THE JOCRNAJ. OF U ROLOGY Copyrii(ht © 1975 by The Williams & Wilkins Co.
Vol. 114. Oct o ber
Prin ted in US.A.
EARLY, AGGRESSIVE MA:'JAGEME:'JT OF INTRAOPERATIVE URETERAL INJ URIES WILLIAM H. HO CH,* ELROY D. KURSH
AND
LESTER PERSKY
From the Division of Urology, Department of Surgery, University Hospitals of Cleveland, Cleveland, Ohio
ABSTRACT
M ost urologic surgeons prefer prox imal urin a ry divers ion as a n initia l step in the repair of intraoperative ureteral injuries but a n early direct attack on the injured area is being attempted more often. Our report concerns 36 ureteral injuries in 24 patients during the last 5 years . In 19 pa tients 20 injuri es were recogn ized and managed during post.operative convalescence. Repair cons isted of uret eron eocystoto my in 8 patien ts, ureteroureterostomy in 6 a nd ureteral deligat ion in 4. Ureteral cath et er manipulat ion alone was successful in 2 cases . Satisfactory ureteral repa ir was achieved in 2:3 patients . Definitive m a nagement was in itiated upon d iagnosis in all but 1 patient. We recommend an early. direct . aggressive approach to the injured area whenever possible. With th e increased number of o_perations performed yea rly there h as been a n assoc iated increase in the number of intraop erat ive uret eral inj uries. Thes e injuries m ay a nd have occ urred during an y procedure in which dissection brings the ureter into the operative fi eld and a variety of techniques exists for their correction. Most urologic s urgeons prefer proximal urinary diversion as an init ial step in ureter al repair.'· 2 H owever. in recent years, a n earl y, direct attac k on th e injured area is being attempted more frequentl y. 3 Cont roversy exists as to the optimal approach.
procedures incl uded exc1s1on of ovarian tumor, cesarea n sect io n . va ginal procedure, s uprapubic urethropexy an d prolapse repa ir. Th e gen e ra l s urgical cases resulting in uret cra l injur:, involved aortic surgery, s igmoid colon s urgery. posterior pelvic exent eration , lys is of a dh esions, excision of retroperitonea l m ass and appendect omy. Twentytwo patient s had unilateral and 2 had bilateral
MATERIALS AND METHODS
Twent y-s ix intraoperati ve ureteral injuries were managed in 24 p a tients durin g the last 5 yea rs . These patients ranged in age from 18 to 64 yea rs old and a ll b ut 5 were women . During t h e co urse of the primary operations 6 injuries in 5 pa tients were recognized a nd repaired. In the remaining 19 patients ureteral dam age became clinically ap parent only in the postoperati ve period. In these patients. with 4 exceptions, d efiniti ve repair was initiated within 3 ' " weeks of injur:--·. D elay in 3 cases was owing to fa ilure of d iagnosis a nd in t he oth er case to t h e decision to a llow th e int ense inflammatory response p resen t initi a lly to resolve. Gynecologic procedures contribut ed t o the majority of ureteral injuries but 7 injuries were the result of general surgica l procedures (table I l. Ureteral d amage occurred dur ing the course of t ran sa bdo minal hysterecto m y in 11 cases. Other Accepted for publication M ay :m. 197:1. Read at a nnual meet ing of West ern Section. America n Urological Assoc iation, Port la nd , Oregon . April J:l-- 1, . 1975. *Current address: David Grant Unit ed States Air Force M ed ical Cent er. T ravis Air Force Rase. Californ ia 94535 . 530
111JUfl eS .
In th e 10 pat ien ts with obstruc t ed ureters not iced in t h e postoperative period pa in a nd fever were th e predomin a tin g sy mptoms , while wetness, either vaginally or through the drain s ite, or incis ion a nnounc ed t h e presence of ureteral injury in the 9 patients with fistul as . Not infrequently some loin discomfort was relieved with the decompress ing urin a ry lea k. Prolonged adyn a mic il eus, beyond that which would have been a nt ic ipated as a result of the primary procedure, was occasion a lly present. No pa tient s were frank ly sept ic although mild hyperpyrex ia. leukocytosis a nd positive u ri nary cul tu res were documented frequ ently . One patient presented with anuria. In all but >l cases definitiv e s urg ical m a nagement was in iti ated soon aft er establis hment of th e di agnosis. All patient s unde rwe nt excretory urography (IVP) in th e process of evaluat ion a nd a ll stud ies were a bnormal. Hydrouret eronephros is was present in 14 patien ts and non -visualization occurred 6 times. In those patien ts with fis tulous co mmunicat ions to the vag ina. pooling of co nt rast medium in the vag in a was ident ifi ed frequently a nd t h e fistul a cou ld he visuali zed ra re!\' with this study. Retrograde pyelogra ph \· was performed in all cases . A uret era l cat heter s uccess full~, n egot iated th e in jured segment in 1 of t h e lO patient s with obstruction a nd 1 of the 9 p a ti ents with fist ulas. Of th ese pat ients 1 re4uired additional treatment to resolve t he injury .
531
EARLY, AGGRESSIVE MA:-,;AGEME:-,;T OF INTRAOPERATIVE URETERAL INJURIES TAl-lLE I.
Priman· operation No. Cases
Gynecolop,ic pr
Vol. 114. Oct o ber
Prin ted in US.A.
EARLY, AGGRESSIVE MA:'JAGEME:'JT OF INTRAOPERATIVE URETERAL INJ URIES WILLIAM H. HO CH,* ELROY D. KURSH
AND
LESTER PERSKY
From the Division of Urology, Department of Surgery, University Hospitals of Cleveland, Cleveland, Ohio
ABSTRACT
M ost urologic surgeons prefer prox imal urin a ry divers ion as a n initia l step in the repair of intraoperative ureteral injuries but a n early direct attack on the injured area is being attempted more often. Our report concerns 36 ureteral injuries in 24 patients during the last 5 years . In 19 pa tients 20 injuri es were recogn ized and managed during post.operative convalescence. Repair cons isted of uret eron eocystoto my in 8 patien ts, ureteroureterostomy in 6 a nd ureteral deligat ion in 4. Ureteral cath et er manipulat ion alone was successful in 2 cases . Satisfactory ureteral repa ir was achieved in 2:3 patients . Definitive m a nagement was in itiated upon d iagnosis in all but 1 patient. We recommend an early. direct . aggressive approach to the injured area whenever possible. With th e increased number of o_perations performed yea rly there h as been a n assoc iated increase in the number of intraop erat ive uret eral inj uries. Thes e injuries m ay a nd have occ urred during an y procedure in which dissection brings the ureter into the operative fi eld and a variety of techniques exists for their correction. Most urologic s urgeons prefer proximal urinary diversion as an init ial step in ureter al repair.'· 2 H owever. in recent years, a n earl y, direct attac k on th e injured area is being attempted more frequentl y. 3 Cont roversy exists as to the optimal approach.
procedures incl uded exc1s1on of ovarian tumor, cesarea n sect io n . va ginal procedure, s uprapubic urethropexy an d prolapse repa ir. Th e gen e ra l s urgical cases resulting in uret cra l injur:, involved aortic surgery, s igmoid colon s urgery. posterior pelvic exent eration , lys is of a dh esions, excision of retroperitonea l m ass and appendect omy. Twentytwo patient s had unilateral and 2 had bilateral
MATERIALS AND METHODS
Twent y-s ix intraoperati ve ureteral injuries were managed in 24 p a tients durin g the last 5 yea rs . These patients ranged in age from 18 to 64 yea rs old and a ll b ut 5 were women . During t h e co urse of the primary operations 6 injuries in 5 pa tients were recognized a nd repaired. In the remaining 19 patients ureteral dam age became clinically ap parent only in the postoperati ve period. In these patients. with 4 exceptions, d efiniti ve repair was initiated within 3 ' " weeks of injur:--·. D elay in 3 cases was owing to fa ilure of d iagnosis a nd in t he oth er case to t h e decision to a llow th e int ense inflammatory response p resen t initi a lly to resolve. Gynecologic procedures contribut ed t o the majority of ureteral injuries but 7 injuries were the result of general surgica l procedures (table I l. Ureteral d amage occurred dur ing the course of t ran sa bdo minal hysterecto m y in 11 cases. Other Accepted for publication M ay :m. 197:1. Read at a nnual meet ing of West ern Section. America n Urological Assoc iation, Port la nd , Oregon . April J:l-- 1, . 1975. *Current address: David Grant Unit ed States Air Force M ed ical Cent er. T ravis Air Force Rase. Californ ia 94535 . 530
111JUfl eS .
In th e 10 pat ien ts with obstruc t ed ureters not iced in t h e postoperative period pa in a nd fever were th e predomin a tin g sy mptoms , while wetness, either vaginally or through the drain s ite, or incis ion a nnounc ed t h e presence of ureteral injury in the 9 patients with fistul as . Not infrequently some loin discomfort was relieved with the decompress ing urin a ry lea k. Prolonged adyn a mic il eus, beyond that which would have been a nt ic ipated as a result of the primary procedure, was occasion a lly present. No pa tient s were frank ly sept ic although mild hyperpyrex ia. leukocytosis a nd positive u ri nary cul tu res were documented frequ ently . One patient presented with anuria. In all but >l cases definitiv e s urg ical m a nagement was in iti ated soon aft er establis hment of th e di agnosis. All patient s unde rwe nt excretory urography (IVP) in th e process of evaluat ion a nd a ll stud ies were a bnormal. Hydrouret eronephros is was present in 14 patien ts and non -visualization occurred 6 times. In those patien ts with fis tulous co mmunicat ions to the vag ina. pooling of co nt rast medium in the vag in a was ident ifi ed frequently a nd t h e fistul a cou ld he visuali zed ra re!\' with this study. Retrograde pyelogra ph \· was performed in all cases . A uret era l cat heter s uccess full~, n egot iated th e in jured segment in 1 of t h e lO patient s with obstruction a nd 1 of the 9 p a ti ents with fist ulas. Of th ese pat ients 1 re4uired additional treatment to resolve t he injury .
531
EARLY, AGGRESSIVE MA:-,;AGEME:-,;T OF INTRAOPERATIVE URETERAL INJURIES TAl-lLE I.
Priman· operation No. Cases
Gynecolop,ic pr
