|Year : 2016 | Volume
| Issue : 1 | Page : 47-51
Pattern of iatrogenic ureteral injuries in a tertiary health center in Nigeria
Oranusi Chidi Kingsley
Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
|Date of Web Publication||17-Dec-2015|
Oranusi Chidi Kingsley
Department of Surgery, Nnamdi Azikiwe University, Awka/Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State
Objective: To assess etiology, nature of injuries, and reconstruction techniques employed in the management of iatrogenic ureteral injuries. Patients and Methods: A retrospective review of patients with iatrogenic ureteral injuries from January 2009 to December 2013 was done. Records of the patients were reviewed with respect to etiology, mode of presentation, nature of injury, and type of repair done. Results: Twenty patients with iatrogenic ureteral injuries underwent a total of 28 ureteral reconstruction procedures at our institution over the 5-year period. There were 19 female patients (95.5%) and only 1 male patient (4.5%). The mean age of the female patients was 34.5 ± 3.8 years. Of the iatrogenic injuries to the ureter, 50% occurred on the left side while 8 (28.6%) were bilateral. In majority of the cases, 26 (92.9%), these injuries were the result of inadvertent ligation of the ureter. The average time at presentation after the injuries was 29.1 weeks with a range of 2 days to 8 years. The most common gynecological operation implicated was total abdominal hysterectomy (TAH) (55%) followed by myomectomy (20%), ovariectomy (10%), cesarean section (10%), and excision of the right colonic tumor (5%). The commonest mode of presentation was leakage of urine from the vagina as seen in 10 (50.0%) patients while 25% had complete anuria. Ureteroneocystostomy (UNC) was performed in 19 (67.8%) ureters. Psoas hitch and Boari flap were done in four (14.3%) and three (10.7%) cases, respectively. One patient (3.6%) required a transureteroureterostomy (TUU) and another one (3.6%) required a right nephroureterectomy. Outcome of the treatment was judged as satisfactory in all the cases as defined by improvement or resolution of the symptoms and normalization of renal function. Conclusion: Abdominal hysterectomy still remains the dominant cause of iatrogenic injury to the ureter. UNC can often be used to establish ureteral continuity in most cases of iatrogenic injuries to the distal ureter. Injuries to the right ureter are more likely to involve the middle third of the ureter, requiring some form of bladder mobilization or bladder flap to establish ureteral continuity. Attention to preventive measures, especially during gynecological surgeries, will help to reduce the incidence of ureteric injuries.
Keywords: Gynecological, iatrogenic, injuries, reconstruction, ureter
|How to cite this article:|
Kingsley OC. Pattern of iatrogenic ureteral injuries in a tertiary health center in Nigeria. Trop J Med Res 2016;19:47-51
| Introduction|| |
Injuries to the ureter can complicate any abdominal or pelvic surgical procedure either from gynecological, urological, or general surgical disease. The incidence rate varies between 0.5-10%., In some rare cases such as malignant ureteral disease or stricture disease of the ureter, a part or the entire ureter may be excised in a curative intent. Following these conditions, significant reconstruction of the ureter may be required and depending on the length of the ureter that is damaged or excised, reconstruction may be done using different approaches.
Iatrogenic ureteral injuries from gynecological surgeries account for between 50 and 75 percent of these injuries in some developing countries, as seen in Africa. In one local study, the prevalence was as high as 92% with total abdominal hysterectomy (TAH) accounting for the commonest cause in 83% of cases.,, This contrasts with reports from the developed nations where a reduction in the proportion of open gynecological ureteral injuries have been noted in the past two decades with an almost exponential increase in iatrogenic ureteral injuries from endoscopic and laparoscopic procedures to the ureter.,
Injuries to the ureter that are recognized during surgery are best managed immediately without significant morbidity. When they are recognized postoperatively, they can often present with severe morbidity so that in some cases, adequate attention must be paid to resuscitation of the patient before definitive repair can be done.
This study is a retrospective analysis of the etiology, nature of injuries, and reconstruction techniques employed in the management of these injuries and outcome in a tertiary institution in Nigeria.
| Patients and Methods|| |
A review of patients with iatrogenic ureteral injuries spanning a period of 5 years, from January 2009 to December 2013, was conducted at the Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Southeastern Nigeria. The clinical and theatre records of the patients who had repair of ureteric injuries during the period were analyzed. The information retrieved from the notes included the patients' age, mode of presentation, etiology of injury, nature of injury, and types of reconstruction done. Data were expressed in simple proportions and analysis was done with Microsoft Excel 2007®.
| Results|| |
A total of 25 patients were diagnosed with ureteral injuries over the period; only 20 had complete records and were analyzed for the study. A total of 28 ureteral reconstructions were carried out on these patients over the period. There were 19 female patients (95.5%) and 1 male patient (4.5%). [Table 1] summarizes the demographics and characteristics of the patients. The mean age of the female patients was 34.5 ± 3.8 years.
|Table 1: Demographics and characteristics of patients with iatriogenic ureteral injuries|
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50% of the patients had left sided injuries, while 28.6% (8 cases) were bilateral. Majority of these cases, 26 (92.9%), were the result of inadvertent ligation of the ureter. Eleven patients (55.0%) sustained iatrogenic injury to the ureter following TAH; this was followed by myomectomy (20%), cesarean section (10%), excision of right colonic tumor (5%), and ovariectomy (10%). All the patients who had ureteral injuries from cesarean section, myomectomy and seven hysterectomy patients were referred from the general practitioner. Four hysterectomy-associated injuries were recorded in our center.
Most of the cases, i.e., 18 (90.0%), of injuries were discovered postoperatively and two (10%) were identified during surgery. The average time to presentation after the injuries was 29.1 weeks with a range of 2 days to 8 years. The commonest mode of presentation was leakage of urine from the vagina as seen in 10 (50.0%) patients while 25% had complete anuria [Table 2]. Of the ureteric injuries, 78% occurred at the distal ureter with 63.6% occurring in the left ureter. Most of the injuries (78.0%)occurred at the distal ureter. The left ureter was injured in most cases(63.6%). Twenty-one percent of iatrogenic injuries to the right ureter involved the middle third of the right ureter.
For patients whose injuries were discovered postoperatively, surgical repair was done as soon as all the necessary evaluations were completed and the patient was judged to be stable, ranging from 1-3 weeks. Preoperative assessment in most cases involved the use of ultrasound scan, intravenous urogram (IVU), and assessment of renal function [serum creatinine (SCr)]. The reconstructions carried out for the injured ureters are shown in [Table 3]. A refluxing ureteroneocystostomy (UNC) was performed in 19 (67.8%) ureters. One patient (3.6%) had a transureteroureterostomy (TUU) and one (3.6%) had a right nephroureterectomy. No mortality was recorded in our series. All the ureters were stented for a period of 7-10 days. Outcome of the treatment was judged to be satisfactory in all the cases as defined by the resolution of symptoms and normalization of renal function. The follow-up period ranged from 2 weeks to 12 months. The hospital stay for patients ranged 8-12 days. Follow up was done with ultrasound scan and SCr measurements scan and SCr measurements at 2 weeks and 4 weeks after the surgery and then yearly.
| Discussion|| |
Radiographically, the ureters can be described as having the following three parts: The upper part that extends from the renal pelvis to the upper border of the sacrum, the middle part that extends from the upper border of the sacrum to the lower border of the sacrum, and the lower or distal part that extends from the lower border of the sacrum to the bladder. The ureters are most commonly injured at the distal segment. Anatomical landmarks where injury can occur to the ureter include the ovarian vascular pedicle at the infundibulopelvic ligament, where the ureter passes under the uterine artery, the vaginal fornices, and the lateral rectal pedicles. During ureteroscopy, the ureters can be injured at the intramural portion of the distal ureter or at the middle segments during stone manipulations.
There are different approaches to the repair of an injured ureter depending on the length of the defect. Short and uncomplicated ureteral defects can be managed with direct ureteroureterostomy (UU), distal defects can be managed with ureteral reimplantation ureteroneocystostomy (UNC). For mid-ureteral defects, the bladder can be mobilized and ureteral continuity can be achieved with the creation of a psoas bladder hitch  or a Boari bladder flap  that, in combination, was described by Kelami et al. In longer ureteral defects or for more complex injuries, intestinal segments may be used for substitution.
Nearly all gynecological and obstetric procedures have been reported to cause ureteric injury. This study still confirms that open gynecologic surgery remains the commonest cause of iatrogenic ureteral injury in our environment accounting for 85% of all ureteral injuries, with TAH accounting for 55% of the cases. The incidence of ureteric injuries following gynecological surgeries has been estimated at 0.35%. Chianakwana et al. in a review of urological injuries following gynecological operations from this center about a decade ago estimated the incidence of urological injuries to be 1.7%. TAH accounted for 87.5% of the cause of iatrogenic ureteral injuries. These injuries often befall women during the reproductive periods of their life. Apart from the anatomical closeness of the urinary tract to the female genital organs, certain factors may explain the reasons why iatrogenic ureteral injuries are common following gynecological surgeries. This include excessive bleeding during surgery, such surgeries being undertaken in not too ideal situations, multiple adhesions in and around the bladder and lower ureter from previous surgeries, infiltrations from pelvic malignancies, operations undertaken by inexperienced surgeons, and relatively large size of the uterus at the time of surgery (cesarean hysterectomy). These injuries may be unavoidable even in the hands of the most skilled surgeon. Myomectomies and cesarean sections accounted for 20% of the causes of iatrogenic injuries to the ureter in this study. This figure is lower than that reported from sub-Saharan Africa, which indicated that cesarean section was responsible for 31-72% of cases of iatrogenic ureteral injuries surpassing hysterectomies as the commonest cause of iatrogenic injuries to the ureter in that region., Iatrogenic injuries to the ureter from laparoscopic surgeries or upper tract endoscopic surgeries were not observed in this study because this mode of treatment is still nonexistent in our institution.
Ureteric ligation was the most common form of injury to the ureter. This has previously been reported from our center. Reports in the literature are varied concerning the nature of injuries to the ureter. While some report ligation as the most common form of injury,, Oboro et al., reported transection as the most common type of injury in their study. However, ligation injuries seem to dominate in the literatures. From this study, most injuries to the left ureter occurred at the distal third of the ureter and the left ureter was injured in 50% of our patients (14 vs 6). This tendency for injury to the left ureter can be explained anatomically. The left ureter is much closer to the cervix than the right ureter. Significant finding from this report is the to the right ureter accounting for 21% of iatrogenic ureteral injuries. This can be explained anatomically by the apparent shorter length of the right ureter.
Unrecognized ureteral injury is often associated with a high patient morbidity and potential loss of the involved renal unit. The only nephrectomy in this study was due to delayed recognition and severe hydronephrosis with the loss of renal function. In the immediate postoperative period following iatrogenic ureteral injury, presentation could vary from oliguria to complete anuria depending on whether the injury was unilateral or bilateral. A high index of suspicion is required for diagnosis in the immediate postoperative period. Delayed presentation (>3 weeks) of urine leakage from the vagina usually results from an ureterovaginal fistula resulting from tissue necrosis at the point of ligation. Flank pain was observed in one of our patients 8 years after a cesarean section, with severe hydronephrosis of the left kidney. We did not observe any patient with urinary ascites or leakage of urine from the wound as reported in one local study.
The aim of surgical repair of iatrogenic ureteral injuries is to restore anatomic continuity of the urinary tract and to preserve renal function. This can be achieved in nearly all the patients once the diagnosis is done early enough before an irreversible damage is done to the involved renal unit. It is generally agreed that injuries discovered during surgery should be repaired immediately. Only two patients in our series had their injuries discovered during surgery for right colonic tumor and a difficult hysterectomy for malignancy. Injuries to the ureters under the forgoing situations are quite understandable because of the distortions in the anatomy of the ureter. However, in 90% (18/20) of our case series, the diagnosis was done postoperatively. For these categories of patients, controversy exists as to the appropriate time for surgical intervention. While some urologists advocate immediate repair, others prefer a delayed repair especially in situ ations in which renal function has been compromised., However, the timing for a “delayed” repair is still not defined among urologists. A period of upper tract drainage is often advocated for patients with severe renal compromise before definitive surgery. For those with partial ligation or incomplete obstruction, an internal stent (double J stent) can be maneuvered through the area of stenosis to allow adequate drainage of the involved renal unit before definitive surgery. For patients with complete obstruction in the setting of bilateral obstruction and impaired renal function, a percutaneous nephrostomy tube can be inserted prior to definitive surgery. We have always adopted a policy of immediate repair as soon as the patient is optimized for surgery. We did not observe any mortality in our case series.
UNC was the commonest reconstructive procedure undertaken for injuries to the distal ureter. This was consistent with other studies., This was performed in 67.8% of the cases. Bladder mobilization was required in eight (28.6%) patients. A bladder flap (Boari flap) was done in three (10%) patients on the right ureter and a psoas hitch in combination with UNC and TUU was done in five (19%) patients on the right ureter. The higher levels of injury to the right ureter could explain why more extensive reconstructions, requiring mobilization of bladder flaps, are more common on the right side. Other treatment options for high injuries of the ureter include end-to-end anastomosis, ileal interposition, and in some cases renal autotransplantation. These extensive surgical procedures can further increase the morbidity and mortality associated with the injury. UNC is easy to perform and it should be the preferred option for injuries in the distal ureter. Patients who have undergone ureteral reconstruction should be followed up for life because of late risk of ureteric stricture/stenosis and reflux disease. Attention to anatomical details during surgery, avoidance of blind clamping of bleeders during gynecological operations, and continued medical education of the medical staff can help to reduce the incidence of iatrogenic ureteral injuries.
| Conclusion|| |
Abdominal hysterectomy still remains the dominant cause of iatrogenic injury to the ureter. UNC can often be used to establish ureteral continuity in most cases of iatrogenic injuries to the distal ureter. Injuries to the right ureter are more likely to involve the middle third of the ureter, requiring some form of bladder mobilization or bladder flap to establish ureteral continuity. Attention to preventive measures will help to reduce the incidence of ureteric injuries.
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[Table 1], [Table 2], [Table 3]