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Introduction Complete ureteral avulsion represents a rare and fearsome complication of ureteroscopy, reported in less than 1% of cases. In literature there are few reports and different options are presented for its treatment. We present a case of a ureteral avulsion managed with ileal ureter replacement. Case presentation A 67‐year‐old man with a left proximal ureter stone was treated at our department with ureteroscopy. During retrieval of the instrument a complete ureteral avulsion was discovered, with a so‐called “scabbard lesion”. We decided to proceed with immediate laparotomy and we performed a ileal ureter replacement. Conclusion Ureteral avulsion is a rare complication but must be known as a possible complication in high volume center. There is no standard definition regarding its treatment, and in our experience immediate treatment with ileal ureter replacement proved to be safe and effective without any changes in renal function.
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Case Report
Immediate ileal ureter replacement for ureteral avulsion during
Mauro Ragonese, Nazario Foschi, Francesco Pinto, Luca Di Gianfrancesco,
Pierfrancesco Bassi and Marco Racioppi
Urology Clinic, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy
Abbreviations & Acronyms
NA = not assessed
SWL = shock wave
UPJ = ureteropelvic junction
UVJ = ureterovesical
Correspondence: Mauro
Ragonese M.D., Urology Clinic,
A. Gemelli Hospital, Catholic
University of the Sacred Heart,
Largo Francesco Vito 1, 00198
Rome, Italy. Email:
How to cite this article:
Ragonese M, Foschi N, Pinto F,
Di Gianfrancesco L, Bassi P,
Racioppi M. Immediate ileal
ureter replacement for ureteral
avulsion during ureterescopy.
IJU Case Rep. 2020; 3: 241
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Received 15 April 2019;
accepted 6 July 2020.
Online publication 18 August
Introduction: Complete ureteral avulsion represents a rare and fearsome complication
of ureteroscopy, reported in less than 1% of cases. In literature there are few reports
and different options are presented for its treatment. We present a case of a ureteral
avulsion managed with ileal ureter replacement.
Case presentation: A 67-year-old man with a left proximal ureter stone was treated at
our department with ureteroscopy. During retrieval of the instrument a complete
ureteral avulsion was discovered, with a so-called “scabbard lesion”. We decided to
proceed with immediate laparotomy and we performed a ileal ureter replacement.
Conclusion: Ureteral avulsion is a rare complication but must be known as a possible
complication in high volume center. There is no standard definition regarding its
treatment, and in our experience immediate treatment with ileal ureter replacement
proved to be safe and effective without any changes in renal function.
Key words: ileal ureter replacement, reconstructive surgery, ureteral avulsion,
ureteroscopy, urinary stone.
Keynote message
Even if rare, ureteral avulsion must be known as a complication of endoscopic surgery and
its management could be challenging.
Increased technology has reduced complication rates of ureteroscopy, however, even if a
specic classication is lacking, the rate of complications ranges from 0 to 28%.
Among these, iatrogenic ureteral injuries vary from minor mucosal petechiae to erosion,
perforation, false routes, and rarely, complete ureteral avulsion.
The term ureteral avulsion refers to the discontinuation of the full thickness of the ureter
and has been rstly introduced to describe an upper urinary tract injury after blunt trauma or
due to stone basketing procedures.
We present a case of complete ureteral avulsion during ureteroscopy, treated with immedi-
ate surgical intervention and ileal ureter replacement.
Case presentation
A 67-year-old man presented to our Clinic for a 10 mm right proximal ureter stone and with
a nephrostomy tube inserted 1 week before in another hospital for recurrent colicky pain not
responsive to painkillers.
He has a history of calcium oxalate stone disease and he underwent multiple SWL treat-
ments for other stones and even for the same ureteral stone 2 weeks before.
After discussion of the therapeutic options we decided to perform a semi-rigid ureteroscopy
to treat the stone. After a retrograde pyelography that showed a stop of contrast progression
at the level of the stone, a hybrid guidewire (Ultra-Track; Olympus, Hamburg, Germany) was
positioned in the renal pelvis above the stone. A 8 Ch semi-rigid ureteroscope (Karl Storz
©2020 The Authors. IJU Case Reports published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Urological Association 241
IJU Case Reports (2020) 3, 241--243 doi: 10.1002/iju5.12202
Endoscopy, Tuttlingen, Germany) was inserted into the right
ureter alongside a second wire in the working channel
according to the railwaytechnique.
We noticed some friction at the level of the UVJ that was
hardly overcome by the instrument. The lumen of the ureter
just below the stone was narrow and the ureteral mucosa was
pale and rigid; the instrument maneuverability was reduced
because the ureteroscope was tightly wedged in the ureteral
lumen; we decided to try with a exible ureteroscope or even-
tually to place a JJ stent. The safety guidewire was left inside,
but when the scope was pulled out, we noticed that the
avulsed ureter was covering the ureteroscope as a scabbard.
We performed an antegrade pyelography that conrmed that
the total ureteral avulsion occurred just below the UPJ. After
an accurate surgical consultation with all the surgical staff and
an adequate discussion with the patients relatives, we decided
to proceed with laparotomy in the same session with the aim
of an immediate ureteral reconstruction. We found out a com-
plete avulsion, with a lesion at the level of the UVJ and
another one at the proximal ureter where the stone was
located. We noticed that remaining ureter was too short to per-
form a reimplantation and after a having checked the integrity
and the normality of the ileum, we decided to proceed with
ileal ureter replacement.
A terminal ileum loop 20 cm away from ileocecal valve
was isolated. A 20 cm segment was transected and the conti-
nuity of ileum was restored with a GIA
stapler (Medtronic,
Minneapolis, MN, USA).
The proximal end was then anastomosed to the renal pelvis
after placement of a JJ stent and the terminal end, in an isoperi-
staltic fashion, was brought down and a direct end-to-side ileal-
bladder anastomosis was realized, after having performed a
bladder psoas hitching to reduce the tension of the anastomosis.
Post-operative course was uneventful and after 7 days we
performed an antegrade pyelography (Fig. 1) and removed
the nephrostomy. The patient was discharged in postoperative
day 10 and the JJ stent was removed 6 weeks after surgery
without any complication.
We follow-up the patient with a computed tomography
scan after 3 months that showed no hydronephrosis and a
good excretory phase. After 9 months the patient underwent
a renal scintigraphy which was completely normal. One year
after surgery the patient has not had any infections and serum
creatinine remain stable. We decide to keep following-up him
with a renal ultrasound once every 3 months and a renal
scintigraphy after 1 year.
Ureteral avulsion is a rare but serious complication of ure-
teroscopy. Despite its low incidence, it is important to be
aware of this complication because inappropriate management
could lead to nephrectomy.
Determinant mechanism of the lesion is multifactorial but
some risk factors are described: proximal stone location, pre-
vious SWL treatment as proved by Fuganti et al.
Gotkas et al. showed there is a higher urine inammatory
cytokines level after SWL
with an increased inammation
and fragility of the ureter.
Furthermore, the presence of symptoms for more than
3 months, stones above the ischial spines, stones >5mmin
width, a dilated proximal ureter, and involvement of a less
expert urologist were factors associated with a statistically sig-
nicantly higher incidence of intra-operative complications.
There is not any general rule for optimal management of
ureteral avulsion and different reports have been published
with conicting results (Table 1).
In the management of ureteral avulsion there are different
factors to take into account: age of the patient, comorbidity, pre-
vious surgery, renal function, degrees of tearing and length of
the ureter, and even surgeons experience and centre facilities.
Different conservativemanagement are described in liter-
ature but whenever a repositioning is attempted, there is a
high risk of stricture and renal failure in long-term follow-up
with an increase risk of subsequent nephrectomy.
Autotransplantation is described as an alternative particu-
larly in young patients. In elderly people and without any
specic study of the vascular anatomy, the choice of auto-
transplantation must be evaluated only as a delayed, elective
procedure in high volumecenter.
Appendix interposition has also been reported as a treat-
ment option for extensive injuries in some literature reports
but it is suitable for short defect.
Ileal ureter replacement is a type of reconstructive surgery
routinely performed in our department for long ureteral stric-
tures or for ureteral cancer in which conservative treatment is
Even if the patient did not undergo any type of bowel
preparation, it has been largely demonstrated for reconstruc-
tive surgery in bladder cancer and for colorectal surgery that
Fig. 1 Antegrade pyelography showing normal outflow from the right kidney.
242 ©2020 The Authors. IJU Case Reports published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Urological Association
bowel preparation is not necessary and does not give any
advantage when the ileal segment is used.
Considering patients age, his normal renal function, and
our experience, we decided to choose this immediate recon-
structive intervention that has been shown to be a safe option
for the patient even in the long term.
Conflict of interest
The authors declare no conict of interest.
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the endourological society ureteroscopy global study: indications, complica-
tions, and outcomes in 11,885 patients. J. Endourol. 2014; 28: 1319.
2 Geavlete P, Georgescu D, Nit
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Table 1 Therapeutic options for ureteral avulsion during ureterosocpy
Ureteral lesion No. cases Technique of reconstruction
Meng et al.
UPJ 3 Autotransplantation
Stein et al.
UPJ and UVJ 2 Ileal ureter replacement (1 open, 1 laparoscopic)
Alapont et al.
Proximal ureter
Mid ureter
3 1 UCNS with Boari flap
1 nephrectomy
1 repositioning, ended with nephrectomy 3 months later
Sevinc et al.
2 distal ureter
1 total ureter
3 2 UCNS +psoas hitch
1 ileal ureter replacement
Ordon et al.
Proximal ureter 3 Nephrectomy
Taie et al.
UVJ in 1 patient
UVJ and UPJ in 5 patients
6 1 simple UCNS
2 Boari flap
1 ileal ureter replacement
2 nephrectomy (1 after initial double ureteral anastomosis)
Unsal et al.
UVJ and UPJ 4 2 double anastomosis for male patients, 2 double anastomosis with Boari flap
for two female patients (1 ended with renal atrophy)
Ge et al.
1 UVJ and UPJ
1 3 cm above UPJ
2 distal ureter
4 Double anastomosis (nephrectomy after 11 months)
Tsai et al.
Proximal ureter
2 End-to-end anastomosis
Retroperitoneal transureteroureterostomy
Martin et al.
UPJ 4 1 autotransplantation
1 ileal ureter replacement
1 UCNS with bladder psoas hitch
1 Boari flap
Georgescu et al.
N.A. 3 1 nephrectomy
1 end-to-end anastomosis
1 Boari flap
©2020 The Authors. IJU Case Reports published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Urological Association 243
Management of a rare complication during endoscopic procedures
... The scarcity of literature, as well as small case series, reflects the exploration of IUR for UA [12,13,28]. Our study reported that ten patients had the longest followup range of 5 to 131 months, demonstrating the treatment and consideration of ureteral avulsion under ureteroscopy, which is rare. ...
Full-text available
Introduction To describe our initial experience with ileal ureteral replacement (IUR) for the management of ureteral avulsion (UA) during ureteroscopic lithotripsy. Methods Between September 2010 and April 2021, ten patients received ileal ureteral replacement for ureteral avulsion during ureteroscopic lithotripsy. Anterograde urography and computed tomography urography (CTU) were applied to evaluate the lesion. Follow-up was performed with magnetic resonance urography and renal ultrasound as well as clinical assessment of symptoms. We retrospectively analysed the clinical data of ten patients treated with ileal ureteral replacement for the treatment of ureteral avulsion. Results Four patients underwent open ileal ureteral replacement, two underwent laparoscopic ileal ureteral replacement, and four underwent robotic-assisted ileal ureteral replacement. The mean operative time (OT) was 310 min (range 191–530). The mean estimated blood loss (EBL) was 193 mL (range 10–1000). The mean length of the ileal graft was 21 cm (range 12–25). The median postoperative hospital time was 13 days (range 7–19). All surgeries were effectively completed, and no case required open conversion in laparoscopic and robotic-assisted surgeries. There was no obvious hydronephrosis according to contrast-enhanced computed tomography 3-dimensional reconstruction images without serious complications or progressive hydronephrosis during a median follow-up duration of 51 months (range 5–131), and the success rate was 100%. Conclusions Our initial results and experience showed that ileal ureteral replacement for the management of ureteral avulsion during ureteroscopic lithotripsy is safe and feasible.
Background: Ureteroscopy is well-established as a primary treatment modality for urolithiasis. Ureteral avulsion, particularly complete or full-length avulsion with a resultant long segment of the ureter left attached to the ureteroscope, is a rare but devastating complication of the procedure. Management of this complication is challenging. Moreover, general consensus regarding the optimal management is undetermined. We report our experience of managing a complete ureteral avulsion case via an extended Boari flap technique with long-term results. Case summary: A 41-year-old female patient subjected to complete ureteral avulsion caused by ureteroscopy was referred to our hospital. A modified, extended Boari flap technique was successfully performed to repair the full-length ureteral defect. Maximal mobilization of the bladder and affected kidney followed by psoas hitch and downward nephropexy maximized the probability of a tension-free anastomosis. Meticulous blood supply preservation to the flap also contributed to the success. During the 4-year study period, no complications except for a mild urinary frequency and a slightly lower maximum urinary flow rate were reported. The patient was satisfied with the surgical outcomes. Conclusion: The extended Boari flap procedure is a feasible and preferred technique to manage complete ureteral avulsion, particularly in emergencies.
Full-text available
Objective: To evaluate the treatment modalities of total ureteral avulsion and to clarify the risk factors of this serious complication. Methods: This study retrospectively analyzed the data of 3 patients with complete ureteral avulsion during ureteroscopy. Of the three patients, two had distal ureteral complete avulsion, and one total ureteral avulsion on both ends. Ureteroneocystostomy (UNC) was immediately performed after distal ureteral avulsion cases. Ileal ureter substition was performed on the same session after the total ureteral avulsion in both ends. Two of the patients were under chronic use of corticosteroid treatment due to diagnosis of idiopathic trombocytopenic purpura and myastenia gravis and all patients had unsuccesful shockwave litotripsy (SWL) treatment history with at least 1 month period before surgery. Results: The patient who had ileal ureter substitution was followed at 3-month intervals by ultrasonography and renal function tests and she was uneventful after a 2 year follow-up period. The patients treated with UNC were followed up at 3 month interval by ultrasonography and renal function tests. They had normal renal function 1 year after the operation Conclusion: Complete ureteral avulsion is a rare but severe complication. Treatment modality can vary and ileal ureter can be applied succesfully in the total ureter avulsion in both ends when bladder capacity is not enough for a Boari flap. Failed SWL and/or corticosteroid treatment history of patients seems to increase the risk of the ureteral avulsion.
Full-text available
Ureteral avulsion is an uncommon yet severe complication of ureteroscopy. Among 8336 patients who received ureteroscopic procedures in our hospital from December 2001 to December 2011, we encountered two cases of ureteral avulsion. The first of these experienced disruption at the ureteropelvic junction due to extraction of the tubular ureter from the urethra, which was corrected by immediate open surgery to reposition and anastomose the ureter. The second patient sustained a proximal ureteral disruption following retrieval of the ureteroscope, which was wedged in the narrow lumen of the proximal ureter, and led to simultaneous extraction of the distal ureter. Immediate surgical intervention was performed to maintain ureteral continuity. Mild hydronephrosis was observed in kidneys that were ipsilateral to the ureteral avulsion in both patients. However, no physical discomfort or loss of renal function was indicated after 12 months.
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Objectives: To evaluate semirigid retrograde ureteroscopy complications on a significant series of patients and to establish the factors associated with the occurrence of intraoperative complications. Patients and methods: Between June 1994 and June 2013, 8150 semirigid ureteroscopic procedures for ureteral lithiasis were performed in 7456 patients. We used semirigid ureteroscopes(8 9.8F Wolf, 8 and 10F Storz, Olympus Endoeye digital 8.5 9.9F). Lithotripsy was done with pneumatic, electrohydraulic or Ho:YAG laser lithotripters. The preoperative parameters including gender, calculi location and size, impaction, degree of hydronephrosis, stone number and associated malformation as well as intraoperative aspects (stone extractors, fragmentation devices, operative time and surgeon experience) were evaluated in relation with complication rate. Results: The stone-free rate after a single ureteroscopic procedure was 90.9%. Intraoperative incidents occurred in 348 cases (4.3%). The overall rate of intraoperative complications was 2.8% (228 cases). These were represented by lesions of the ureteral mucosa (139 cases), perforation (58 cases), bleeding (16 cases), ureteral avulsion (3 cases) and extra-ureteral stone migration (12 cases). Statistical analysis shows a significant association between the complication rate on the one hand and stone size, location and impaction,operative time and surgeon experience on the other hand. Conclusions: Due to technological advances and increased experience, the semirigid retrograde ureteroscopic treatment of ureteral lithiasis increased efficacy, while the incidence of intraoperative complications decreased. Most of these complications are minor and can be managed by conservative approach.
Full-text available
Purpose: To assess the current indications for ureteroscopy (URS) treatment, outcome in terms of stone-free rate, and intra- and postoperative complications using the modified Clavien grading system. Patients and methods: The Clinical Research Office of the Endourological Society collected prospective data as part of the URS Global Study for consecutive patients treated with URS at centers around the world for 1 year. URS was performed according to study protocol and local clinical practice guidelines. The stone size and location were recorded and postoperative outcome and complications, graded according to the modified Clavien grading system, reported. Results: Between January 2010 and October 2012, 11,885 patients received URS at 114 centers in 32 countries; 1852 had only renal stones, 8676 had only ureteral stones, and 1145 patients had both types of stone. Fragmentation was performed principally using a laser device (49.0%) or a pneumatic device (30.3%); no device was used in 17.9% of the patients. A high stone-free rate (85.6%) was achieved. The large majority of patients did not receive any further treatment for renal or ureter stones (89.4%). The postoperative complication rate was low (3.5%). The most frequent complication was fever (1.8%); a blood transfusion was required in 0.2% of patients. The majority of complications were Clavien grade I or II (2.8% of patients). Conclusion: URS is an established minimal invasive treatment for urinary stones with a high success rate and low morbidity. Recent advances have expanded the indication for urinary stones, which now ranges from treatment of smaller sized distal ureter stones by semirigid URS to larger sized renal pelvis stones treated by flexible URS.
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To evaluate the treatment alternatives of total avulsion of the ureter from both ends including ureteropelvic junction (UPJ) and ureterovesical junction (UVJ). Total ureteral avulsion on both ends of the ureter was examined in 4 cases performing ureteroscopy. In two male patients of the four cases, avulsion was noticed intraoperatively and ureteral re-anastomosis at UPJ and re-implantation at UVJ were performed immediately. Boari flap was performed for one female patient immediately and for the other female patient who was referred from another hospital after the ureteroscopy, 4 days later. One patient who had ureteral re-implantation was followed with 3-month intervals by ultrasonography and abdominal X-ray. At the end of 1 year, it was determined that kidney parenchyma was normal and the patient had kidney and upper ureteral stones. Percutaneous nephrolithotomy was performed, and the patient was stone-free at the end of the operation. Two years after the surgery, both kidneys were normal. This is the only case who had a successful ureteral re-implantation in literature. The other patient turned up a year later for routine checks after the ureteral stent was removed. Then, hydronephrosis and renal atrophy were detected. The patient did not accept nephrectomy or any other intervention and he was lost to follow-up. Boari flap procedure was performed after UPJ repair for the other two female patients. Their kidneys were both normal 3 months after the operation. In case of ureteral avulsion from both ends of the ureter in the male patients, as bladder capacity is not enough for a Boari flap, proximal anastomosis and distal re-implantation could be a good choice for the management of this untoward event. This new approach also saves time for reconstructive treatments if necessary. If bladder capacity is enough to reach UPJ, Boari flap could be a good choice in female patients.
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To evaluate the prevalence and type of rigid ureteroscopy complications and suggest a new method for ureteral avulsion prevention. Between March 2002 and March 2009, we retrospectively evaluated 2955 patients who had undergone diagnostic or therapeutic ureteroscopy for asymptomatic hematuria, migrated ureteral stent, or transurethral lithotripsy. They were enrolled from four hospitals in Ahvaz, Iran. Complications were encountered in 241 (8%) patients, including transient hematuria (4.2%), mucosal erosion (1.4%), stone migration (1.3%), ureteral perforation (1.2%), and fever and/or sepsis (1.0%). Ureteral avulsion occurred in 6 (0.2%) patients. Mostly, complications were managed conservatively, using ureteral stenting. Ureteral avulsions were managed using a new technique. In our series, the complication rate is comparable with the literature. A new technique was used in case of ureteroscope entrapment in the ureter, to lessen the occurrence of ureteral avulsion.
The aim of this report was to look for a good solution to full-length ureteral avulsion. This report retrospectively analyzed the data of the patient. The patient underwent ureteroscopic management. Full-length avulsion of ureter occurred during ureteroscopy. Pyeloureterostomy plus greater omentum investment outside the avulsed ureter and ureterovesical anastomosis were performed immediately. The patient was followed-up 25 months. After the first operation, the patient developed hydronephrosis because of press of fibrosis tissue outside ureter and anastomotic atresia of ureter-bladder. When we finished the second operation, the renal function recovered well. Full-length avulsion of ureter is a severe complication. Pyeloureterostomy plus greater omentum investment outside the avulsed ureter and ureterovesical anastomosis are probably a good choice.
Extracorporeal shockwave lithotripsy (ESWL) has dramatically changed the treatment of urinary lithiasis and has been the first treatment option for the majority of patients for more than two decades. Despite its significant benefits, it induces acute renal injury that extends from the papilla to the outer cortex. We evaluated the severity of the inflammatory response to ESWL by measuring the urinary excretion of the cytokines TNF-α, IL-1α, and IL-6. The study included 21 selected patients and 14 control subjects. All patients underwent the same ESWL procedure (2,500 shockwaves at 100 shockwaves/min and 0.039 J from the lithotripter). Urine TNF-α, IL-1α, and IL-6 levels were measured using standard ELISA kits. In the study population (patients and controls), we did not detect TNF-α in the urine samples. The levels of both IL-1α (2.5 pg/ml) and IL-6 (3.8 pg/ml) measured before ESWL were not significantly different from the control group (2.5 and 5.2 pg/ml, respectively; p > 0.05). Twenty-four hours after ESWL, in contrast to IL-1α (4 pg/ml), urine IL-6 (19.7 pg/ml) increased significantly (p < 0.05). Fourteen days after ESWL, IL-1α increased to 5 pg/ml, while IL-6 (7 pg/ml) decreased to the control level. Urine cytokine levels may be used to evaluate the inflammatory response to ESWL. After ESWL, IL-6 levels increased in the early phase, while IL-1α levels increased later. These two markers may be used to measure the severity of inflammation. In contrast to IL-1α and IL-6, urine TNF-α excretion was not increased by ESWL. We believe that the inflammatory response to ESWL can be detected by the urinary excretion of IL-1α for up to 14 days.
Ureteral avulsion during ureteroscopic stone management is extremely rare. To date, many publications reporting avulsion have been associated with "blind basket extraction" under fluoroscopy and the use of the Dormia stone basket. Fortunately, despite the significant rise in the numbers of ureteroscopic cases being performed, the rate of ureteral avulsion remains low. This is likely in part because of improvements in ureteroscope technology and stone manipulation devices. We present three recent cases of ureteral avulsion referred to our center for further management. To our knowledge, these cases represent the first published description of avulsion where the ureteroscope became wedged in the intramural ureter, resulting in full-length avulsion of the ureter. The avulsion occurs both proximally and distally with a resultant length of ureter left attached to the ureteroscope. We dub this mechanism the "scabbard" avulsion. We describe the most likely mechanism of this injury, with suggestions on how to prevent it and how to release the ureteroscope should it become wedged in the intramural ureter.