Arterio-ureteral fistula: a nationwide cross-sectional questionnaire analysis.

PURPOSE: Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but potentially lethal. Although the number of reports has increased over the past two decades, the true incidence and contemporary urologists' experience and approach in clinical practice remains unknown. This research is conducted to provide insight in the incidence of AUF in The Netherlands, and the applied diagnostic tests and therapeutic approaches in modern practice. METHODS: A nationwide cross-sectional questionnaire analysis was performed by sending a survey to all registered Dutch urologists. Data collection included information on experience with patients with AUF; and their medical history, diagnostics, treatment, and follow-up, and were captured in a standardized template by two independent reviewers. Descriptive statistics were used. RESULTS: Response rate was 62% and 56 AUFs in 53 patients were reported between 2003 and 2018. The estimated incidence of AUF in The Netherlands in this time period is 3.5 AUFs per year. Hematuria was observed in all patients; 9% intermittent microhematuria, and 91% presenting with, or building up to massive hematuria. For the final diagnosis, angiography was the most efficient modality, confirming diagnosis in 58%. Treatment comprised predominantly endovascular intervention. CONCLUSION: The diagnosis AUF should be considered in patients with persistent intermittent or massive hematuria.

Modification of the Indiana Pouch Ileo-Caecal Cutaneous Continent Urinary Diversion: Tubular Ileal Afferent Limb for Ureteral Anastomosis Has Low Stricture Rate and Allows Ileal Ureter Replacement.

OBJECTIVE: The aim of the study was to introduce our new modification of the Indiana pouch with a refluxing ureteral anastomosis in a tubular afferent ileal segment of the ileo-caecal urinary reservoir. PATIENTS AND METHODS: Between February 2008 and December 2020, we performed a total of 37 modified continent ileo-caecal pouches for urinary diversion when orthotopic bladder substitution was not possible. Hereby, we modified the Indiana pouch procedure with a new refluxing end-to-end ureteral anastomosis into an 8-cm afferent tubular ileal segment. RESULTS: We performed the modified Indiana pouch in 27 women (73%) and 10 men (27%). The median age of the patients at time of operation was 64 years (43-80 years). To date, the average follow-up is 69 months (3-156 months). In 32/37 cases, we performed the new pouch procedure after radical cystectomy for muscle-invasive bladder cancer and in 1/37 cases after radical cystectomy for locally advanced prostate cancer. In 4 cases, the procedure was performed after total exenteration of the pelvis due to locally advanced bladder, colorectal, or gynaecological cancers. Ureteral anastomotic strictures were seen in 2/37 patients (5.4%) or 2/72 (2.8%) of renal units. CONCLUSIONS: Our modification of the Indiana pouch cutaneous continent urinary diversion with the ureteral anastomosis to a tubular segment of the pouch is easy to perform and effective in reducing the rate of ureteral anastomotic strictures. By lengthening, the afferent tubular ileal segment, it additionally allows easy ureteral replacement.

Comparison of oncological outcomes and major complications between laparoscopic radical hysterectomy and abdominal radical hysterectomy for stage IB1 cervical cancer with a tumour size less than 2 cm.

OBJECTIVE: To compare the oncological outcomes and major complications of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for stage IB1 cervical cancer (FIGO 2009) with a tumour size less than 2 cm. METHODS: We retrospectively compared the oncological outcomes and major complications of 1207 stage IB1 cervical cancer patients with a tumour size less than 2 cm who received LRH (n = 546) or ARH (n = 661) in 37 hospitals. RESULTS: (1) There was no significant difference in 3-year overall survival (OS; 97.3% vs. 98.5%, P = 0.288) or 3-year disease-free survival (DFS; 95.1% vs. 95.4%, P = 0.792) between LRH (n = 546) and ARH (n = 661).(2) The rate of any 1 complication refers to the incidence of one or more complications in a patient, which was higher with LRH than ARH (OR = 4.047, 95% CI = 2.035-8.048, P < 0.001). Additionally, intraoperative complications occurred with LRH (OR = 12.313, 95% confidence intervals [CI] = 1.571-96.493, P = 0.017), and postoperative complications (OR = 3.652, 95% CI = 1.763-7.562, P < 0.001) were higher with LRH than ARH. The ureteral injury rate was higher with LRH than with ARH (1.50% vs. 0.20%, OR = 9.814, 95% CI = 1.224-78.712, P = 0.032). The ureterovaginal fistula rate was higher with LRH than ARH. The rates of obturator nerve injury, bladder injury, vesicovaginal fistula, rectovaginal fistula, venous thromboembolism, bowel obstruction, chylous leakage, pelvic haematoma, and haemorrhage were similar between the groups. CONCLUSIONS: The oncological outcomes of LRH and ARH for stage IB1 cervical cancer patients with a tumour size less than 2 cm do not differ significantly. However, incidences of any 1 complication, intraoperative complications, and postoperative complications were higher with LRH than ARH, with complications manifesting mainly as ureteral injury and uterovaginal fistula.

Ureteral Diameter as Predictor of Ureteral Injury during Ureteral Access Sheath Placement.

PURPOSE: We determined the association between ureteral diameter and ureteral injury during ureteral access sheath placement. MATERIALS AND METHODS: Patients were prospectively enrolled in the study from July 2014 to September 2015. All patients underwent preoperative noncontrast computerized tomography and had a 12Fr to 14Fr ureteral access sheath placement without pre-stenting. A measurement of proximal ureteral diameter was carried out by 2 urologists and 1 radiologist. Ureteral wall injuries were evaluated by 2 endourologists using the 5-grade classification. RESULTS: A total of 68 patients were included and the overall success rate for sheath placement was 94.1% (64). Among this group 46 patients (71.9%) had evidence of any type of injury to the ureter wall and the rate of high grade injuries was 26.1% (12). The ureteral diameter of patients who had a high grade injury was significantly smaller compared to those with low grade injuries (mean±SD 3.29±0.46 mm vs 4.5±0.97 mm, p <0.001). On multivariate analysis narrower proximal ureteral diameter was associated with a higher risk of high grade ureteral injury (OR 2.8, 95% CI 1.9-3.4, p <0.001), regardless of age, gender, body mass index, and middle and distal ureteral diameter. CONCLUSIONS: The proximal ureteral diameter is associated with high grade ureteral injury. A smaller ureteral diameter increases the risk and the severity of ureteral injury. Therefore, preoperative measurement of the ureteral diameter is recommended for ureteral access sheath placement to predict the risk of ureteral injury.

Does Ureteral Stent Drainage Prior to Cystectomy Increase the Risk of Subsequent Upper Tract Urothelial Carcinoma and Ureteral Complications?

OBJECTIVE: To guide management of preoperative hydronephrosis prior to radical cystectomy (RC), we compared post-RC risks of upper tract urothelial carcinoma (UTUC) and ureteroenteric anastomotic complications between ureteral stent and percutaneous nephrostomy tube drainage. METHODS: Patients who underwent RC for urothelial carcinoma without a prior diagnosis of UTUC at our institution between 2000 and 2015 were included and divided into 4 patient groups: (1) no hydronephrosis (75%, N = 787); (2) hydronephrosis without preoperative upper tract drainage (13%, N = 132); (3) hydronephrosis treated with nephrostomy tube (3%, N = 36); (4) hydronephrosis treated with ureteral stent (9%, N = 94). The incidence of post-RC UTUC and ureteral complications was compared using Kaplan-Meier analyses and multivariable Cox proportional hazard modeling. RESULTS: We identified a total of 1049 patients who underwent RC (median postoperative follow-up 4.3 years). Five-year post-RC UTUC incidence was 6.6%, 10.2%, 17%, 18.7% for groups 1-4, respectively (P= .13). On multivariable analysis, nephrostomy tube drainage (hazard ratio [HR] 4.10, P = .02) and preoperative ureteral stenting (HR 2.35, P = .04) were both associated with UTUC after RC, but ureteral stenting did not have a significantly higher association with UTUC than nephrostomy tube drainage. Severe hydronephrosis was also associated with development of UTUC (HR 4.03, P = .02). The incidence of ureteroenteric anastomotic complications did not vary by drainage modality. CONCLUSION: Preoperative hydronephrosis was associated with UTUC after RC, but ureteral stent placement did not increase the risk of UTUC or ureteral complications relative to nephrostomy tube placement. The choice of hydronephrosis drainage pre-RC should not be guided by concern for UTUC risk.

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.

Ureteral pseudodiverticulosis and urothelial cell carcinoma: rethinking the association.

PURPOSE: To compare frequency of new and recurrent urothelial cell carcinoma (UCC) among patients with and without pseudodiverticulosis on imaging. METHODS: This retrospective case-control study compared all 113 sequential patients with ureteral pseudodiverticulosis on radiographic urography between 1/1/2002 and 12/31/2012. Six patients were lost to follow-up. 107 patients without pseudodiverticulosis were matched by imaging modality, clinical indication, and tumor grade. Known UCC and primary outcome of new or recurrent UCC were determined through pathology on cystoscopy or clinical follow-up. RESULTS: Nearly half of patients with pseudodiverticulosis had known UCC at the time of imaging (49/107, 46%). Mean cystoscopy follow-up was 7.0 and 4.6 years for pseudodiverticulosis cases with and without known UCC, respectively, and 7.5 and 7.3 years for controls, respectively. Mean clinic follow-up was 7.5 and 6.0 years for pseudodiverticulosis cases with and without known UCC, respectively, and 6.4 and 7.6 years for controls, respectively. Among patients with known UCC at the time of imaging, similar rates of recurrent UCC were demonstrated on follow-up among patients with pseudodiverticulosis (6/49, 12%) and without (7/49, 14%). Among patients with no known history of UCC at the time of imaging, no patients with pseudodiverticulosis developed UCC on follow-up and 5% (3/58) of patients without pseudodiverticulosis developed UCC. CONCLUSION: Although half of patients with ureteral pseudodiverticulosis have a known diagnosis of UCC, the presence of pseudodiverticulosis did not signify an increased likelihood of developing new or recurrent UCC over the follow-up period.

[Ureteral injuries complicating gynecologic surgery]. / Les traumatismes urétéraux compliquant une chirurgie gynécologique.

Iatrogenic ureteral lesions may occur after any pelvic surgery. They are severe and can affect renal function and even vital prognosis. This study aimed to determine the clinical aspects and the therapeutic approaches of this injury. We conducted a retrospective study of six patients with iatrogenic ureteral lesions following gynecologic or obstetric surgery whose data were collected in the Department of Urology in Kairouan on a period of 4 years (2012-2016). The average age of our patients was 46 years. They were all multiparous. Clinical symptoms were variable depending on the type of lesion. Intravenous urography is very useful for diagnosis. It was performed in 4 cases showing abnormalities. Treatment was based on the insertion of a catheter in one case and on 5 uretero-vesical reimplantations. The postoperative course was marked by a nephrectomy. Iatrogenic ureteral lesions have become a rarity. They are correlated with the degree of medicalization in the country. Gynecological and obstetric surgery is the main cause of iatrogenic ureteral lesions. Prognosis is conditioned by early diagnosis and the anatomic condition of the ureter.

Ureteric stricture rates and management after robot-assisted radical cystectomy: a single-centre observational study.

OBJECTIVE: Benign ureterointestinal anastomosis (BUIA) stricture is a recognized complication after open radical cystectomy. The evidence for stricture rates following robot-assisted radical cystectomy (RARC) is limited. This article reports stricture rates from a single high-volume RARC centre. MATERIALS AND METHODS: Between December 2003 and December 2015, 371 patients underwent RARC with a totally intracorporeal urinary diversion. All patients received a ureteric anastomosis utilizing the 'Wallace plate' with a running suture technique. Monofilament suture was used in the first 81 patients (22%) and a barbed suture (Quill™) in the remaining 290 patients (78%). RESULTS: Median follow-up was 33 months and minimum follow-up was 7.9 months. The median time to stricture formation was 165 days (range 10-495 days). Twenty-four patients (6.5%) developed BUIA strictures. Six of 81 patients (7.4%) in the monofilament group and 18 of 290 (6.2%) in the barbed suture group developed strictures (p = .22). Fifteen patients (63%) had a stricture on the left side, seven (29%) on the right side and two patients (8%) developed bilateral ureteric strictures (p = .002). Strictures occurred in 11 of 131 patients (8.3%) with an orthotopic neobladder and 13 of 240 (5.4%) with an ileal-conduit urinary diversion (p = .17). CONCLUSIONS: The overall incidence of ureteric strictures is low in patients undergoing RARC with totally intracorporeal urinary diversion. Strictures were more common on the left side, which has been described in open series and is probably related to the increased mobilization on the left side required to cross the ureter to the right side.

Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility.

BACKGROUND: The ureter is the second most common site affected by urinary tract endometriosis, after the bladder. Optimal strategies in the diagnosis and treatment of ureteral endometriosis (UE) are not yet well defined. OBJECTIVE AND RATIONALE: The aim of this study was to systematically review evidence regarding the epidemiology, pathophysiology, diagnosis, medical and surgical treatment, impact on fertility and risk of malignant transformation of UE. SEARCH METHODS: A systematic literature review, by searching the MEDLINE and PUBMED database until April 2018, was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and was registered in the PROSPERO registry (www.crd.york.ac.uk/PROSPERO CRD42017060065). A total of 67 articles were selected to be included in this review. OUTCOMES: The involvement of the ureter by endometriosis is often asymptomatic or leads to non-specific symptoms. When the diagnosis is delayed, UE may lead to persistent hydronephrosis and eventually loss of renal function. Ultrasonography is the first-line technique for the assessment of UE; alternatively, magnetic resonance imaging provides an evaluation of ureteral type involvement. The surgical treatment of UE aims to relieve ureteral obstruction and avoid disease recurrence. It includes conservative ureterolysis or radical approaches, such as ureterectomy with end-to-end anastomosis or ureteroneocystostomy performed in relation to the type of ureteral involvement. Fertility and pregnancy outcomes are in line with those observed after surgical treatment of deep infiltrating endometriosis (DIE). Current evidence does not support the potential risk of malignant transformation of UE. WIDER IMPLICATIONS: In this article, we review available evidence on ureteral endometriosis, providing a useful tool to guide physicians in the management of this disease. Diagnosis and management of UE remain a challenge. In relation to the degree of ureteral involvement and the association with other DIE implants, the surgical approach should be planned and carried out in an interdisciplinary collaboration between gynecologist and urologist.

Diagnosis and management of 365 ureteric injuries following obstetric and gynecologic surgery in resource-limited settings.

INTRODUCTION: Ureteric injuries are among the most serious complications of pelvic surgery. The incidence in low-resource settings is not well documented. METHODS: This retrospective review analyzes a cohort of 365 ureteric injuries with ureterovaginal fistulas in 353 women following obstetric and gynecologic operations in 11 countries in Africa and Asia, all low-resource settings. The patients with ureteric injury were stratified into three groups according to the initial surgery: (a) obstetric operations, (b) gynecologic operations, and (c) vesicovaginal fistula (VVF) repairs. RESULTS: The 365 ureteric injuries in this series comprise 246 (67.4%) after obstetric procedures, 65 (17.8%) after gynecologic procedures, and 54 (14.8%) after repair of obstetric fistulas. Demographic characteristics show clear differences between women with iatrogenic injuries and women with obstetric fistulas. The study describes abdominal ureter reimplantation and other treatment procedures. Overall surgical results were good: 92.9% of women were cured (326/351), 5.4% were healed with some residual incontinence (19/351), and six failed (1.7%). CONCLUSIONS: Ureteric injuries after obstetric and gynecologic operations are not uncommon. Unlike in high-resource contexts, in low-resource settings obstetric procedures are most often associated with urogenital fistula. Despite resource limitations, diagnosis and treatment of ureteric injuries is possible, with good success rates. Training must emphasize optimal surgical techniques and different approaches to assisted vaginal delivery.

Endometriosis on the uterosacral ligament: a marker of ureteral involvement.

OBJECTIVE: To evaluate the association between ultrasound measurements of endometriosis nodules on the uterosacral ligament (USL) and the risk of ureteral involvement, as well as to assess whether associations with other ultrasound variables increase the sensitivity and specificity of the diagnosis of ureteral endometriosis. DESIGN: Cross-sectional, observational study. SETTING: University hospital. PATIENT(S): Four hundred sixty-three women with deep infiltrating endometriosis (DIE). INTERVENTION(S): Patients diagnosed with DIE underwent transvaginal ultrasound endometriosis mapping before laparoscopic surgery for full excision of endometriotic lesions. MAIN OUTCOME MEASURE(S): Preoperative ultrasound evaluation, intra- and postoperative assessment, and anatomopathologic confirmation. RESULT(S): Of the 463 patients who participated in the study, 111 (23.97%) presented with endometriosis nodules with USL involvement on ultrasound examination conducted by a single radiologist. Receiver operating characteristic curve analysis showed that the size of the USL nodule had a statistically significant association with ipsilateral ureteral involvement. After multivariate logistic regression, the variables reduction in ovarian mobility, ureteral changes on the right side, size of the USL nodule, and presence of endometrioma on the left side were significantly associated with a ureteral endometriosis nodule. However, the combined result for the variables cited was worse than the diagnostic analysis using only the size of the USL nodule. CONCLUSION(S): Uterosacral ligament nodules with ultrasound measurements of 1.75 cm and 1.95 cm on the right and left sides, respectively, significantly increase the risk of ureteral involvement. Even with the association of other ultrasound variables, there was no improvement in sensitivity. Therefore, USL nodule size is a key measure for therapeutic planning and consent of the patient.

Incidence of Iatrogenic Ureteral Injury During Open and Laparoscopic Colorectal Surgery: A Single Center Experience and Review of the Literature.

INTRODUCTION: Iatrogenic ureteral injury is a rare but potentially devastating complication of colorectal surgery. We evaluated the incidence and management of iatrogenic ureteral injuries in colorectal surgery during the transition phase from open to laparoscopic surgery. MATERIALS AND METHODS: We conducted a retrospective single center study. All patients who underwent colorectal surgery between 2004 and 2014 were evaluated by collecting data of electronic patient charts. Both acute and elective procedures were included. RESULTS: A total of 3302 colorectal procedures were performed in the study period. Of these, 2817 operations were performed open and 484 laparoscopically. A total of 23 iatrogenic ureteral injuries were identified, of which 5 were found during laparoscopic surgery. The cumulative incidence of ureteral injuries was 0.6% for open procedures and 1.0% for laparoscopic procedures. CONCLUSIONS: Ureteral injury is a rare complication of colorectal surgery. The incidence might rise with the increasing use of laparoscopy.

Ureteroarterial fistula: A review of the literature.

Ureteroarterial fistulas are rare, erosive defects that occur between the distal segments of the ureter and the adjacent blood vessels in individuals with urologic and vascular comorbidities. Characterized by diffuse, pulsatile bleeding into the urinary tract, this condition carries a significant mortality rate in the absence of early recognition. Recent treatment efforts have focused on use of endovascular stenting techniques as an alternative to open surgical closure of the underlying defects in hemodynamically stable patients. We provide a literature review detailing the characteristics, mechanism, and management of ureteroarterial fistulas.

Iatrogenic ureteral trauma: a 16-year single tertiary centre experience.

INTRODUCTION: lItrogenic ureteral injuries can occur during various abdominopelvic and retroperitoneal surgical procedures including gynecological, urological, colorectal and vascular. OBJECTIVE: The aim of our study was to examine the incidence and types of iatrogenic ureteral injuries occurred over the period of 16 years, as well as to evaluate the values of applied diagnostic and therapeutic procedures. METHODS: A retrospective analysis of clinical data (medical records and operative reports) of 55 patients (11 male and 44 female; mean age 54.5 years) with verified iatrogenic ureteral injury from 1998 to 2014, was performed. RESULTS: latrogenic ureteral injuries occurred during gynecological procedures in 55%, urological in 25%, colorectal in 15% and vascular in 5% of cases. Mechanisms of injury were incomplete transection (n=23), complete transection (n=1), ligation (n=7), partial perforation (mucosal abrasion) (n=1 3) and total perforation (n=1). The most frequent diagnostic procedures for postoperative identification of ureteral injuries were abdominal ultrasonography, excretory urography, antegrade pyeloureterography and retrograde ureteropyelography. Early therapeutic procedures were applied in 35 (64%), while delayed in 20 cases (36%). Early (<30 days) or late (>30 days) postoperative complications were verified in 14 cases (25%). CONCLUSION: Among different surgeries that may lead to the development of iatrogenic ureteral injury, gynecological procedures represent the most common cause. Rapid diagnosis enables immediate ureteral repair and is associated with low morbidity rates, representing a major factor contributing to the treatment success and ultimately preserving the renal function.

Complications after polymeric and metallic ureteral stent placements including three types of fistula.

PURPOSE: To report complications, including three types of fistula, intractable hematuria, and pain, which can develop after polymeric ureteral stent (PUS) or metallic ureteral stent placements and to evaluate the risk factors for these adverse events. PATIENTS AND METHODS: We reviewed seven patients referred to our trauma and reconstructive subdivision for complications that presented after placement of a PUS (two patients), double-layered, coated, self-expandable, mesh metallic stent (three patients), Memokath stent (one patient), or Resonance stent (one patient). We retrospectively reviewed their medical records and accessed the predisposing factors, mechanism of injury, diagnosis, and interventional and surgical management. RESULTS: The two patients with PUS presented with ureteroarterial fistula (UAF). Among patients with a self-expandable metallic mesh stents, UAF developed UAF in one patient, ureteroenteral fistula (UEF) developed in one patient, and ureterovaginal fistula (UVF) developed in one patient. There were five patients with fistula who had a history of pelvic surgery, radiation therapy, long-term ureteral stent, or high-pressure balloon dilation. Surgical procedures were needed to manage these problems, including nephrectomy in two patients and bypass surgery with ureter ligation in two patients. UAF was seen with massive gross hematuria that necessitated angiography. UEF required small bowel resection. The patient with UVF underwent multiple surgeries for recurrent fistula. Patients with a Memokath or Resonance stent presented with intractable flank pain and hematuria. These persons required a surgical or other procedure to remove the stents. CONCLUSIONS: UAF should be highly suspected in patients with long-term ureteral stents, especially if gross hematuria develops. The placement of a metallic ureteral stent using a high-pressure balloon should be performed cautiously, especially in patients with a history of pelvic surgery or radiation.

Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries.

INTRODUCTION AND HYPOTHESIS: Genitourinary fistula poses a public health challenge in areas where women have inadequate access to quality emergency obstetric care. Fistulas typically develop during prolonged, obstructed labor, but providers can also inadvertently cause a fistula when performing obstetric or gynecological surgery. METHODS: This retrospective study analyzes 805 iatrogenic fistulas from a series of 5,959 women undergoing genitourinary fistula repair in 11 countries between 1994 and 2012. Injuries fall into three categories: ureteric, vault, and vesico-[utero]/-cervico-vaginal. This analysis considers the frequency and characteristics of each type of fistula and the risk factors associated with iatrogenic fistula development. RESULTS: In this large series, 13.2 % of genitourinary fistula repairs were for injuries caused by provider error. A range of cadres conducted procedures resulting in iatrogenic fistula. Four out of five iatrogenic fistulas developed following surgery for obstetric complications: cesarean section, ruptured uterus repair, or hysterectomy for ruptured uterus. Others developed during gynecological procedures, most commonly hysterectomy. Vesico-[utero]/-cervico-vaginal fistulas were the most common (43.6 %), followed by ureteric injuries (33.9 %) and vault fistulas (22.5 %). One quarter of women with iatrogenic fistulas had previously undergone a laparotomy, nearly always a cesarean section. Among these women, one quarter had undergone more than one previous cesarean section. CONCLUSIONS: Women with previous cesarean sections are at an increased risk of iatrogenic injury. Work environments must be adequate to reduce surgical error. Training must emphasize the importance of optimal surgical techniques, obstetric decision-making, and alternative ways to deliver dead babies. Iatrogenic fistulas should be recognized as a distinct genitourinary fistula category.

Ureteral injuries in colorectal surgery: an analysis of trends, outcomes, and risk factors over a 10-year period in the United States.

BACKGROUND: Iatrogenic ureteral injuries during colorectal surgical procedures are rare. Little is known about their incidence, associated outcomes, and predisposing factors. OBJECTIVE: The purpose of this study was to examine the trends of iatrogenic ureteral injuries in the United States over a decade, as well as their outcomes and risk factors. DESIGN: This was a retrospective study. SETTINGS: The nationwide inpatient sample from 2001 to 2010 was analyzed. PATIENTS: Included were patients with colorectal cancer, benign polyps, diverticular disease, or inflammatory bowel disease undergoing colorectal surgery. MAIN OUTCOME MEASURES: Trends of iatrogenic ureteral injuries occurring in colon and rectal surgical procedures were examined over a 10-year period. Mortality, morbidity, length of stay and total charge associated with ureteral injuries were analyzed on multivariate analysis. Finally, a predictive model for ureteral injuries was built using patient, hospital, and operative variables. RESULTS: An estimated 2,165,848 colorectal surgical procedures were performed in the United States over the study period, and 6027 ureteral injuries were identified (0.28%). The rate of ureteral injuries was higher in the second half of the decade (2006-2010) compared with the first half (2001-2005; 3.1/1000 vs 2.5/1000; p < 0.001). Ureteral injuries were independently associated with higher mortality (OR, 1.45; p < 0.05), morbidity (OR, 1.66; p < 0.001), longer length of stay (mean difference, 3.65 days; p < 0.001), and higher hospital charges by $31,497 (p< 0.001). Risk factors for ureteral injuries included rectal cancer (OR, 1.85), adhesions (OR, 1.83), metastatic cancer (OR, 1.76), weight loss/malnutrition (OR, 1.08), and teaching hospitals (OR, 1.05). Protective factors included the use of laparoscopy (OR, 0.91), transverse colectomy (OR, 0.90), and right colectomy (OR, 0.43). LIMITATIONS: This was a retrospective study from an administrative database. CONCLUSIONS: Iatrogenic ureteral injuries are rare complications in colorectal surgery; however, their incidence appears to be rising. Ureteral injuries are associated with higher mortality, morbidity, hospital charge, and length of stay, and their incidence can be predicted by several factors.

Retroperitoneal and retrograde total laparoscopic hysterectomy as a standard treatment in a community hospital.

OBJECTIVE: To report our experience with a modified procedure for total laparoscopic hysterectomy based on a retrograde and retroperitoneal technique. This surgical approach is analyzed on a consecutive series of patients in a community hospital and theoretical educational advantages are proposed. STUDY DESIGN: All patients undergoing hysterectomy from January 2012 to April 2013 were included in the study. A detailed description of the technique is given. As main outcome measures we evaluated: the number and rate of patients excluded from laparoscopic approach, the rate of late complications need readmission, the rate of transfusions, the rate of conversion to laparotomy and the number of minor complications. The main concern of the study was ureteral complications. RESULTS: Overall 174 patients underwent hysterectomy in our unit. The rate of patients submitted to laparoscopic hysterectomy was 97.5%. The number of complications needing re-admission was three (2%). The rate of conversion was 2.7%. In the study period, two (1.2%) ureteral complications were observed (late fistulae). There were four bladder lesions but the patients were released on the same day as the patients with no lesion. CONCLUSIONS: Opening the retroperitoneum allows rapid control of the main uterine vessels by coagulation, and constant checks on the ureter. Difficult benign situations can be managed. Even in a non-referral center about 94% of hysterectomies can be performed by laparoscopic surgery. This approach is helpful and may be reproducible in gynecological procedures.

Comparative study of one-stitch versus Lich-Gregoir ureterovesical implantation for kidney transplants.

OBJECTIVE: To compare the outcomes of standard Lich-Gregoir technique and a modified one-stitch technique of ureteroneocystostomy in renal transplantation. PATIENTS AND METHODS: Data from 645 transplant recipients by two different ureteroneocystostomy techniques were retrospectively reviewed at the first Affiliated Hospital, Medical College of Xi'an Jiaotong University, between January 2002 and December 2007. RESULTS: There were 418 recipients in the Lich-Gregoir group and 227 in new one-stitch group. The overall ureteral complication rate for new one-stitch technique was 19.8 % (n = 45) as opposed to 15.79 % (n = 66) for the Lich-Gregoir technique. No significantly different rate of ureteral complications occurred in two groups (P > 0.05). In comparison, there was a higher proportion of hematuria at the limit of statistical significance in new one-stitch group (P < 0.05). Average operative time for the modified one-stitch and Lich-Gregoir techniques was 8.8 ± 1.4 and 21.9 ± 6.1 min, respectively (P < 0.05). Urinary tract infections, delayed graft function and rejection rates were not significantly different between the two groups (P > 0.05). CONCLUSION: Although the modified one-stitch technique may predispose patients to higher rates of hematuria, it has no significant difference in ureteral complications compared with the Lich-Gregoir group. Based on this large series and data analyses, we believe that this new technique will become one of our multiple choices in our setting.