Endoscopic management of iatrogenic ureteric strictures.

1. Endoscopic management of iatrogenic ureteric strictures. Vijayanand.B , Sriram.K , Sunil Shroff. SRMC

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

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

4. 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.

5. CT KUB

6. CT KUB

7. CT KUB

8. Initial management • USG guided PCN • Treated for bronchopneumonia • Renal parameters reverted to normal

9. Further management After 6 weeks , surgery was planned.

10. RGP

11. 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

13. 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.

14. 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.

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

16. 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.

17. Treatment depends on Diagnosis made Immediate - intra-op diagnosis. Delayed - after few days to weeks.

18. If diagnosed intra-op Grade 1 DJ stenting Grade 2 DJ stenting PCN

19. 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.

20. Mode of presentation • Can present post operatively - Stricture - Urinoma - Fistula - Obstructive uropathy.

21. Stricture • Endo balloon dilatation. • DJ stenting. • Endoscopic ureterotomy. (using Ho:YAG Laser).

22. 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).

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

24. 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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