Discussion
Our research has that the type of ureteral injury is a crucial factor in
urological intervention decisions and treatment efficacy in IUI. We
observed that it was more often diagnosed in the postoperative period if
IUI was caused by thermal injury. Endourological interventions were
performed more frequently in cases, and half of those procedures
required repeated urological interventions.
IUI incidence has increased due to the rise in the overall number of
surgeries and the widespread use of minimally invasive surgical
techniques (2, 3). The most common causes of ureteral trauma are suture
ligation, blunt injury, partial/total transection, and ischemia due to
thermal damage (20). Early detection of trauma and immediate ureteral
correction surgery reduces kidney and ureter related complications (7,
21). In postoperative IUI cases, sepsis (Odds Ratio: 11.9), urinary
fistula (Odds Ratio: 23.8), and mortality (Odds Ratio: 1.4) are more
common than those diagnosed perioperatively (22). More repetitive
urological interventions may be required in (23).
Approximately three-quarters of IUI malpractice litigation end up
against surgeons. Prolonged urinary leakage, delayed ureteral
reconstruction, inattentive postoperative care, and insufficient
surgical training are the most common accusations (24). Therefore, it is
essential to choose the appropriate treatment in IUI.
The recommended treatment in IUI is ureteroureterostomy or ureteral
reimplantation according to the traumatic ureter segment (8, 10, 11,
25). However, endourological approaches are often chosen as initial
care due to short hospital stay, fewer complication, and low treatment
cost (26). Reported success rates for endoscopic IUI management range
from 17% to 84% (13-18). In study, we initially treated 59.25% (n =
16/27) of the patients with endourological methods.
Endourological intervention recommended in patients with a ureteral
stenosis segment smaller than 2 cm or a small fistula tract with a
mostly preserved ureter wall (16). Successful results have been reported
antegrade stent approach with endoscopic ’rendezvous’ method in patients
diagnosed with postoperative IUI (12). Delayed diagnosed IUI treated
with endoscopic realignment for partial or complete transected ureter in
11 patients had a 45.46% (n = 5/11) ureteral stricture at the
follow-up. The authors concluded that ureteral stenosis frequency is
high in IUI cases, and patient selection is the main factor for
treatment success (14). 1185 (n = 9/76) of the cases due to thermal
injury and others to suture ligation (18). In a study including 76 IUI
cases, 29 patients diagnosed during the perioperative period underwent
open reconstructive surgery, and all recovered without complications.
Forty-seven patients were diagnosed late, a double loop stent was placed
with an endourological approach, and only seven of these recovered
without complications (27).
In studies, the type of ureteral injury was not specified. Because of
the heterogeneity in IUI etiology, the low incidence of cases, and the
variety of treatment choices, success rates of treatment results may
have spread over a wide range.
There are a limited number of publications investigating IUI due to
thermal damage (28). Tissue coagulation devices that work with
ultrasonic-based energy vary depending on the device’s technical
features but can cause an increased temperature between 33-100 ° C on
the surrounding tissue (29) and lateral spread may 10 mm. In
ultrasonically activated electrocautery, the temperature rises very
quickly up to 350 ° C, and the lateral spread can reach up to 22 mm
(30). These tissue heat quantities are higher than 60 ° C, even at 25 mm
from the device. Therefore, it has been shown that ultrasonic
electrocoagulation devices causes significant histological damage in
thin-walled organs such as the ureter, which cannot be detected
macroscopically (31). While performing thermal ablation of a mass in the
renal hilum, it has been reported that ureteropelvic junction stenosis
developed in the postoperative follow-up due to thermal damage without
any perioperative complications (32).
We detected 85.71% (n = 6/7) of patients with cold transection IUI
during gynecological surgery. This rate was 35% (n = 7/20) in thermal
injuries, which was statistically significantly lower than cold
transection (Table 2). Almost one-third of the thermal injuries could
not recognize perioperative settings, supporting previous studies (31).
Thermal injury cases were mostly treated endoscopically and had higher
complication rates than the cold transection IUI (Table 3).
We believe that high complication rates are observed in patients treated
with endourological intervention after thermal IUI since the traumatic
ureter segment was not excised. Although the endoscopic surgical method
did not fail in the early period, we observed complications due to
ureter in half of the patients during follow-up. Therefore, in our
opinion, surgical techniques in which the traumatic part of ureter is
excised should be preferred in suspected thermal IUI cases to avoid
complications (such as stricture or fistula).
The study’s limitations are the retrospective nature and a low number of
cases due to IUI characteristics, and the lack of knowledge of the
energy setup of energy-based surgical instruments used during ureter
dissection.