Immediate ileal ureter replacement for ureteral avulsion during ureterescopy

Abstract

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.

Full text

Case Report
Immediate ileal ureter replacement for ureteral avulsion during
ureterescopy
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
lithotripsy
UCNS =
ureterocistoneostomy
UPJ = ureteropelvic junction
UVJ = ureterovesical
junction
Correspondence: Mauro
Ragonese M.D., Urology Clinic,
A. Gemelli Hospital, Catholic
University of the Sacred Heart,
Largo Francesco Vito 1, 00198
Rome, Italy. Email:
mauroragonese@yahoo.it
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–
243.
This is an open access article
under the terms of the Creative
Commons Attribution-
NonCommercial-NoDerivs
License, which permits use and
distribution in any medium,
provided the original work is
properly cited, the use is non-
commercial and no
modifications or adaptations are
made.
Received 15 April 2019;
accepted 6 July 2020.
Online publication 18 August
2020
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.
Introduction
Increased technology has reduced complication rates of ureteroscopy, however, even if a
specific classification 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.
1–2
The term ureteral avulsion refers to the discontinuation of the full thickness of the ureter
and has been firstly introduced to describe an upper urinary tract injury after blunt trauma or
due to stone basketing procedures.
3
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 “railway”technique.
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 flexible 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 confirmed 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 patient’s 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
TM
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.
Discussion
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.
4
Gotkas et al. showed there is a higher urine inflammatory
cytokines level after SWL
5
with an increased inflammation
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-
nificantly higher incidence of intra-operative complications.
6
There is not any general rule for optimal management of
ureteral avulsion and different reports have been published
with conflicting 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 surgeon’s experience and centre facilities.
Different “conservative”management 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.
6,7
Autotransplantation is described as an alternative particu-
larly in young patients. In elderly people and without any
specific study of the vascular anatomy, the choice of auto-
transplantation must be evaluated only as a delayed, elective
procedure in “high volume”center.
Appendix interposition has also been reported as a treat-
ment option for extensive injuries in some literature reports
8
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
mandatory.
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
M RAGONESE ET AL.

bowel preparation is not necessary and does not give any
advantage when the ileal segment is used.
Considering patient’s 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 conflict of interest.
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Table 1 Therapeutic options for ureteral avulsion during ureterosocpy
Ureteral lesion No. cases Technique of reconstruction
Meng et al.
9
UPJ 3 Autotransplantation
Stein et al.
10
UPJ and UVJ 2 Ileal ureter replacement (1 open, 1 laparoscopic)
Alapont et al.
11
Proximal ureter
Mid ureter
3 1 UCNS with Boari flap
1 nephrectomy
1 repositioning, ended with nephrectomy 3 months later
Sevinc et al.
6
2 distal ureter
1 total ureter
3 2 UCNS +psoas hitch
1 ileal ureter replacement
Ordon et al.
12
Proximal ureter 3 Nephrectomy
Taie et al.
13
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.
14
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.
15
1 UVJ and UPJ
1 3 cm above UPJ
2 distal ureter
4 Double anastomosis (nephrectomy after 11 months)
Autotransplantation
2 UCNS
Tsai et al.
16
UPJ
Proximal ureter
2 End-to-end anastomosis
Retroperitoneal transureteroureterostomy
Martin et al.
17
UPJ 4 1 autotransplantation
1 ileal ureter replacement
1 UCNS with bladder psoas hitch
1 Boari flap
Georgescu et al.
18
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