Iatrogenic Thermal Energy-Induced Distal Ureteric Injury and Its Management by Laparoscopy Ureteroureterostomy

Abstract

Background and objectives: Most thermal energy-induced distal ureter injuries are missed intraoperatively as they are caused by delayed ischemia-induced necrosis of the affected part leading to fistula, and a delayed presentation. The injuries of the distal ureter are commonly managed by ureteroneocystostomy, which has long-term complications related to vesico-ureteric reflux (VUR). We present our experience of management of distal ureter injury due to thermal energy by laparoscopy ureteroureterostomy and the role of various methodologies for its diagnosis.

Methods: It is a retrospective, single-center study that was conducted from January 1, 2020 - December, 31 2022.

Results: A total of 8 cases were enrolled in the study. All cases had an uterovaginal fistula (UVF) post-laparoscopic gynecology surgery. The bilateral ureteric injury was observed in 2 cases. The median post-surgery time to diagnose UVF in the study was 10 days. All cases were managed by laparoscopy ureteroureterostomy (LUUS). Six cases underwent immediate surgery after the diagnosis; whereas 2 cases had initial double-J stent placement as treatment, which subsequently failed following which the LUUS was performed. There were not any immediate or long-term complications such as leakage, stenosis, fistula, or any requirement for revision surgery.

Conclusion: The management of thermal energy-induced ureteric injury is exceptional as compared to other types of ureteric injury. Our approach should be toward immediate surgical management rather than a conservative one to avoid long-term complications and sequelae. Iatrogenic lower ureteral injury can be managed successfully by LUUS, maintaining the normal anatomy and physiology of VUR.

Keywords: Double-J stent; Laparoscopy ureteroureterostomy; Reimplantation of the ureter; Thermal energy-induced ureter injury; Uretero-vaginal fistula; Vesico-ureter reflux.

Figure 1.

Inflamed pelvic peritoneum tissue with no frank intraoperative leak seen.

Figure 2.

Right lower ureteric defect, identified after the retroperitoneal ureteric dissection.

Figure 3.

Endo view of identification of injured distal ureteric end with the help of cystoscopy guided insertion of guide wire.

Figure 4.

Insertion of guide wire into the proximal cut end of the left ureter laparoscopically.

Figure 5.

A) Double-J stent in situ with ureteric fistula before excision of devitalized tissue. B) Double-J stent in situ with ureteric fistula after excision of devitalized tissue. C) Laparoscopy ureteroureterostomy mucosa to mucosa with polyglactin 910 (Vicryl3-0). D) Final end view after laparoscopy ureteroureterostomy.

Figure 6.

Development of right lower ureteric defect with persistent double-j stent in situ for 21 days (prophylactic placement post primary surgery in case 8).

Figure 7.

Left side lower ureter with murk color, absent capillary vessel suggestive of devitalized tissue (highlighted in circle).

Figure 8.

Incision line (highlighted by dashed line) for posterior peritoneal dissection towards uterosacral ligament in total laparoscopic hysterectomy to avoid lateral thermal energy spread. Starred line indicates an incision with a high probability for ureteric injury due to lateral thermal energy spread.

Figure 9.

Area around the vesico-uterine ligament, to be avoided with the use of thermal energy, as it may lead to ureteric injury (area between the starred circumference).

Figure 10.

Right-sided partial cut end of vaginal artery at 2 o’clock position in total laparoscopic hysterectomy.

Figure 11.

Cut end of the posterior peritoneum to be avoided to prevent ureteric injury due to lateral thermal energy spread (highlighted by starred line).

Figure 12.

Double-j stent in situ with cyanosed proximal ureteric end (highlighted in circle), which needs to be excised.