Endoscopic management of iatrogenic ureteric strictures.

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Endoscopic management of iatrogenic ureteric
strictures.

• Vijayanand.B , Sriram.K , Sunil Shroff.
• SRMC

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History

• 33 yr female
• Right loin pain, 4 weeks
• Fever since, 2 weeks.
• Difficulty in breathing , 1 week.
• Reduced urine output, 2 days.

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History

• No co-morbid associated factors
• Hysterectomy 4 weeks earlier.
• Contrast CT thorax 2 days prior to admission.

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• Hb 10.2 gm
• TC 12600
• BUN 40 mg/dl
• S.Creatinine 2.4mg/dl
• S.Electrolytes -- WNL
• USG abdomen Right gross hydrouretero nephrosis
• Parenchymal thickness 2.2 cms.

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CT KUB
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CT KUB
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CT KUB
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Initial management

• USG guided PCN
• Treated for bronchopneumonia
• Renal parameters reverted to normal

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Further management

• After 6 weeks , surgery was planned.

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RGP
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Antegrade Manipulations

• Passed a 0.025 Terumo guidewire from the
  nephrostomy down and slipped it through the
  strictured area
• Exchanged with PTFE 0.035 over 5 Fr ureteric
  Catheter
• Olive tipped dilators used to dilate the area

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Grade of ureteral injuries

• Grade I (haematoma) - Contusion or
  Haematoma.
• Grade II (laceration) - Less than
  50 transection.
• Grade III (laceration) - Greater than
  50 transection.
• Grade IV (laceration) - Complete
  transection with 2
  cm of devascularization.
• Grade V (laceration) - Avulsion with
  greater than 2 cm of
  devascularization.

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Type of Ureteral injuries

• Crushing by misapplication of the clamps
• Ligation with a suture
• Transection ( Partial / complete)
• Angulation of the ureter with secondary clips.
• Ischaemia from ureteral stripping
  electro-coagulation.
• Resection of a segment of ureter.
• Combination of the above.

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Incidence of surgical injury

• Gynecologic surgery 50 66
• General / Colorectal Surgery 15 25
• Abdominal vascular surgery 5 10
• Ureteroscopy (perforation) 1 - 5

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Sites of ureteral injuries

• usually involves the lower third
• Ovarian vascular pedicle at infundibulo-pelvic
  ligament
• Ureteric relation with the uterine artery.
• Cardinal ligament, where the ureter crosses under
  the uterine artery.
• Cardinal ligament tunnel, dorsal to the
  infundibulo -pelvic ligament near or at the
  pelvic brim.
• Vaginal fornices.
• Lateral rectal pedicles.
• Pathological distortion of the ureteral anatomy.

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Treatment depends on

• Diagnosis made
• Immediate - intra-op diagnosis.
• Delayed - after few days to weeks.

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If diagnosed intra-op

• Grade 1
• DJ stenting
• Grade 2
• DJ stenting
• PCN

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If diagnosed intra-op

• Grade 3,4,5(depending on the level of injury)
• Short segment loss
• Open or Lap. Ureteric reimplantation.
• Open or Lap. Uretero-ureterostomy.
• Open or Lap. Psoas hitch.
• Long segment loss
• Open or Lap. Boari flap.
• Open or Lap. Ileal ureter.

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Mode of presentation

• Can present post operatively
• - Stricture
• - Urinoma
• - Fistula
• - Obstructive uropathy.

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Stricture

• Endo balloon dilatation.
• DJ stenting.
• Endoscopic ureterotomy.
• (using HoYAG Laser).

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Post-op. periodUrinoma

• PCN placement.
• Per-cutaneous drainage of the urinoma (if needed)
• Wait for edema, induration to settle down.
• Ante grade nephrostogram, 6 weeks later.
• Definitive repair on a later date.
• (depends on the type of ureteral injury).

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Newer developments

• Endoscopic Laser luminization
• Laparoscopic ileal ureter.
• Lap SIS replacement of ureter.

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References

• Endoscopic Management of Ureteral Strictures.
  Evan R. Goldfischer a and Glenn S. Gerber a. The
  Journal of urology, 1997 Elsevier.
• AA Selzman, JP Spirnak - The Journal of urology,
  1996 - Iatrogenic Ureteral Injuries A 20-Year
  Experience in Treating 165 Injuries.
• Urological injuries during obstetric and
  gynaecological surgical procedures. Shrivastava
  A, Nandanwar S, Bhattacharya. M .Journal of
  Postgraduate Medicine, Year 1991, Volume 37,
  Issue 1.
• Ileal substitution as a Salvage Procedure in the
  management of iatrogenic ureteric injuries. Gupta
  NP, Chahal R, Wadhwa. Indian Journal of Urology,
  Year 1997, Volume 13, Issue 2.

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• THANK YOU