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Unformatted text preview: Endoscopic management of
iatrogenic ureteric strictures.
Vijayanand.B , Sriram.K , Sunil Shroff.
33 yr female
Right loin pain, 4 weeks
Fever since, 2 weeks.
Difficulty in breathing , 1 week.
Reduced urine output, 2 days.
No co-morbid associated factors
Hysterectomy 4 weeks earlier.
Contrast CT thorax 2 days prior to
admission. Hb 10.2 gm%
BUN 40 mg/dl
S.Electrolytes -- WNL
USG abdomen: Right gross hydrouretero
Parenchymal thickness: 2.2 cms. CT KUB
CT CT KUB
CT CT KUB
CT Initial management
USG guided PCN
Treated for bronchopneumonia
Renal parameters reverted to normal Further management
After 6 weeks , surgery was planned. RGP
RGP Antegrade Manipulations
Passed a 0.025” Terumo
guidewire from the
nephrostomy down and
slipped it through the
Exchanged with PTFE
0.035 over 5 Fr ureteric
Olive tipped dilators used
to dilate the area Grade of ureteral injuries
Grade I (haematoma)
Grade - Contusion or Haematoma. Grade II (laceration)
(laceration - Less than 50% transection. Grade III (laceration)
(laceration) - Greater than 50% transection. Grade IV (laceration)
Grade - Complete transection with
2 cm of devascularization. Grade V (laceration)
(laceration) - Avulsion with greater than
2 cm of devascularization.
cm Type of Ureteral injuries
Crushing by misapplication of the clamps
Ligation with a suture
Transection ( Partial / complete)
Angulation of the ureter with secondary
Ischaemia from ureteral stripping electrocoagulation.
Resection of a segment of ureter.
Combination of the above. 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
usually involves the lower third
Ovarian vascular pedicle at
Ureteric relation with the
Cardinal ligament, where the
ureter crosses under the
Cardinal ligament tunnel,
dorsal to the infundibulo
-pelvic ligament near or at
the pelvic brim.
Lateral rectal pedicles.
Pathological distortion of the
ureteral Treatment depends on
Immediate - intra-op diagnosis.
- after few days to weeks. If diagnosed intra-op
PCN 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
Can present post operatively
- Obstructive uropathy.
Endo balloon dilatation.
(using Ho:YAG Laser).
(using Post-op. period
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).
(depends Newer developments
Endoscopic Laser luminization
Laparoscopic ileal ureter.
Lap SIS replacement of ureter. References
Endoscopic Management of Ureteral Strictures. Evan
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
AA Selzman JP
- Iatrogenic Ureteral Injuries: A 20-Year Experience
Iatrogenic Ureteral Injuries
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.
1997, THANK YOU
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This note was uploaded on 12/27/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.
- Fall '11