Complete ureteral avulsion

Reconstruction of full-length ureter defects by laparoscopic bladder flap forming

To evaluate the safety and efficacy of laparoscopic bladder muscle flap reconstruction in the treatment of extensive ureteral avulsion. Patients with full-length (re length > 20 cm) and upper ureteral (avulsion length > 10 cm) defects were eligible. All patients were treated with laparoscopic bladder muscle flap reconstruction. Peri-operative information and post-operative complications were recorded. The kidney function, urinary ultrasound or computed tomography (CT), sun-renal function tests emission computed tomography (ECT) and cystography after operation were recorded. Ten patients were included (7 with full-length and 3 with upper ureteral defects). Median age was 56 years and 70% of them were female. The average operation time and blood loss was 124 min and 92.2 ml. There was no treatment-related adverse effects including urinary leakage, renal colic, fever, etc. The median follow-up was 18.5 months (3–39 months). The surgery did not significantly alter the renal function and separation degree of the renal pelvis during long-term follow-up. Double J stents were removed in nine patients (90%) within six months after operation. Only one case was diagnosed with post-operative anastomotic stricture, and subsequently received laparoscopic ipsilateral nephrectomy one year after the reconstruction operation. All cases had normal voiding and pear-shaped cystography. Laparoscopic bladder flap repair is a safe and effective treatment approach together with several advantages for patients with full-length or upper ureteral avulsion.

Case report series: management of complete ureteral avulsion with review of the relevant literature

Background

Endoscopic operations and ureteroscopy have become the first choice for ureteral calculi and ureter-related operations. The ratios of the complications, which are mostly iatrogenic, range between 9 and 11%. Total ureteral avulsion during URS is quite rare with a prevalence of 0–0.3%. We present three total ureteral avulsions we experienced in our clinic during the last 2 years and their treatment.

Case presentation

During the last 2 years, we experienced three total ureteral avulsions: one of these occurred in our clinic and the other two occurred in an external center and were referred to us. In two cases, the omental flap was rotated after ureteral reimplantation and the ureter was completely wrapped inside the omental flap. In the third case, boari flap was formed from the bladder. Due to the presence of extrarenal wide renal pelvis, anastomosis was made with boari flap after a y–v flap was rotated on the renal pelvis. D-J stents of the patients were removed at the end of 3 months. Although there was mild hydronephrosis, parenchymal thinning and a significant decrease in functions were not observed. Ureteral avulsion of the patients was successfully managed without the need for nephrectomy.

Conclusion

Ureteral avulsion management is an extremely difficult condition for both the surgeon and the patient. So, the most important thing is to prevent ureteral avulsion. Ureteroplasty and omental flap treatment are applicable methods with quite successful results for complete ureteral avulsions.

Management of ureteric avulsion during ureteroscopy: a systematic review and our experience

Background

Ureteric avulsion is a disastrous intraoperative complication that can happen to any urologist during a common endoscopic procedure like ureteroscopy. The aim of this study is to evaluate the various management options of ureteric avulsion during ureteroscopy and also report our relevant experience in this topic.

Results

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses of existing literature in English language was used in the period 1967–2019 with a literature search in PubMed, Cochrane Library and Google Scholar. Forty-three patients in twenty-three articles who had undergone management of ureteric avulsion during ureteroscopy were identified for review. There were 15 proximal, 19 two-point (“scabbard”) and 9 distal avulsions. All distal avulsions were managed successfully with ureteroneocystostomies or Boari flaps. Boari flaps and ureteropyelostomy with ureterovesicostomy were the common procedures used for proximal avulsions. Proximal avulsions had more varied outcomes with salvage rates of 86.9%. Procedures which incorporated the avulsed distal ureter for reconstruction had poor results.

Conclusion

Management of ureteric avulsion during ureteroscopy is a surgical challenge. While management of distal avulsions is straightforward in the form of ureteroneocystostomies and has uniformly good results in most hands, proximal avulsions need expertise in management and choosing ideal reconstruction, with variable results following reconstruction. Extended Boari flaps, ileal ureter and autotransplantation are good options for proximal avulsions. Reconstruction using the distal avascular ureter should be avoided for better long-term results.

Management of full-length complete ureteral avulsion

INTRODUCTION

Complete ureteral avulsion is one of the most serious complications of ureteroscopy. The aim of this report was to look for a good solution to full-length complete ureteral avulsion.

CASE PRESENTATION

A 40-year-old man underwent ureteroscopic management. Full-length complete avulsion of ureter occurred during ureteroscopy. Pyeloureterostomy plus greater omentum investment outside the avulsed ureter and ureterovesical anastomosis were performed 6 hours after ureteral avulsion. The patient was followed-up during 34 months. Double-J tube was removed at 3 months after operation. Twenty three months after the first operation, the patient developed hydronephrosis because of a new ureter upside stone, then rigid ureteroscopy and holmium laser lithotripsy were used successfully.

CONCLUSION

Pyeloureterostomy plus greater omentum investment outside the avulsed ureter and ureterovesical anastomosis may be a good choice for full-length complete ureteral avulsion.

Ureteral reconstruction with abdominal wall muscle flap: experimental study in rabbits

The authors detail the experimental development of a technique for the reconstruction of the ureter using a tubular shape, muscle flap of the abdominal wall. the preliminary results indicate the feasibility of this surgical technique.

Ureterorenoscopy with stenting and its effect on male sexual function: A controlled randomised prospective study

Seventy-two male patients, who were included in this study, underwent ureteroscopic stone surgery (study group). Forty-two healthy males were enrolled as control group. Changes in sexual function were evaluated using International Index of Erectile Function questionnaire in pre-operative, first and third postoperative terms. Overall satisfaction in relation to the age, operation time, presence of stents, body mass index, educational status, previous operations, International Index of Erectile Function score, International Prostate Symptom Score, Quality of Life, income status, Male Sexual Health Questionnaire, stone-free rates and Beck's depression scale were evaluated. Erectile and ejaculatory functions, quality of life and lower urinary tract symptoms were negatively affected due to ureteroscopic stone surgery, while educational status, psychogenic aspect and income status remained stable. In conclusion, ureteroscopic stone surgery with JJ catheterisation seems to have a progressively decreasing negative effect on male sexual function and whenever possible, stenting should be avoided. If JJ stenting is necessary, patients should be informed that they may experience sexual dysfunction at least for 3 months and if stenting proves necessary the indwelling should be kept as short as possible.

Possible complications of ureteroscopy in modern endourological era: two-point or "scabbard" avulsion

Indication has led ureteroscopy to be a worldwide technique, with the expected appearance of multiple types of complications. Severe complications are possible including ureteral perforation or avulsion. Ureteral avulsion has been described as an upper urinary tract injury related to the action of blunt trauma, especially from traffic accidents, being the mechanism of injury, the result of an acute deceleration/acceleration movement. With the advent of endourology, that term is also applied to the extensive degloving injury resulting from a mechanism of stretching of the ureter that eventually breaks at the most weakened site, or ureteral avulsion is referred to as a discontinuation of the full thickness of the ureter. The paper presents a case report and literature review of the two-point or "scabbard" avulsion. The loss of long segment of the upper ureter, when end-to-end anastomosis is not technically feasible, presents a challenge to the urological surgeon. In the era of small calibre ureteroscopes these complications, due to growing incidence of renal stones will become more and more actual. Our message to other urologists is to know such a complication, to know the ways of treatment, and to analyse ureteroscopic signs, when to stop or pay attention.

How to manage total avulsion of the ureter from both ends: our experience and literature review

OBJECTIVES

To evaluate the treatment alternatives of total avulsion of the ureter from both ends including ureteropelvic junction (UPJ) and ureterovesical junction (UVJ).

METHODS

Total ureteral avulsion on both ends of the ureter was examined in 4 cases performing ureteroscopy. In two male patients of the four cases, avulsion was noticed intraoperatively and ureteral re-anastomosis at UPJ and re-implantation at UVJ were performed immediately. Boari flap was performed for one female patient immediately and for the other female patient who was referred from another hospital after the ureteroscopy, 4 days later.

RESULTS

One patient who had ureteral re-implantation was followed with 3-month intervals by ultrasonography and abdominal X-ray. At the end of 1 year, it was determined that kidney parenchyma was normal and the patient had kidney and upper ureteral stones. Percutaneous nephrolithotomy was performed, and the patient was stone-free at the end of the operation. Two years after the surgery, both kidneys were normal. This is the only case who had a successful ureteral re-implantation in literature. The other patient turned up a year later for routine checks after the ureteral stent was removed. Then, hydronephrosis and renal atrophy were detected. The patient did not accept nephrectomy or any other intervention and he was lost to follow-up. Boari flap procedure was performed after UPJ repair for the other two female patients. Their kidneys were both normal 3 months after the operation.

CONCLUSIONS

In case of ureteral avulsion from both ends of the ureter in the male patients, as bladder capacity is not enough for a Boari flap, proximal anastomosis and distal re-implantation could be a good choice for the management of this untoward event. This new approach also saves time for reconstructive treatments if necessary. If bladder capacity is enough to reach UPJ, Boari flap could be a good choice in female patients.