SIU 2024: (CO-01) Total Ureteric Avulsion in URS – Why and How to Manage
Speaker: Dr. Tanuj Bhatia, India
Important Takeaways
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Risk factors of ureteric avulsion include previous infections, rigid instrumentation, large access sheaths, and the improper use of extraction baskets.
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Key signs of avulsion are excessive resistance, a “give-way” sensation, and pale or folded mucosa indicating compromised blood flow.
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Prevention involves avoiding excessive force, fragmenting stones adequately, and considering staged procedures with stenting if resistance is encountered.
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Immediate management includes staying calm, calling for help, draining the kidney via percutaneous nephrostomy, and thoroughly evaluating the injury.
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Delayed repair (2-3 days) allows for better planning, tissue assessment, informed consent, and multidisciplinary involvement if necessary.
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Definitive surgical options vary based on injury location and may include uretero-neo cystostomy, ileal ureter interposition, or auto transplantation.
Key Highlights
Dr. Bhatia introduced the topic, Ureteric avulsion, which is an uncommon yet severe complication during ureteroscopy, involving the partial or complete tearing away of the ureter from its surrounding structures. It most commonly affects the proximal ureter, where the wall structure is thinner and more susceptible to damage. Although infrequent, avulsion can lead to significant morbidity and is challenging to manage, requiring immediate and careful attention to prevent long-term complications.
Risk Factors for Avulsion:
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Proximal ureteric location: The upper ureter has thinner muscular layers and a weaker structural composition, making it more vulnerable.
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Previous ureteric conditions: Recurrent infections, inflammation, and prior instrumentation can weaken the ureter, increasing avulsion risk.
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Surgical factors: Use of excessive force with rigid instruments, handling larger or impacted stones without adequate fragmentation, and using large access sheaths or dilators are primary contributors.
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Use of extraction baskets: When not used carefully, baskets increase the risk by trapping stones too large for safe retrieval, causing undue tension on the ureter.
Recognition of Ureteric Avulsion:
Dr. Bhatia emphasised the importance of tactile and visual cues during ureteroscopy. Avulsion typically presents as excessive resistance during advancement or withdrawal of the instrument, often accompanied by a “give-way” sensation. White or pale mucosa visible in the ureter suggests compromised blood flow, and unusually tight or folded lumen during instrument manipulation signals impending avulsion.
Prevention Strategies:
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Avoid excessive force during instrument manipulation.
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Stage complex cases when significant resistance or difficult anatomy is encountered.
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Limit the size of stone fragments before retrieval, ideally keeping fragments smaller than the ureteral lumen.
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Maintain a low threshold for halting the procedure and considering staged treatment with stenting.
Immediate Management of Ureteric Avulsion:
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Stay Calm and Avoid Panic: Remaining composed allows for effective assessment and execution of the next steps.
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Call for Assistance: Engaging experienced colleagues or specialists can aid in managing the situation.
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Evaluate the Extent of Injury: Determine if the avulsion involves a complete tear or partial injury to the ureteral wall. Immediate drainage of the kidney is essential, typically via percutaneous nephrostomy, to prevent hydronephrosis and infection.
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Counselling the Patient and Family: As Dr. Bhatia noted from personal experience, this includes explaining the rare but serious nature of the complication and discussing potential follow-up interventions.
Definitive Surgical Management Options:
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Lower Ureteric Avulsion: Managed by uretero-neocystostomy, reimplanting the ureter into the bladder.
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Upper and Middle Ureteric Avulsion: Often require more extensive repair, including autotransplantation, ileal ureter interposition, or boari flap, depending on the patient’s anatomy and the surgeon’s expertise.
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Delayed vs. Immediate Repair:
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Immediate repair may seem attractive, but it lacks optimal assessment of the injury’s full extent and may increase risk due to devascularization and lack of consent.
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Delayed repair (2-3 days post-injury) allows for better planning, full informed consent, adequate bowel preparation if using an ileal segment, and patient stabilisation.
Case Example:
Dr. Bhatia described a case where a total avulsion led him to perform an ileal ureter interposition. He opted to drain the kidney with a percutaneous nephrostomy first, allowing time for patient counselling and detailed planning before definitive repair. The surgery involved mobilising an ileal segment, anastomosing it to the ureter proximally, and connecting it distally to the bladder. After eight weeks, the stent was removed, and imaging at six months showed good drainage without complications.
Outcome and Recommendations:
Regular follow-up with imaging is essential to monitor for stricture or other long-term complications. In Dr. Bhatia’s case, the patient maintained good renal function and drainage at follow-ups one year later.
Key recommendations include being vigilant for tactile warning signs, favouring staged procedures when in doubt, and maintaining a multidisciplinary approach for complex cases.
Conclusion:
Ureteric avulsion, while rare, demands a well-coordinated response involving immediate decompression, potential transfer to a higher-level facility, and a deliberate approach to definitive repair. Delaying complex reconstructive surgery allows for better preparation and mitigates risks associated with immediate intervention, thereby enhancing long-term outcomes.
Société Internationale d'Urologie Congress, 23-26 October 2024, New Delhi, India.
