Aftermath of Grade 3 Ureteral Injury from Passage of a Ureteral Access Sheath: Disaster or Deliverance? (original) (raw)
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Entrapped Ureteral Access Sheath: An Unusual Problem
The Journal of Tepecik Education and Research Hospital
Flexible ureteroscopy is well-known and performed procedure by urologists, yet instrument related complications may suprise even experienced surgeons. In this study, we present a unique instrument related complication during flexible ureteroscopy. A 68 year old male patient with 1.9 cm left upper ureteral stone presented to us. With semi-rigid ureteroscope laser lithotripsy performed. Stone got retropulsed into lower pole of the kidney. The procedure was converted to retrograde intrarenal surgery. Within Porges-Coloplast Retrace® Ureteral Access Sheath 12 Fr and 35 cm (UAS) with Karl Storz Flex-X2 fiber-optic ureteroscope (fURS) stone fragmentation completed. After removal of fURS from the patient, UAS got tried to pull away but it got stuck into the patient. Hanging part of the UAS below the external meatus cutoff and the internal spiral part withdrew. But it didn't come off. So pulling the residual piece of UAS from the orifice level tried with cystoscope and foreign body forceps. It didn't work out and sheath got split to two pieces from the orifice level. After that another enterance to the bladder had performed with cystoscope and left orifice had incised. 8 mg dexamethasone had administerated to the patient and lidocaine including lubricant gel got injected inside and around the UAS. It didn't come off. Decision made that ending the procedure after placing double-J stent, then after 3-4 weeks when the ureteral edema got regressed removal of the residual UAS. Four weeks later with cystoscope and foreing body forceps residual UAS got removed by two pieces. Ureteral edema can led entrapment UAS inside of the ureter. Most of the cases moderate traction and withdrawing the internal spiral part of UAS is enough to pull away. In cases that these solutions are insufficient, stenting and planning another endoscopic procedure after a few weeks may help avoiding unnecessary open surgery.
Turkish journal of trauma & emergency surgery, 2018
BACKGROUND: Ureteral access sheaths (UASs) are commonly used in retrograde intra-renal surgery (RIRS). Despite their advantages, there is a risk of ureteral trauma during their placement and subsequent stricture following surgery. The aim of this study was to evaluate the UAS force of insertion (FOI) during placement and its impact on ureteral trauma. METHODS: Seven female patients who underwent RIRS for kidney stones were included in the study. A digital force gauge (Chatillon DFX II; Ametek Test and Calibration Instruments, Largo, Florida, USA) was connected to the distal end of the UAS and the UAS FOI was continuously measured during insertion. UASs of different sizes were used and ureteral injury was evaluated under direct vision with the Post-Ureteroscopic Lesion Scale (PULS) score. RESULTS: Five pre-stented patients and 2 non-stented patients were included in the study. The size of the UASs used in non-stented patients was 9.5/11.5-F and 10/12-F, whereas one 11/13-F and four 12/14-F sheaths were used in the pre-stented patients. The highest maximal UAS FOI observed was 5.9 Newton (N) in a pre-stented patient with a 12/14-F UAS, where a second attempt was performed after initial failure. The lowest maximal UAS FOI was 0.91 N in a non-stented patient using a 9.5/11.5-F UAS. A semirigid ureteroscopy with a 7.8-F sheath was performed in this patient prior UAS placement. The PULS score was 1 in the 2 non-stented patients and 0 in all of the pre-stented patients. CONCLUSION: In this small cohort, a preoperative JJ stent seemed to protect the ureter, even with larger diameter UASs of 12/14-F. Non-stented RIRS with a UAS is possible, but may cause low-grade ureteral trauma.
Journal of laparoendoscopic & advanced surgical techniques. Part A, 2015
In the present study, intraoperative ureteral injuries inflicted during retrograde intrarenal surgery (RIRS) with ureteral access sheath (UAS) use were evaluated using the Post- Ureteroscopic Lesion Scale (PULS). Patients in whom a UAS was used during RIRS and for whom ureter images were video recorded during the procedure were included in the study. PULS grading was performed after UAS removal, and video sequences of all patients were viewed by a junior resident, a senior resident, and four experienced urologists and assessed according to the PULS. Ureteral lesions in distal, middle, proximal, and multiple locations were evaluated and compared according to the PULS scale. The inter-rater reliability of PULS grading among various urologists was also evaluated. The evaluation comprised 101 patients. In 77 patients, 9.5/11.5 French UAS devices were used, and in 24 patients, 12/14 French UAS devices were used. The stone-free rate, clinical insignificant residual fragments, and final st...
Treatment of impacted lower third ureteral stones with the use of the ureteral access sheath
Urological Research, 2006
We present our experience with the use of the ureteral access sheath for the management of small impacted lower third ureteral stones, in comparison with more standard techniques. Ninety-eight consecutive patients, aged 18-73 years (mean 48.5), with small (diameter < or =10 mm) impacted lower third ureteral stones (<5 mm in 56, and 5-10 mm in 42 patients) were randomly managed with either a 12/14F coaxial ureteral dilator/sheath and a 7.5F flexible ureteroscope (group A; 48 patients), or with balloon dilatation and the 7.5F flexible ureteroscope (group B; 50 patients). In both groups, stones were grasped and extracted with a basket, and when necessary they were disintegrated with a 1.9F electrohydraulic lithotripsy (EHL) probe. Postoperatively, excretory urography was performed at 1 month and patients were followed-up for 1 year. The mean operative time was 45.5 min in group A, and 58.5 min in group B (P<0.05). EHL was performed in 16 (33.3%) patients of group A, and in 12 (24%) patients of group B. In group B, balloon dilatation was performed in 28 (56%) patients. Ureteral perforation was revealed in 4 (8%) patients of group B. The follow-up imaging tests showed stone-free status in 46 (95.8%) patients of group A and in all (100%) patients of group B. No long-term complications were recorded. Endoscopic management of small impacted lower third ureteral stones with the ureteral access sheath is a quicker and safer procedure, in comparison with the more standard approach, bearing comparable efficacy.
International Urology and Nephrology, 2005
Objective: To investigate the changing pattern in incidence, aetiological factors and the effect of early diagnosis and surgical treatment on the outcome of iatrogenic ureteric injuries in our Urology Unit over a 5 year period. Patients/Methods: All patients with ureteric injuries caused as a result of any surgical procedures (iatrogenic ureteric injuries) were studied during a 5 year period (1998)(1999)(2000)(2001)(2002). Data collected and analysed included yearly incidence of injury, aetiological factors, modalities of treatment and the outcome of management of the injuries. During the study period, our general surgical colleagues had a policy of requesting ''J'' stent insertion prior to major abdominopelvic surgical procedures. During the same period, in nearly all difficult cases of ureteroscopy (URS) + lithoclast lithotripsy±Dormia basket, a ureteric catheter or ''J'' stent was prophylactically inserted by urological surgeons. Results: There were 82 iatrogenic ureteric injuries in 75 patients over the 5 year period. The total number of iatrogenic ureteric injuries declined from 26 (31.7%) in 1998 to 10 (11.8%) in 2002. Urological, obstetrics and gynaecological and general surgical procedures were involved in 69(84.1%), 7(8.7%), and 4(4.9%) of the injuries respectively. The commonest types of injuries encountered were; injury to ureteric mucosa post URS or lithoclast calculi disintegration 34 (41.5%), complete ureteric perforation 15 (18.3%) and false passage 15 (18.3%). The most severe complications encountered were complete ureteric avulsions 3 (3.75%) and loss of ureteral segment 2 (2.4%). The commonest treatment options used were ''J'' stent insertion or ureteric catheter placement (48, 59.4%), percutaneous nephrostomy (17, 20.7%), laparotomy and removal of suture on tied ureters (5, 6.1%). Two (2.4%) nephrectomies were performed because of poor renal function in one patient and severe damage to a functioning renal unit during a difficult retroperitoneal surgery in another patient. Recognition and treatment of ureteric injuries at the time of surgery was associated with less morbidity compared to those in whom the diagnosis was delayed. The overall successful resolution of ureteric injuries in this series was 77/82 (93.9%). There was no mortality attributable to these ureteric injuries. Conclusion: In our Unit, the incidence of significant iatrogenic ureteric injuries has shown a decline over a 5-year period. We attribute this trend to the prophylactic use of ''J'' stents or ureteric catheter placement and good surgical technique during major abdomino-pelvic surgeries in our hospital. Endourological procedures are the commonest causes of ureteric injuries. Prompt diagnosis and institution of appropriate corrective surgical procedures often result in a very satisfactory outcome in about 94% of cases.
Immediate and late management of iatrogenic ureteric injuries: 28years of experience
Arab Journal of Urology, 2015
Objective: To evaluate the long-term results after managing intraoperative and late-diagnosed cases of iatrogenic ureteric injury (IUI), treated endoscopically or by open surgery. Patients and methods: Patients immediately diagnosed with IUI were managed under the same anaesthetic, while those referred late had a radiological assessment of the site of injury, and endoscopic management. Open surgical procedures were used only for the failed cases with previous diversion. Results: In all, 98 patients who were followed had IUI after gynaecological, abdominopelvic and ureteroscopic procedures in 60.2%, 14.3% and 25.5%, respectively. The 27 patients diagnosed during surgery were managed immediately, while in the late-referred 71 patients ureteroscopic ureteric realignment with stenting was successful in 26 (36.6%). Complex open reconstruction with re-implantation or ureteric substitution, using bladder-tube or intestinal-loop procedures, was used in 27 (60%), 16 (35.5%) and two (4.5%) patients of the late group, respectively. A long-term radiological follow-up with a mean (range) of 46.6 (24.5-144) months showed recurrent obstruction in 16 (16.3%) patients managed endoscopically and reflux in six (8.3%) patients. Three renal units only (3%) were lost in the late-presenting patients. Conclusion: Patients managed immediately had better long-term results. More than a third of the late-diagnosed patients were successfully managed endoscopically
We aimed to compare different treatment approaches in patients with failed ureteral access sheath placement during first flexible ureterorenoscopy (f-URS) session. Patients with kidney stones measuring 1-2 cm, presented to our urology clinic between April 2019 and April 2021, were included in the study for evaluation. Patients were randomized into two groups, in case of a failed ureteral access sheath placement during the first f-URS session. In group 1, ureteral JJ stent was placed for dilation and second session of f-URS was planned 4-6 weeks later. In group 2, mini percutaneous nephrolithotomy (mPNL) was performed in the same session. Pre-operative demographic data, operative and post-operative characteristics including complications and success rates were compared. Patients were assessed by Short-Form-36 (SF-36) questionnaires to compare overall life quality after each procedure. Twenty-four patients were included in each group. Pre-operative demographic data and stone character...
Complications of Ureteroscopic Approaches, Including Incisions
Current Clinical Urology, 2006
Ureteroscopy has progressed from cystoscopic examination of a dilated ureter in a child in 1929 and the initial use of rigid ureteroscopes in the 1980s, to its current state of small caliber semirigid and flexible instruments. In this chapter the authors review complications of ureteroscopy including those associated with incisional techniques where one would anticipate a higher incidence of complications. They review the history and development of modern ureteroscopes, focusing on engineering advances. Clinical points made include proper patient selection and preparation; proper use of dilators, wires, and ureteral access sheaths; and the incidence, identification, and management of complications associated with ureterorenoscopy (both intraopertively and postoperatively).
Retrospective view and treatment of iatrogenic ureteral injuries
Annals of Medical Research, 2020
Aim: Ureteral injuries are rare. Iatrogenic ureteral injury is the most common cause of ureteral traumas. This letter aims, evaluation of iatrogenic ureteral traumas and treatments. Material and Methods: Thirty two patients with major iatrogenic ureteral trauma were enrolled. Sonography, intravenous pyelography, CT of abdomen (contrast-enhanced and non-contrast enhanced), antegrade X-rays or diagnostic ureterenoscopy are used for the diagnosis. All patients were undergone endoscopic ureterenoscopy before the ureter was surgically repaired. Next, the surgical technique was decided. Injuries that can be managed with endoscopic approach were treated by inserting a Double J stent. For patients who were not eligible for endoscopic treatment, treatment was decided according to the location of ureteral injury. Results: Of the patients, 25 were female and 7 were male and mean age was 46.31±16.485 years. Ureteral injury was secondary to gynecologic intervention in 16 patients, general surgery procedures in 6 patients and urologic surgery in 10 patients. According to AAST, Grade 4-5 injury was identified in 71.9% of 32 patients, while Grade 3 and Grade 2 injuries were noted in 15.6% and 12.5% of patients, respectively. Four patients were treated in late period, while intraoperative or early treatment was instituted for 28 patients. Conclusion: Iatrogenic ureteral injuries develop mostly after laparoscopic or endoscopic pelvic surgeries. We should prefer endoscopic insertion of Double J stent for the first-line treatment.