Endoscopic Management of Iatrogenic Ureteral Injury: A Case Report and Review of the Literature

Abstract

Background: Iatrogenic ureteral injury represents an uncommon, but significant, complication of gynecologic surgery. Endoscopy has typically played little to no role in the treatment of these injuries, which are traditionally managed with re-exploration or delayed repair. Delayed repair with temporary urinary diversion exposes the patient to significant morbidity. We present a case in which iatrogenic ureteral injury is managed definitively with endoscopy alone.

Case Presentation: We present a 32-year-old female who developed a delayed postpartum hemorrhage following cesarean section, necessitating emergent hysterectomy. Postoperatively, there was concern for right ureteral injury. A computed tomography (CT) urogram was obtained showing right-sided hydronephrosis, but no obvious ureteral injury. After developing right flank pain, the patient was taken to the operating room for further evaluation. On semirigid ureteroscopy, a suture was identified within the lumen of the ureter and incised with the holmium laser, effectively treating the obstruction. At a 10-week follow-up, a renal ultrasound showed no hydronephrosis. At 8 months, the patient reports she is doing well with no flank pain.

Conclusion: We present, to the best of our knowledge, the first published report in the United States of an iatrogenic ureteral ligation managed effectively in an acute postoperative setting with endoscopic holmium laser release, without balloon dilation, sparing the patient from delayed surgical intervention and the potentially associated morbidity. It is our belief that an initial retrograde pyelogram followed by a ureteroscopic evaluation should be performed as this allows for proper characterization of the injury, and may allow one to attempt definitive endoscopic management.

Introduction and Background

The incidence of iatrogenic ureteral injury during routine gynecologic pelvic operations is 0.5%–1.5%.¹ If the injury is recognized at the time of the initial procedure, it can be repaired in the same setting using traditional open, laparoscopic, or robotic techniques. If identified in a delayed manner, this presents a surgical conundrum for the consulting urologist. If recognized in the early postoperative period (less than a week), the patient is a candidate for re-exploration and ureteral repair. If recognized more than 1 week from the initial operation, the typical conservative approach is a delayed repair in 2–3 months following temporary urinary drainage. Either option exposes the patient to significant morbidity. Thus, we describe a case in which we were able to avoid pelvic re-exploration and treat complete suture ligation of the ureter using simple endoscopic techniques.

Case Report

A 32-year-old previously healthy gravida 5, para 6 female, status postcesarean section delivery of twins, re-presented 9 days postpartum with delayed-onset hemorrhage, secondary to retained products of conception. She required significant blood product resuscitation and an emergent hysterectomy. Visualization of the pelvic anatomy at the time of surgery was reportedly poor. On postoperative day (POD) 1, there was concern for right ureteral injury, which prompted transfer to our facility for specialty urologic care. On arrival, the patient was admitted to the medical ICU, secondary to disseminated intravascular coagulation, where she received further resuscitation. On POD 3, a computed tomography (CT) urogram revealed right-sided hydronephrosis, but delayed images failed to show contrast beyond the proximal ureter. On POD 4, the patient developed significant right flank pain. Due to a nondiagnostic CT urogram, the patient was taken to the operating room for further delineation of a potential right ureteral injury. An open-ended ureteral catheter was cystoscopically placed into the right ureteral orifice. A fluoroscopic scout image showed a previously instilled CT contrast now extending down to the distal right ureter with a 2.5 cm gap between the tip of the open-ended ureteral catheter and the contrast (Fig. 1). This suggested complete right ureteral obstruction. A hydrophilic wire was unable to be passed. A semirigid ureteroscope was inserted into the right ureteral orifice and advanced. A blue suture, consistent with polypropylene, was visualized and noted to be causing complete right ureteral obstruction. A 272 μm holmium laser fiber was used to incise the suture. The ureter was then visibly open. A right retrograde pyelogram was performed showing a completely patent right ureter with no focal narrowing (Fig. 2). A 6F × 24 cm ureteral stent was placed (Fig. 3). The next day, her right flank pain had resolved and she was discharged home. The stent was removed in the clinic 4 weeks later. A renal ultrasound was performed 10 weeks following intervention and showed that her hydronephrosis had resolved. At 8 months, the patient reports she is doing well and has no flank pain.

FIG. 1.

A scout film showing an open-ended ureteral catheter within the right ureteral orifice before retrograde contrast injection. The contrast seen in the ureter is from a CT urogram performed the day before. Lack of contrast filling in the distal ureter is consistent with complete ureteral obstruction. CT, computed tomography.

FIG. 2.

Right-sided retrograde pyelogram showing complete filling of the right ureter following holmium laser suture ligation.

FIG. 3.

Right ureteral stent in place within the right renal collecting system following holmium laser suture ligation.

Discussion and Literature Review

An unrecognized iatrogenic ureteral injury from pelvic gynecologic surgery is an uncommon, but devastating, complication. These injuries are associated with significant morbidity and often lead to secondary invasive surgical interventions for repair. In our case, we identified the ureteral injury in the acute postoperative setting, managed it with simple, minimally invasive endoscopic techniques, and the patient had an excellent urologic outcome.

On review of the literature, there have been few reports published on acute endoscopic management of iatrogenic ureteral injuries. Razvi and coworkers reported on a ureteral injury secondary to suture ligation following a cesarean section managed in the acute postoperative setting, utilizing a combination of ureteroscopy and balloon dilation. At 6 months of follow-up, the patient had normal kidney function with no evidence of hydronephrosis on imaging.² Wang and colleagues reported a case of endoscopic release of ureteral ligature 4 days following a hysterectomy.³ This was the first publication in the English literature to describe acute endoluminal management for inadvertent ureteral ligation. In the report, they detail the use of a semirigid ureteroscope and blind placement of a holmium laser fiber through the ureteral wall to transect a silk suture. Hong and coworkers reported on five patients with iatrogenic ureteral injuries managed in a delayed manner (mean 3.5 months since initial surgery), utilizing semirigid ureteroscopy and the holmium laser.¹ In 75% of patients, they effectively performed a laser ureteroureterostomy to treat complete ureteral obstruction, with evidence of normal renal function at a mean follow-up of 3.75 years. Finally, Zhang and colleagues reported on 12 patients who underwent management of suture ligation of the ureter, utilizing a combination of semirigid ureteroscopy, holmium laser, and balloon dilation.⁴ Their report does not mention the timing of intervention. At 3–4 months of follow-up, most patients had improved or resolved hydronephrosis on standard intravenous pyelography.

Iatrogenic gynecologic ureteral injuries comprise several etiologies. Before surgical repair, one should consider whether the injury has led to ureteral obstruction or if the ureter has been left in discontinuity. Ureteral obstruction-related injuries include, but are not limited to, partial or complete ligation (suture, clip, or energy) and crush injury. Injuries resulting in discontinuity of the ureter include, but are not limited to, transection (sharp, stapler, or energy), resection, and avulsion. Before attempting repair, the differential should be narrowed. Speaking with the initial surgeon can be extremely valuable, but direct interaction is not always feasible. Obtaining imaging, such as a CT urogram, is valuable, and may help delineate the location/type of injury, foreign objects associated with the ureter, and overall anatomic detail. If the injury can be managed endoscopically, this should be attempted. Start with a retrograde pyelogram, and if indicated, direct inspection of the ureter via ureteroscopy. One may then consider definitive endoscopic management via use of the laser, balloon dilation, or some combination thereof. In every case, one should be prepared for maximally invasive management such as open ureteroureterostomy or transureteroureterostomy, direct ureteral reimplant with or without psoas hitch and/or Boari flap, ileal ureter, autotransplant, or nephrectomy.

In our experience, the CT urogram provided excellent anatomic detail, but failed to identify the location of the injury. In the operating room, we performed a retrograde pyelogram, which showed clear evidence of a complete distal ureteral obstruction. We then inspected this area via ureteroscopy and were able to mange the injury using simple endoscopic techniques. Had we been unable to endoscopically manage this injury, we were fully prepared to open the abdomen and perform a direct ureteral reimplant with or without a psoas hitch.

Ultimately, to the best of our knowledge, this is the first published case report in the United States of an iatrogenic ureteral injury managed in an acute postoperative setting, utilizing semirigid ureteroscopy and the holmium laser, without the need for balloon dilation. This technique is simple, effective, and may spare patients from undergoing a secondary, maximally invasive surgical intervention.

Conclusion

Ureteral injuries represent a potentially devastating complication following pelvic surgery. Historically, these were managed with open reconstruction in a delayed manner following initial temporary drainage. As medical technology has improved, we now have multiple, minimally invasive surgical options to offer these patients. In this report, we described the management of complete suture ligation of the ureter in the acute postoperative setting, utilizing semirigid ureteroscopy and the holmium laser with excellent results. In the appropriately selected patient, this technique is simple, effective (especially when attempted within 1 week of the initial injury), and may spare patients from undergoing a secondary, maximally invasive surgical intervention. Before temporary percutaneous drainage (if feasible), or maximally invasive open repair, it is our belief that an initial retrograde pyelogram followed by ureteroscopic evaluation should be performed. This allows for proper characterization of the injury, and may allow one to attempt definitive endoscopic management.

Abbreviations Used

CT

computed tomography

POD

postoperative day

Disclosure Statement

No competing financial interests exist.

Cite this article as: Klett DE, Mazzone A, Summers SJ (2019) Endoscopic management of iatrogenic ureteral injury: A case report and review of the literature, Journal of Endourology Case Reports 5:4, 142–144, DOI: 10.1089/cren.2019.0020.