Intraoperative Urology Consultation

Hadley Wood

Kenneth Angermeier

Perioperative Considerations

The distal third of the ureter, and more commonly the left-sided ureter, is most likely to be injured.
Risk factors for injury: large pelvic masses, radiation, chemotherapy, previous pelvic surgery, and inflammatory processes such as diverticulitis or inflammatory bowel disease (IBD).
Overall, cystotomy (35%) is the most common iatrogenic genitourinary injury in a colorectal procedure, followed by incomplete ureteral transection (29%), complete proximal and distal ureteral injuries (17% and 15%, respectively), urethral injury (3%), and injury to a preexisting ileal conduit (1%).

Delayed Presentation

Delayed presentation is associated with significant morbidity and mortality (Fig. 35-1).

FIGURE 35-1 ▪ Morbidity and mortality associated with undiagnosed and recognized ureteral injury, thus emphasizing the importance of detection and early repair. (Blackwell RH. Kirshenbaum EJ, Shah AS, Kuo PC, Gupta GN, Turk TMT. Complications of recognized and unrecognized iatrogenic ureteral injury at time of hysterectomy: a population based analysis. J Urol. 2018;199(6):1540-1545.)

Approximately two-thirds of all ureteral injuries go undetected at the time of initial injury.
Postoperative presentations of ureteral injuries include sepsis, urinoma formation, abscess, obstructive uropathy, renal insufficiency, ileus, peritonitis, and death.
Fistulization is most likely to involve vagina, sigmoid colon, or cecum.
Significant morbidity associated with undetected injuries.
- Higher hospital total charges, longer length of hospital stay and greater incidences of anastomotic leak, renal failure, and wound complications (Fig. 35-1).
Ureteral injuries/fistulae often coexist with bladder injuries, and therefore, upper tracts must be evaluated for all bladder injuries with magnetic resonance urography (MRU), computed tomography urography (CTU), or retrograde pyelograms to rule in or rule out concomitant ureteral involvement.
Large proportion of ureteral injuries are missed as these could be partial injuries, ureteral contusion, devascularization, or thermal trauma and could manifest in delayed manner.

Safeguards

Ureteral catheters
Lighted ureteral catheters
Intraoperative cystoscopy
Intraureteral indocyanine green (ICG)

Ureteral Catheters

Most common form of primary prevention performed prior to colorectal surgery used chiefly in low anterior resections (LARs), abdominoperineal resections (APRs), prior history of radiation, and previous abdominal surgery.
Employed in ˜4%-5% of all colorectal surgeries (increased incidence from 1.1% in 2004 to almost 4.4% in 2011).
Time factors: 11.3 minutes of added operative duration.
Current dogma: while prophylactic catheters do not prevent injury, they do result in intraoperative recognition of injury and facilitate in immediate repair at the time of primary surgery.
- Emerging literature suggesting benefit to ureteral catheters, however, no randomized control trials to date.
Side effects: hematuria, urinary tract injury (UTI), rare: ureteral perforation, edema, and reflux pain

Lighted Ureteral Catheters

Increasingly utilized in laparoscopic procedures to facilitate ureteral identification when tactile feedback (eg, robotic surgery) is limited.
No ureteral injuries demonstrated in a large 5-year retrospective cohort examining the use of lighted ureteral catheters in almost 500 cases of laparoscopic LARs and left colectomies in the setting of diverticulitis and malignancy.

Intraoperative Cystoscopy

Can be utilized to evaluate for bladder injury, particularly low trigonal and bladder neck injuries that may not be well-visualized directly
Can be performed with injection of intravenous (IV) dye to visualize ureteral jets (eg, fluorescein, indigo carmine, methylene blue)
Five-fold increase in intraoperative detection of ureteral and bladder injuries

Intraureteral Indocyanine Green

ICG injected into the lumen of ureter and subsequent visualization of fluorescent green enhanced ureter noted under near-infrared fluorescence.
Main application in robotics, where tactile feedback is limited.

Types of Ureteral Injury

Laceration: complete or partial
Ligation: suture versus stapled
Crush
Thermal injury
Kink
Ischemic/de-vascularization
Periureteral inflammation/fibrosis (extrinsic, as with diverticular phlegmon)

Intraoperative Consultation for Injury

Preoperative assessment should include a good history review, including previous radiation, malnutrition, chemotherapy, and assess contralateral kidney/prior imaging.
Intraoperative assessment should include hemodynamic stability, availability of family/power of attorney and previous renal disease, and brief review of entire operative course and anatomy with primary surgeon.
Patient may require repositioning or reprepping, to permit cystoscopy or access to genitalia for catheterization or cystoscopy.
If fluoroscopy is needed, as with retrograde pyelography to assess ureters for injury, C-arm access may be impaired by table positioning. Direct injection retrograde with methylene blue for on-table assessment or antegrade injection of IV dye may allow for intraoperative identification without fluoroscopy and repositioning.
Cystoscopy equipment available (including tubing and light source)
Guidewires, open-ended ureteral catheters, double J and single J ureteral stents, fine scissors (eg, tenotomy), fine-needle drivers (eg, for 4.0 or 5.0 suture), and fine, atraumatic forceps

Intraoperative Management of Ureteral Injury

Urology consultation, if available
Direct inspection of the ureter when injury suspected
Contralateral ureter and bladder should also be examined. Bladder is the most commonly injured organ in the lower urinary tract.
Assess for relevant comorbidities. For example, does the patient have impaired renal function? Are both kidneys present and working? Does the patient have baseline urologic disease, such as urinary incontinence, bladder obstruction, or atonic bladder? All may impact decision-making about reconstructive options.
Small or incomplete injuries may be managed with ureteral stenting alone, although direct repair is preferred for injuries that are directly visualized.

Ureteral Repairs

Most injuries occur in the pelvic ureter; thus, 90% of ureteral injuries can be managed with three procedures including:
- Ureteroneocystostomy or ureteral reimplant
- Psoas hitch
- Boari flap +/- psoas hitch
Mid-ureteral repairs are mostly managed with ureteroureterostomy, Boari-psoas hitch, or (more rarely) transureteroureterostomy (TUU).
Upper ureteral repairs may be managed with UU, TUU, or ureterocalycostomy with or without concomitant nephropexy/renal mobilization.
Complete ureteral injuries may require ileal ureter replacement (contraindicated in cases of IBD or previous radiation to the abdomen) or renal autotransplant.
Ureteral ligation with percutaneous nephrostomy in cases where no options exist.

Endourologic

FIGURE 35-2 ▪ Retrograde pyelogram performed on-table demonstrates left distal ureteral suture ligation. Patient ultimately required release of suture ligature with stenting.

Endourologic options can be diagnostic and therapeutic. These may also be employed when an open repair may not be feasible, given an early post-op time period when it may be difficult to intervene with open surgical management or if the patient is unstable and cannot undergo an open repair (Fig. 35-2).
Proximal diversion with occlusion (via nephrostomy tube and a nephroureteral catheter that is occlusive)
Ureteral stent placement with retrograde pyelogram

Technique

Open Options for Repair

Proximal Ureteral Injury

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