URETERAL
AVULSION AS A COMPLICATION OF URETEROSCOPY
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J.M. ALAPONT, E. BROSETA, F. OLIVER, J.L. PONTONES, F. BORONAT, J.F. JIMÉNEZ-CRUZ
Department of Urology, La Fe University Hospital, Valencia, Spain
ABSTRACT
Purpose:
Report and review the literature on ureteral avulsion as a rare complication
of ureteroscopy.
Materials and Methods: We analyzed 3 cases
of ureteral avulsion in a series of 4,645 ureteroscopic procedures performed
from January 1990 to December 2001. We especially report the different
managements for this complication.
Results: Due to the different extent of
the injury, each patient was treated in a particular way, including a
patient managed by means of an endourological approach.
Conclusions: When performing ureteroscopy
or using Dormia baskets, one should always bear in mind the possibility
of serious complications, including ureteral avulsion or perforation.
The use of an extremely careful technique of ureteral insertion, the mandatory
placement of a safety guidewire, and a working guidewire, all minimize
the risk of untoward events.
Key words:
ureter; ureteroscopy; lithiasis; intraoperative complications
Int Braz J Urol. 2003; 29: 18-23
INTRODUCTION
Since
its clinical introduction in 1980 by Pérez-Castro & Martínez-Piñeiro
(1), ureteroscopy has experienced an impressive development due to the
technical improvements of new and smaller urological armamentarium. Currently,
ureteroscopy is a worldwide procedure with varied number of diagnostic
and therapeutic possibilities, including treatment of stones, upper urinary
tract tumors, strictures, calyceal diverticula, vascular malformations,
placement of difficult ureteral stents, and diagnosis of filling defects
or hematuria of unknown origin.
However, the technique has complications
including bleeding, ureteral perforation, false passage, urinoma, strictures
and, in a few cases, ureteral avulsion. We report our experience in the
management of ureteral avulsion after ureteroscopy, and we review the
few cases published in the literature.
MATERIALS AND METHODS
Between January 1990 and December 2001 a total of 4,645 transurethral ureteroscopic procedures were performed in our Unit of Endourology. Among those patients 2,508 (53.9%) procedures were performed under a mild sedative regimen and in outpatient basis. The remainder 2,137 (46.1%) cases were referred for general anesthesia. Ureteral avulsion occurred in 3 cases as intraoperative complication, and this is the subject of our analysis.
RESULTS
Case 1
A 68-year-old man was admitted to the hospital
with the main complaint of repetitive left flank pain. The intravenous
pyelography (IVP) revealed a calculus measuring 5x11 mm located in the
upper third of the left ureter, and a concomitant upper pole renal cyst.
After percutaneous cyst puncture, the patient underwent four sessions
of extracorporeal shock wave lithotripsy (ESWL) with a Dornier® DL-50
lithotripter that significantly reduced the bulk of the stone but failed
to clear the fragments. After a three-week period of watchful waiting,
the patient was scheduled for ureteroscopy with a Storz 11.5F rigid ureteroscope
and laser lithotripsy (Candela® MDL-1 lasertripter). The ureteroscopy
was performed under general anesthesia, but the area of stone impaction
could not be negotiated because of severe ureteral kinking. Due to the
age of the patient, and the long time elapsed from the first procedure,
a blind basketing was accepted as a desperate ultimate option to solve
the problem in endourological terms. Therefore, a Dormia basket was inserted
and after a few withdrawal attempts the stone was eventually dislodged
and gently pulled down. However, as the stone was delivered out to the
ureteral orifice, a 7 cm of ureter followed, indicating an ureteral avulsion.
It seems likely that the ureter was ruptured at the site of the stone
impaction. As a first maneuver and under fluoroscopic guidance, a Teflon
guidewire was passed up to the theoretical location of the left renal
pelvis. Persistent fever and pain were observed in the following hours,
and a computed tomography (CT) scan and an IVP showed both urinary extravasation
and a double pigtail stent outside the upper urinary tract. After stabilization
with percutaneous nephrostomy and drainage of the urinoma, the patient
underwent an ureteroneocistostomy with short mucosal tunnel and Boari
flap technique, in order to allow the medial third of the ureter to reach
the bladder without any tension. The radiological sequence is shown in
Figure-1. Convalescence was uneventful, and an IVP one year after the
procedure showed a normal aspect of the collecting system with excellent
renal function.
Case 2
A 64-year-old man presented with a history
of continuous right flank pain. An IVP revealed a stone located in the
middle third of the right ureter and severe upper urinary tract obstruction
with renal function impairment. After 2 failed attempts to place a double
pigtail stent, and 2 ESWL procedures without clearance of the stone, the
patient was scheduled for ureteroscopy (11.5F) with in situ laser lithotripsy
and double pigtail stent placement. After 4,500 pulses of pulsed dye laser
(Candela® MDL-1 lasertripter) the stone was not broken, and as direct
vision of the impacted stone was possible, a Dormia basket was negotiated
behind the calculus and used to retrieve the relatively small stone as
gently as possible. The basket was gently pulled down but, as in the aforementioned
case, the ureter was avulsed in a length of 5 cm. Due to the previous
poor condition of the renal unit, an immediate right nephrectomy was performed.
Recovery was satisfactory and serum creatinine remained within the normal
range.
Case 3
A 56-year-old woman was referred to our
Unit of Endourology from another hospital due to a failure to treat a
right middle ureteral stone after 2 sessions of ESWL. The patient underwent
a right ureteroscopy under general anesthesia, and a glide guidewire was
advanced up to the collecting system. Afterwards the stone was inadvertently
pushed up to the renal pelvis by the irrigating fluid, and an immediate
ESWL was consequently decided. The ureteroscope was gently pulled out
to the bladder, but a 4 cm ureteral degloving injury was observed after
that maneuver. Because of the limited extent of the ureteral avulsion
and the presence of a 3.5 inch safety guidewire, the intussuscepted ureter
was advanced again to its original position over a 7F double pigtail stent.
Following fluoroscopic and sonographic control the catheter was left in
place and only a minimal asymptomatic paravesical urinoma was detected.
A month later the pushed-up calculus was successfully treated by ESWL.
Eight weeks later the double pigtail stent was removed and a subsequent
IVP demonstrated minimal delayed pelviocalyceal filling with mild dilation
from the upper third of right ureter. The patient remained asymptomatic
and was scheduled for ureteroscopy to assess the extent and degree of
the residual stricture and further balloon dilation, if required. However,
after a three-month follow-up the patient had multiple urinary tract infections,
with lack of function of the renal unit and, therefore, a nephrectomy
was performed.
DISCUSSION
In
the last decade ureteroscopy has become an outstanding breakthrough in
the diagnosis and treatment of different ureteral and renal problems.
Today it is increasingly used in the management of the common ureteral
stones, and such frequent indication has led ureteroscopy to be a worldwide
technique, with the expected appearance of multiple types of complications
(9-20%), some of them severe, including ureteral perforation or avulsion,
bleeding, and urinary tract infection (2,3).
Traditionally, the term 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 (4).
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. The first cases were
reported by Hart (5) in 1967, and Hodge (6) in 1973, both after difficult
manipulation of an ureteral stone with Dormia basket.
Although an infrequent event in the endoscopic
management of ureteral calculi (0.2-1%) (7,8), with only few cases reported
in the literature, ureteral avulsion is a potential serious complication
that should always be taken into account when performing such procedures.
The incidence in our series was only 0.11%.
Among the potential factors involved in
the pathogenesis of ureteral avulsion, the presence of an anomalous ureter,
either due to a diseased area or to previous endourologic manipulations,
is an important antecedent in the majority of cases. Furthermore, the
use of multiple-wire baskets for ureteral stones retrieval have also been
implicated, and particularly with regard to the size of the stone (larger
than 1 cm), and the distance the stone has to cross before exiting through
the ureteral meatus (9). Dormia basketing is hardly used in our Unit due
to the aforementioned problems. We much prefer the use of grasping forceps
to retrieve any fragment after ureteroscopy and laser lithotripsy. Rigid
ureterorenoscopes are also a potential source of ureteral avulsion, as
shown in the 2 cases reported by Martin et al. (10), and in 1 patient
of our own series. In the latter cases the ureteral damage was probably
due to the association of a diseased ureter and an improper handling of
the endoscopic instrument that eventually caused the degloving injury.
During the endoscopic procedure it is very difficult to evaluate, in case
of ureteral avulsion, the degree of tissular injury and the extent of
layer involvement. In one third of our cases, the theory of an unique
mucosal injury seems a sensible hypothesis, because it was very easy to
advance the 4 cm intussuscepted flap to its original position through
the safety guidewire previously placed before the attempt of ureteroscope.
Whether it was really just a mucosal breakage or a deeper laceration is
impossible to ascertain, although the eventual loss of the renal unit
would confirm the theory of ureteral avulsion. All injuries occurred during
the initial phase of our learning curve. However, with increasing experience
we are able to go further in some challenging procedures or difficult
cases, and therefore the possibility of ureteral injuries remains a constant
threat, including ureteral avulsions, although with the small caliber
of our current endoscopes such event seems less probable. Therefore, in
the prophylaxis of ureteral avulsion concur especially the endoscopic
skill of the urologist, and the adherence to some basic rules, such as
using a small ureteroscope, or avoiding Dormia basket retrieval of the
stone in cases of large calculus, or partial view of the area where the
calculus is impacted.
Diagnosis of ureteral avulsion is most often
carried out immediately during the endoscopic procedure, after the recognition
of a tubular structure firmly engaged to the ureteroscope following the
extraction maneuvers, as it was observed in our 3 patients. However, in
some cases a delayed diagnosis is performed in the presence of fever,
flank pain, abdominal tenderness, or a flank mass, indicating a retroperitoneal
urinoma or abscess secondary to urine leakage (10). Such clinical diagnosis
should always be confirmed by ultrasonography, CT scan, IVP, or retrograde
pyelography.
Traditionally the treatment of the ureteral
avulsion has been a surgical approach, for which the basic aim is to restore
the ureteral continuity. Nevertheless, clear guidelines about the best
surgical technique are still an unresolved issue. There are some factors
that should be taken into account, such as age of the patient, kidney
function, level of injury, and length of the ureteral defect. In lower
third ureteral lesions, a ureteral reimplantation seems the most rewarding
surgical technique, but severe ureteral injuries associated with higher
localization or loss of a long segment require several methods of repair,
including Boari flap, psoas hitch, transureteroureterostomy, autotransplantation,
or ileal or appendix interposition. The use of a psoas hitch, a Boari
flap or a combination of both seems to be the most sensible option, albeit
restricted to injuries at or below the pelvic brim. However, Chang &
Koch (11) described a modification of the traditional bladder flap procedure
or extended spiral bladder flap for a successful treatment of two patients
with upper ureteral injuries. In case of complete avulsion of the ureter
at the ureteropelvic junction, a dismembered pyeloplasty is the preferred
option. In case of severe tissue loss, autotransplantation, especially
in young patients, or ileal interposition, will yield a satisfactory result
(10,12). Moreover, an alternative method of successful repair of extensive
injuries with appendix interposition was reported in three cases where
the conventional techniques were precluded (13-15). In our series, the
diverse circumstances of patients and injuries, caused that each case
was treated in a different way, including an endourologic approach where
the intussuscepted ureter was advanced again to its original position
and fixed over a 7F double pigtail stent introduced onto a safety guidewire
previously placed up to the kidney as a first step in ureteroscopy.
Our experience, and that of others, all
suggest that carefully performed ureteroscopy is a superb tool for the
urologist, either for diagnostic or therapeutic purposes. However, when
performing an ureteroscopy or using Dormia baskets, one should always
bear in mind the possibility of serious complications, including ureteral
avulsion or perforation. As in many other procedures, a learning curve
phenomenon is observed, so we recommend the use of an extremely careful
technique of ureteral insertion, and the mandatory placement of a safety
guidewire and a working guidewire, to minimize the risks of untoward events.
REFERENCES
- Pérez-Castro E, Martínez Piñeiro JA: Ureteral and renal endoscopy. A new approach. Eur Urol. 1982; 8:117-20.
- Schultz A, Kristensen JK, Bilde T, Eldrup J: Ureteroscopy: results and complications. J Urol. 1987; 137:865-6.
- Blute ML, Segura JW, Patterson DE: Ureteroscopy. J Urol. 1988; 139:510-2.
- Palmer JM, Drago JR: Ureteral avulsion from non-penetrating trauma. J Urol. 1981; 125:108-11.
- Hart JB: Avulsion of the distal ureter with Dormia basket. J Urol. 1967; 97:62-3.
- Hodge J: Avulsion of a long segment of ureter with Dormia basket. Br J Urol. 1973; 45:328.
- Puppo P, Ricciotti G, Bozzo W, Introini C: Primary endoscopic treatment of ureteric calculi. Eur Urol. 1999; 36:48-52.
- Oktay B, Yavasçaoglu I, Simsek Ü, Özyurt M: Intracorporeal pneumatic lithotripsy for ureteral and vesical calculi. Scand J Urol Nephrol. 1997; 31:333-6.
- Abdelsayed M, Onal E, Wax SH: Avulsion of the ureter caused by stone basket manipulation. J Urol. 1977; 118:868-70.
- Martin X, Ndoye A, Konan PG, Feitosa Tajra LC, Gelet A, Dawara M, et al.: Hazards of lumbar ureteroscopy: apropos of 4 cases of avulsion of the ureter. Prog Urol. 1998; 8:358-62.
- Chang SS, Koch MO: The use of an extended spiral bladder flap for treatment of upper ureteral loss. J Urol. 1996; 156:1981-3.
- Shokeir AA: Interposition of ileum in the ureter: a clinical study with long-term follow-up. Br J Urol. 1997; 79:324-7.
- Juma S, Nickel JC: Appendix interposition of the ureter. J Urol. 1990; 144:130-1.
- Die Goyanes A, García Villanueva A, Lavalle Echevarría JA, Cabañas Navarro L: Replacement of the left ureter by autograft of the vermiform appendix. Br J Surg. 1983; 70:442-3.
- Lloyd SN, Kennedy C: Autotransplantation of the vermiform appendix following ureteroscopic damage to the right ureter. Br J Urol. 1989; 63:216-7.
_______________________
Received: October 10, 2002
Accepted after revision: January 24, 2003
_______________________
Correspondence address:
Dr. José Miguel Alapont
Service of Urology, La Fe University Hospital
Avda. Campanar 21, 46009
Valencia, Spain
Fax: + 96 386-2600
E-mail: jmalapont@mundofree.com
EDITORIAL COMMENT
The
authors report 3 cases of “ureteral avulsion” following ureteroscopic
management, occurring during a ten-year period from 1990-2000. The 3 cases
occurred in a series of 4,645 ureteroscopic procedures, representing a
rate of 0.11%.
Ureteral avulsion is a rare but well known
complication of ureteroscopy, almost always related to the use of an ureteroscope
too large to be readily accommodated by the ureter or, in most cases,
by an attempt to pull an inadequately fragmented or impacted stone down
from the proximal or mid ureter. All of these known risks were evident
in the 3 cases reported here. In case one, a 12.5F rigid ureteroscope
was used, which is no longer a contemporary instrument. In case 2, the
size of the ureteroscope was 11.5F. As the author state, the stone was
not fragmented, and an attempt was made to pull the impacted stone down
intact with a basket from the middle third ureter, which is contraindicated.
In case 3, there was a “degloving” injury, which is not a ureteral
avulsion. Rather, this is simply an intussusception of ureteral mucosa,
which can often be managed with a stent, as the authors did here.
Ureteral avulsion is a rare injury, the
risks for which are well described and reiterated in this paper. The best
treatment of ureteral avulsion as a complication of ureteroscopy is prevention,
not reconstruction, and all of the contraindications to stone management
that may lead to that injury are clear in the cases reported here.
Dr. Stevan B. Streem
Head, Section of Stone Disease and Endourology
The Cleveland Clinic Foundation
Cleveland, Ohio, USA