endoscopic management of iatrogenic ureteric strictures
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Endoscopic management of iatrogenic ureteric strictures. Vijayanand.B , Sriram.K , Sunil Shroff. SRMC. History. 33 yr female Right loin pain, 4 weeks Fever since, 2 weeks. Difficulty in breathing , 1 week. Reduced urine output, 2 days. History. No co-morbid associated factors

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endoscopic management of iatrogenic ureteric strictures

Endoscopic management of iatrogenic ureteric strictures.

Vijayanand.B , Sriram.K , Sunil Shroff.

SRMC

history
History
  • 33 yr female
  • Right loin pain, 4 weeks
  • Fever since, 2 weeks.
  • Difficulty in breathing , 1 week.
  • Reduced urine output, 2 days.
history1
History
  • No co-morbid associated factors
  • Hysterectomy 4 weeks earlier.
  • Contrast CT thorax 2 days prior to admission.
slide4
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.
initial management
Initial management
  • USG guided PCN
  • Treated for bronchopneumonia
  • Renal parameters reverted to normal
further management
Further management

After 6 weeks , surgery was planned.

antegrade manipulations
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
grade of ureteral injuries
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.

type of ureteral injuries
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.
incidence of surgical injury
Incidence of surgical injury
  • Gynecologic surgery 50 – 66 %
  • General / Colorectal Surgery 15 – 25 %
  • Abdominal vascular surgery 5 – 10 %
  • Ureteroscopy (perforation) 1% - 5 %
sites of ureteral injuries
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.

treatment depends on
Treatment depends on

Diagnosis made

Immediate - intra-op diagnosis.

Delayed - after few days to weeks.

if diagnosed intra op
If diagnosed intra-op

Grade 1

DJ stenting

Grade 2

DJ stenting

PCN

if diagnosed intra op1
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.
mode of presentation
Mode of presentation
  • Can present post operatively

- Stricture

- Urinoma

- Fistula

- Obstructive uropathy.

slide21

Stricture

  • Endo balloon dilatation.
  • DJ stenting.
  • Endoscopic ureterotomy.

(using Ho:YAG Laser).

post op period urinoma
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).

newer developments
Newer developments
  • Endoscopic Laser luminization
  • Laparoscopic ileal ureter.
  • Lap SIS replacement of ureter.
references
References
  • EndoscopicManagement ofUreteralStrictures. Evan R. Goldfischer a and Glenn S. Gerber a. The Journal of urology, 1997 – Elsevier.
  • AA Selzman, JP Spirnak - The Journal of urology, 1996 - IatrogenicUreteralInjuries: A20-YearExperience 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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