should prompt selective cystoscopy with benign hysterectomy.

The incidence, causes, and management of lower urinary tract injury during total laparoscopic hysterectomy.

OBJECTIVES: Determining the incidence and causes of lower urinary tract injury in patients undergoing total laparoscopic hysterectomy and examining the procedures applied for management. METHODS: Patients who underwent total laparoscopic hysterectomy in a large referral center between 1 January 2015 and 31 October 2017 for benign gynecological reasons were included in the study. Patients who underwent laparoscopic supracervical hysterectomy, laparoscopy-assisted vaginal hysterectomy and robot-assisted laparoscopic hysterectomy were not included in this study. The hospital records of all patients included in the study were examined and the incidence, causes and management of lower urinary tract injuries were reviewed. RESULTS: Total lower urinary tract injury rate was found as 2.01%, and these injuries were evaluated separately as bladder and ureter injuries. All the bladder injuries had occurred on the posterior wall of the bladder during vesicouterine dissection; six cases were intraoperatively detected and one case was detected on the first postoperative day. Most of ureteral injury cases were detected in the early postoperative period (75%). The rates of previous cesarean section and endometriosis were significantly higher in patients with injury to the bladder and ureter than in the control group (p<0,001). There was no significant difference between the patients with lower urinary tract injury and the control group regarding uterine weight, estimated blood loss, bilateral salpingo-oophorectomy, the presence and location of fibroids, and laparoscopic or vaginal closure of the vaginal cuff. CONCLUSION: Laparoscopic hysterectomy may be a good option in appropriate patients, but in case of previous cesarean section and endometriosis cases, patients should be informed about the possible complications in detail before the operation and care should be taken during dissection.

Ureteral stents increase risk of postoperative acute kidney injury following colorectal surgery.

BACKGROUND: Ureteral stents are commonly placed before colorectal resection to assist in identification of ureters and prevent injury. Acute kidney injury (AKI) is a common cause of morbidity and increased cost following colorectal surgery. Although previously associated with reflex anuria, prophylactic stents have not been found to increase AKI. We sought to determine the impact of ureteral stents on the incidence of AKI following colorectal surgery. METHODS: All patients undergoing colon or rectal resection at a single institution between 2005 and 2015 were reviewed using American College of Surgeons National Surgical Quality Improvement Program dataset. AKI was defined as a rise in serum creatinine to ≥ 1.5 times the preoperative value. Univariate and multivariate regression analyses were performed to identify independent predictors of AKI. RESULTS: 2910 patients underwent colorectal resection. Prophylactic ureteral stents were placed in 129 patients (4.6%). Postoperative AKI occurred in 335 (11.5%) patients during their hospitalization. The stent group demonstrated increased AKI incidence (32.6% vs. 10.5%; p < 0.0001) with bilateral having a higher rate than unilateral stents. Hospital costs were higher in the stent group ($23,629 vs. $16,091; p < 0.0001), and patients with bilateral stents had the highest costs. Multivariable logistic regression identified predictors of AKI after colorectal surgery including age, procedure duration, and ureteral stent placement. CONCLUSIONS: Prophylactic ureteral stents independently increased AKI risk when placed prior to colorectal surgery. These data demonstrate increased morbidity and hospital costs related to usage of stents in colorectal surgery, indicating that placement should be limited to patients with highest potential benefit.

Assessment of unilateral ureter obstruction with multi-parametric MRI.

PURPOSE: Quantitative multi-parametric MRI (mpMRI) methods may allow the assessment of renal injury and function in a sensitive and objective manner. This study aimed to evaluate an array of MRI methods that exploit endogenous contrasts including relaxation rates, pool size ratio (PSR) derived from quantitative magnetization transfer (qMT), chemical exchange saturation transfer (CEST), nuclear Overhauser enhancement (NOE), and apparent diffusion coefficient (ADC) for their sensitivity and specificity in detecting abnormal features associated with kidney disease in a murine model of unilateral ureter obstruction (UUO). METHODS: MRI scans were performed in anesthetized C57BL/6N mice 1, 3, or 6 days after UUO at 7T. Paraffin tissue sections were stained with Masson trichrome following MRI. RESULTS: Compared to contralateral kidneys, the cortices of UUO kidneys showed decreases of relaxation rates R1 and R2 , PSR, NOE, and ADC. No significant changes in CEST effects were observed for the cortical region of UUO kidneys. The MRI parametric changes in renal cortex are related to tubular cell death, tubular atrophy, tubular dilation, urine retention, and interstitial fibrosis in the cortex of UUO kidneys. CONCLUSION: Measurements of multiple MRI parameters provide comprehensive information about the molecular and cellular changes produced by UUO. Magn Reson Med 79:2216-2227, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Preoperative assessment of the ureter with dual-phase contrast-enhanced computed tomography for lateral lumbar interbody fusion procedures.

BACKGROUND: Performing the minimally invasive lateral lumbar interbody fusion (LIF), such as the extreme lateral interbody fusion (XLIF) and oblique lateral interbody fusion (OLIF), through a retroperitoneal approach has become increasingly popular. Although urological injury is a major complication of LIF, the anatomical location of the ureter and its risk of injury have not been assessed. The purpose of this study was to evaluate the efficacy of dual-phase contrast-enhanced computed tomography for assessing the location of the ureter and risk of its injury in consecutive LIF cases. METHODS: 27 cases (12 men and 15 women) were enrolled in the study. Dual-phase contrast-enhanced CT was performed preoperatively, and the risk of ureteral injury was assessed. The location of the ureter was classified using the psoas muscle and vertebral body as reference structures for OLIF and XLIF procedures, respectively. During the OLIF procedures, the location of the ureter was additionally assessed with direct vision and manual palpation in all cases. Simultaneously, potential vascular anomalies were assessed with both 3D and axial images of CT. RESULTS: A total of 125 among 162 ureters, excluding 13 with insufficient enhancement and 24 (44.4%) within the kidney at the L2-L3 level, were assessed preoperatively; 113 ureters (90.4%) were classified as anatomically close to the surgical corridor for OLIF, and 20 ureters (16.0%) as having a potential risk of injury during XLIF. In one case, OLIF was converted to a conventional posterior procedure because of a vascular anomaly. Intraoperative findings showed that ureters moved anteriorly with the peritoneum in all cases, as assessed by manual palpation under direct vision. CONCLUSIONS: Dual-phase contrast-enhanced CT is useful in assessing the location of the ureter, kidney, and vascular structures simultaneously. Both OLIF and XLIF have a potential risk of urological injury.

Benefits and risks of ureteral access sheaths for retrograde renal access.

PURPOSE OF REVIEW: Ureteral access sheath (UAS) became increasingly popular worldwide. However, the safety of its routine use remains controversial. The aim of the current revision is to provide a systematic review on the benefits and disadvantages of the UAS. RECENT FINDINGS: A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Two reviewers independently searched the literature, finally identifying 20 articles valuable for this review. The use of UAS demonstrated several advantages to facilitate retrograde intrarenal access, lower intrarenal pressure, protect the ureter, protect the scope, and expedite stone extraction. Despite this, there is also some evidence that UAS use may be associated with acute ureteral injury and long-term complications, apparently related to maneuvers for UAS insertion and mucosal or deeper layers of injury and ischemia. Furthermore, there are still pending questions on the possible increase in stone-free rates, and decrease in operative time and costs. SUMMARY: Although the use of UAS is associated with some risk and limiting factors, it appears from this systematic review that its use is common and safe for the retrograde intrarenal access. Therefore, UAS is highly recommended for the treatment of upper tract disease by means of retrograde intrarenal surgery.

Laparoscopic Hysterectomy and Urinary Tract Injury: Experience in a Health Maintenance Organization.

STUDY OBJECTIVES: To evaluate the incidence, detection, characteristics, and management of urinary tract injury in a cohort undergoing laparoscopic hysterectomy, and to identify potential risk factors for urinary tract injury with laparoscopic hysterectomy. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: Kaiser Permanente San Diego Medical Center, 2001 to 2012. PATIENTS: Women who underwent attempted laparoscopic hysterectomy for benign indications. INTERVENTIONS: Total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparoscopic supracervical hysterectomy. MEASUREMENTS AND MAIN RESULTS: Demographic and clinical characteristics, surgical techniques, and perioperative complications were abstracted from the medical record. Multivariable logistic regression analysis assessed independent risk factors for ureteral or bladder injury. RESULTS: A total of 3523 patients (mean age, 45.9 ± 8.0 years; median parity, 2; range, 0-10), with a median body mass index (BMI) of 29 kg/m(2) (range, 16-72 kg/m(2)), underwent laparoscopic hysterectomy; 20% had intraoperative cystoscopy. The incidence of urinary tract injury was 1.3% (46 of 3523); of the 46 patients with injuries, 19 (0.54%) had ureteral injuries, 25 (0.71%) had bladder injuries, and 2 (0.06%) had both types. Of the 21 ureteral injuries, 6 (29%) were diagnosed intraoperatively and 15 (71%) were diagnosed postoperatively, including 4 with normal intraoperative cystoscopy. Of the 27 bladder injuries, 23 (85%) were identified intraoperatively. In multivariable logistic analysis, a BMI of 26 to 30 kg/m(2) (compared with >30 kg/m(2)) was associated with an increased risk of ureteral injury, and a BMI ≤25 kg/m(2) (compared with >30 kg/m(2)) and the presence of endometriosis were associated with an increased risk of bladder injury. CONCLUSION: Urinary tract injury occurred in 1.3% of laparoscopic hysterectomies, with ureteral injuries almost as common as bladder injuries. Normal intraoperative cystoscopy findings did not exclude the presence of ureteral injury.

Utility of intraoperative cystoscopy in detecting ureteral injury during vaginal hysterectomy.

OBJECTIVES: The aim of this study was to determine the utility of intraoperative cystoscopy in detecting and managing ureteral injury among women undergoing vaginal hysterectomy. METHODS: We performed a secondary analysis of a retrospective cohort study of 593 patients who underwent vaginal hysterectomy for benign indications, with or without additional pelvic floor reconstructive surgery, from January 2, 2004, through December 30, 2005. A logistic regression model determining the propensity to undergo intraoperative cystoscopy was constructed. Comparisons of ureteral injury and cost between patients with and without cystoscopy were adjusted for the cystoscopy propensity score. We further explored the feasibility of using perioperative change in creatinine level to detect ureteral injury. RESULTS: In total, 230 (38.8%) of 593 patients underwent cystoscopy. Six patients (2.6%) in the cystoscopy group and 5 (1.4%) in the no-cystoscopy group had ureteral injuries (odds ratio, 1.92; 95% confidence interval [CI], 0.58-6.36). This association was further attenuated after adjusting for the propensity to undergo cystoscopy (odds ratio, 1.31; 95% CI, 0.19-9.09). Four injuries detected cystoscopically were managed intraoperatively. Adjusted mean-predicted costs for patients undergoing cystoscopy were $10,686 (95% CI, $7500-$13,872) versus $10,217 (95% CI, $6894-$13,540). In the no-cystoscopy group, patients with ureteral injury had a median increase in creatinine level of 0.2 mg/dL, whereas patients without injury had a median decrease of 0.1 mg/dL (P < 0.001). CONCLUSIONS: The level of selection for cystoscopy did not significantly increase the mean predicted costs for patients. Reliance on postoperative creatinine level to detect ureteral injury, while highly sensitive, is limited by a low positive predictive value and variable range.

The prophylactic use of a ureteral stent in laparoscopic colorectal surgery.

BACKGROUND AND AIMS: The insertion of prophylactic ureteral stents in traditional colorectal surgery has been debated for a long time. The aim of this study is to investigate the results of ureteric stent insertion in elective laparoscopic colorectal surgery in terms of complications and costs. MATERIAL AND METHODS: From June 2009 to June 2011 one or two prophylactic ureteral stents were placed in all patients undergoing elective laparoscopic resection of their colon or rectum. RESULTS: A total of 89 patients took part in this study, 61% had a benign disease and 39% malignant. The mean time for ureteral stent insertion was 16 min if one-sided and 21 min if bilateral. Incidental findings were found in the bladder in four (4.5%) patients. In all, 13 (26%) male patients had a benign prostatic adenoma, and 3 (6%) male patients had a significant stenosis of the urethral meatus and required bouginage. Complications due to ureteral stent insertion were transient hematuria in 11 (12.3%) cases, postoperative urinary tract infections in 2 (2.2%) cases, and hydronephrosis in 2 (2.2%) cases. One patient suffered an accidental damage of the right ureter despite the presence of a stent; this was recognized intraoperatively. The total cost for a one-sided ureteral stent insertion is calculated at around €360, and for a bilateral ureteral stent insertion, it is around €410. CONCLUSIONS: The prophylactic use of a ureteral stent in laparoscopic colorectal surgery leads to minor complications and may be cost-effective.

Prevalence and management of complications of ureteroscopy: a seven-year experience with introduction of a new maneuver to prevent ureteral avulsion.

PURPOSE: To evaluate the prevalence and type of rigid ureteroscopy complications and suggest a new method for ureteral avulsion prevention. MATERIALS AND METHODS: Between March 2002 and March 2009, we retrospectively evaluated 2955 patients who had undergone diagnostic or therapeutic ureteroscopy for asymptomatic hematuria, migrated ureteral stent, or transurethral lithotripsy. They were enrolled from four hospitals in Ahvaz, Iran. RESULTS: Complications were encountered in 241 (8%) patients, including transient hematuria (4.2%), mucosal erosion (1.4%), stone migration (1.3%), ureteral perforation (1.2%), and fever and/or sepsis (1.0%). Ureteral avulsion occurred in 6 (0.2%) patients. Mostly, complications were managed conservatively, using ureteral stenting. Ureteral avulsions were managed using a new technique. CONCLUSION: In our series, the complication rate is comparable with the literature. A new technique was used in case of ureteroscope entrapment in the ureter, to lessen the occurrence of ureteral avulsion.

Analysis of 136 ureteral injuries in gynecological and obstetrical surgery from completed insurance claims.

OBJECTIVE: Iatrogenic ureteral injury during pelvic surgical procedures is a well-known complication and important cause of morbidity. The authors investigated the circumstances surrounding registered ureteral injuries in order to identify potential opportunities to prevent such injuries. DESIGN: Evaluation of claims concerning ureteral injuries reported to the Danish Patient Insurance Association. SETTING: Danish Patient Insurance Association. SAMPLE: All registered claims for ureteral injuries from 1996 to 2006. METHODS: Retrospective study of medical records and data from Danish Patient Insurance Association. MAIN OUTCOME MEASURES: Preventable ureteral injuries. RESULTS: From 1996 to 2006, 136 submitted claims concerning ureteral injuries were registered. Among these, 73 claims were approved (54%), and compensation paid. In 44 of these, the injury was caused by negligence. Failure to dissect the ureter despite indications for this procedure was the most common type of negligence. Laparotomy procedures were associated with 107 injuries (79%) and 29 injuries (21%) were caused during laparoscopic procedures. Thirty-four patients suffered from chronic renal dysfunction on the affected side. Only 17 of the ureteral injuries were discovered during the procedure. CONCLUSIONS: Forty-four ureteral injuries could potentially have been avoided using established surgical practices, most importantly by exposing the ureter via dissection when indicated. Most of the ureteral injuries were discovered postoperatively.

Universal ureteral stent placement at hysterectomy to identify ureteral injury: a decision analysis.

OBJECTIVE: Iatrogenic ureteral injury during gynaecological surgery is associated with increased morbidity when not diagnosed during the initial surgery. Preoperative insertion of ureteral catheters may enhance intraoperative recognition of injury and repair, but it is controversial. We sought to analyse the costs of this approach. DESIGN/SETTING/POPULATION: A decision-tree analysis of clinical scenarios of using universal ureteral catheterisation compared with no catheterisation was conducted for benign abdominal hysterectomy and radical hysterectomy. METHODS: Diagnostic-Related Groups and Current Procedural Terminology coding and reimbursement information were used as calculated for Medicare patients in the USA. MAIN OUTCOME MEASURES: Differences in projections of total hospital-related costs related to clinical scenarios of perioperative care for women undergoing hysterectomy with or without ureteral catheterisation. RESULTS: Universal ureteral catheterisation is cost saving when the rate of ureteral injury during benign abdominal hysterectomy or radical hysterectomy is greater than 3.2%. CONCLUSIONS: The cost savings of universal ureteral catheterisation at hysterectomy depend on the injury rate but are minimal at common levels of injury.

Iatrogenic ureteric injuries: incidence, aetiological factors and the effect of early management on subsequent outcome.

OBJECTIVE: To investigate the changing pattern in incidence, aetiological factors and the effect of early diagnosis and surgical treatment on the outcome of iatrogenic ureteric injuries in our Urology Unit over a 5 year period. PATIENTS/METHODS: All patients with ureteric injuries caused as a result of any surgical procedures (iatrogenic ureteric injuries) were studied during a 5 year period (1998-2002). Data collected and analysed included yearly incidence of injury, aetiological factors, modalities of treatment and the outcome of management of the injuries. During the study period, our general surgical colleagues had a policy of requesting "J" stent insertion prior to major abdominopelvic surgical procedures. During the same period, in nearly all difficult cases of ureteroscopy (URS) + lithoclast lithotripsy+/-Dormia basket, a ureteric catheter or "J" stent was prophylactically inserted by urological surgeons. RESULTS: There were 82 iatrogenic ureteric injuries in 75 patients over the 5 year period. The total number of iatrogenic ureteric injuries declined from 26 (31.7%) in 1998 to 10 (11.8%) in 2002. Urological, obstetrics and gynaecological and general surgical procedures were involved in 69(84.1%), 7(8.7%), and 4(4.9%) of the injuries respectively. The commonest types of injuries encountered were; injury to ureteric mucosa post URS or lithoclast calculi disintegration 34 (41.5%), complete ureteric perforation 15 (18.3%) and false passage 15 (18.3%). The most severe complications encountered were complete ureteric avulsions 3 (3.75%) and loss of ureteral segment 2 (2.4%). The commonest treatment options used were "J" stent insertion or ureteric catheter placement (48, 59.4%), percutaneous nephrostomy (17, 20.7%), laparotomy and removal of suture on tied ureters (5, 6.1%). Two (2.4%) nephrectomies were performed because of poor renal function in one patient and severe damage to a functioning renal unit during a difficult retroperitoneal surgery in another patient. Recognition and treatment of ureteric injuries at the time of surgery was associated with less morbidity compared to those in whom the diagnosis was delayed. The overall successful resolution of ureteric injuries in this series was 77/82 (93.9%). There was no mortality attributable to these ureteric injuries. CONCLUSION: In our Unit, the incidence of significant iatrogenic ureteric injuries has shown a decline over a 5-year period. We attribute this trend to the prophylactic use of "J" stents or ureteric catheter placement and good surgical technique during major abdomino-pelvic surgeries in our hospital. Endourological procedures are the commonest causes of ureteric injuries. Prompt diagnosis and institution of appropriate corrective surgical procedures often result in a very satisfactory outcome in about 94% of cases.

Assessment of stricture formation with the ureteral access sheath.

OBJECTIVES: To analyze the long-term incidence of ureteral stricture formation in a series of patients in whom a new-generation ureteral access sheath was used. A new generation of ureteral access sheaths has been developed to facilitate ureteroscopic procedures. However, some have questioned their safety and whether the device might cause significant ureteral trauma. METHODS: Between September 1999 and July 2001, 150 consecutive ureteroscopic procedures with adjunctive use of an access sheath were performed. A retrospective chart review to April 2002 was done. Of the 150 patients, 130 underwent ureteroscopy for ureteral stones. Patients who underwent endoureterotomy or treatment of transitional cell carcinoma were excluded from this analysis. Sixty-two patients had follow-up greater than 3 months and were included in the analysis. Overall, 71 ureteroscopic procedures were performed, with 9 patients undergoing multiple procedures. Ninety-two percent of the patients had pathologic findings above the iliac vessels. The average patient age was 45.3 years (range 17 to 76), and 70% and 30% of the patients were male and female, respectively. The mean clinical follow-up was 332 days (range 95 to 821), and follow-up imaging was performed within 3 months after ureteroscopy in all patients. RESULTS: The 10/12F access sheath was used in 8 ureteroscopic procedures (11.2%), the 12/14F access sheath in 56 (78.9%), and the 14/16F access sheath in 7 (9.8%). One stricture was identified on follow-up imaging of 71 procedures performed, for an incidence of 1.4%. The patient developed the stricture at the ureteropelvic junction after multiple ureteroscopic procedures to manage recurrent struvite calculi. The access sheath did not appear to be a contributing factor. CONCLUSIONS: The results of our series indicate that the ureteral access sheath is safe and beneficial for routine use to facilitate flexible ureteroscopy. However, awareness of the potential ischemic effects with the use of unnecessarily large sheaths for long periods in patients at risk of ischemic injury should be considered. We advocate the routine use of the device for most flexible ureteroscopic procedures proximal to the iliac vessels.

Laparoscopic donor nephrectomy: why not?

OBJECTIVES: Laparoscopic donor nephrectomy has undergone explosive worldwide growth as the method of choice for removal of living donor kidneys. However, the method does have some distinct disadvantages as well. The objective is to define real and potential difficulties with the generalized uncritical acceptance of this surgical technique. METHODS: The literature and personal experience at the largest laparoscopic donor program were reviewed and consolidated. Critical areas of technique and management were analyzed. RESULTS: Laparoscopic living donor nephrectomy has increased the pool of willing potential renal donors. In experienced has the recipient renal function results are equivalent to open nephrectomy. CONCLUSIONS: There are risks in performing the operation to the donor and to the allograft. These risks are potentially catastrophic and mitigate against any casual attitudes about embarking on a laparoscopic donor nephrectomy program.