iatrogenic ureteral injuries conrad.pptx

ureteral injuries

1. Iatrogenic ureteral injuries : challenges and difficulties in surgical reconstruction Ahmed Eliwa , MD Zagazig University Secretary of reconstructive urologic surgery at EUA Member of U-MEGE, ISURO

2. 0.3% to 1.5%. Selzman AA, Spirnak JP. Iatrogenic ureteral injuries: a 20-year experience in treating 165 injuries. J Urol. 1996 Mar;155(3):878-81. doi : 10.1016/s0022-5347(01)66332-8. PMID: 8583597. 91% 7% 2% Urological 42% Gynecological 34% general surgical 24%

3. Iatrogenic ureteral injuries Iatrogenic Ureteral injuries varies from insignificant mucosal abrasion to avulsion Perforated Crushed electrocoagulation

4. Why UI are challenging? ureteral injuries may be overlooked

5. Why these injuries are challenging? Complexity in surgical or endoscopic management

6. How to best management Plan of iatrogenic ureteric injuries ?

7. Strategies in managing ureteral injuries Unfortunately this is no the situation in every case

8. Later….

9. Factors affecting surgical option Ureter Site of injury Gap Type of injury Patients' factors Kidney factors Tissue Availability of substitution Other

10. Best repair option 2nd repair option

11. Scenario I Upper ureteric injury Short segment

12. Post URS tight Ur

13. Post spinal fixation in Obese DM female Pt

14. Closing or injecting saline in the nephrostomy tube may help you to find the ureter

15. 1EPA

16. Spine Hip Pelvis and acetabulum

17. Best repair option 2nd repair option

18. Scenario II Total ureteral Loss

19. Gaizauskas A, Markevicius M, Gaizauskas S, Zelvys A. Possible complications of ureteroscopy in modern endourological era: two-point or "scabbard" avulsion. Case Rep Urol. 2014;2014:308093. doi : 10.1155/2014/308093. Epub 2014 Dec 28. PMID: 25610699; PMCID: PMC4291154. 43 Female single RT Kidney doing RT URS after failed ESWL

20. 6m later

21. 2 ILEA

22. Best repair option 2nd repair option

23. Scenario III Middle ureter Long gap

24. 57 y cardiac male 4 session radiochemo 2 y ago followed by left hemicolectomy and incidental Right hemicolectomy ileo -transverse anastomosis double barrel colostomy Oncosurgeon discovered that he excised the distal third of the right ureter with RT colonic mass

25. Rt uretro-cutaneous anastomosis The stoma retracted and burst Abdomen right nephrostomy [14 month ago ]

26. 3BF

27. 60 years old male Left URS 3.5 m ago Left PCN was fixed at the day of URS S creatinine 2.5 No CMD No previous surgery

28. 3long Boari

29. Best repair option 2nd repair option

30. Scenario IV Distal third ureter The ligated ureter

31. Best repair option 2nd repair option

32. Scenario V Life threatening Damage control

33. we were called at ER by surgery for female patient who underwent LAP cholecystectomy and cyst marsupialization SHOCK IPFF Exploration Retroperitoneal hematoma

34. How to prevent ureteral iatrogenic injuries ?

35. Preventive Measures Identification and reidentification It is not enough to identify the ureter in one location . convert fibrosis , identify the ureter in an unaffected area. high level of suspicion regarding this injury. The use of prophylactic ureteric stents.

36. The best strategy is to avoid iatrogenic ureteral injuries The 2 nd best is the intraoperative diagnosis and immediate management Damage control in life threatening situation TAKE HOME MESSAGES

37. In the OR Insert PCN and ureteral catheter whenever possible Antegrade and retrograde contrast studies are important Endoscopy Exposure TAKE HOME MESSAGES: IN the OR

38. After surgery Communicate with other Rapidly investigate any surgical problem TAKE HOME MESSAGES: After surgery

39. urological procedures share 30% of all iatrogenic ureteral injuries ureteroscopy is the most common cause of ureteral damage. Perforation mucosal abrasion small-bore, semi-rigid, and flexible fiber optic technology. Assimos DG, Patterson LC, Taylor CL. Changing incidence and aetiology of iatrogenic ureteric injuries. J Urol. 1994; 152: 2240-6. Stoller ML, Wolf JS Jr. Endoscopic ureteral injuries. In: McAninch JW, editors. Traumatic and Reconstructive Urology, Chapter Philadelphia: WB Saunders Co; 1996. p.199-212. Preston JM. Iatrogenic ureteric injury: common medicolegal pitfalls. BJU (Inter). 2000; 86:313-7. Meng MV, Freise CE, Stoller ML. Expanded experience with laparoscopic nephrectomy and autotransplantation for severe ureteral injury. J Urol. 2003; 169:1363-7. Abboudi H, Ahmed K, Royle J, Khan M S, Dasgupta P, N'Dow J.Ureteric injury: a challenging condition to diagnose and manage.

40. to always suspect its presence retrograde pyelography or ureteroscopy C-arm portable radiography and fluoroscopy anterior cystotomy Direct visualization of ureteric injury Nat. Rev. Urol. 10, 108–115 (2013); published online 15 January 2013; doi : 10.1038/nrurol.2012.254

41. Don’t add insult to injury زاد الطين بِلَّة More   haste   less   speed في العجلة الندامة و في التأني السلامة

42. Surgical steps and decision pre-operative endoscopy Ureteral stent or cath incision Transperitoneal approach Identify the proximal and distal stumps Measure the defect Reconstruct the ureter