Original Research Paper

Iatrogenic Ureteric Injury: Management Of Uretero- Vaginal Fistula And Ureteric Injury In A Single Center: A Case Series

Abstract :

INTRODUCTION: Injury to ureter is a risk to any pelvic or lower abdominal surgery. Gynecologic surgery remains the most common cause of ureteric injury. Most cases of ureteric injury present as uretero- vaginal fistula with continuous incontinence with normal voiding after several days of primary surgery.AIMS AND OBJECTIVES: The objective of the study was to evaluate management of iatrogenic ureteral injuries including those Uretero- vaginal Fistulas after elective or emergency gynecologic surgeries.METHODS: 22 patients of iatrogenic ureteral injuries after operative procedures were evaluated from May, 2015 to January 2021 by retrospective data collection and prospective observation. The diagnosis of Uretero- vaginal Fistula was based on clinical features, CECT scan with urography, cystoscopy, Retro Grade Pyelogram depending on clinical situation.RESULTS: Among 22 cases, 20 cases were from gynecologic operations in which 14 cases were Elective Hysterectomy, 4cases were Emergency Hysterectomy due to intractable PPH, and 2 cases were ovarian cystectomy. In 14 cases of Hysterectomy 12 cases were Abdominal Hysterectomy (4 were laparoscopic and 8 open) and 2 cases were Vaginal Hysterectomy. In remaining 2 non gynecologic surgeries were due to ureteric injury during URSL. 3 cases presented with B/L ureteric injury, one from elective and two from emergency hysterectomy with anuria and sepsis managed with B/L PCN, later by B/L open ureteric reimplantation. 2 cases of URSL and 5 cases of Hysterectomy were diagnosed as ureteric injury during primary procedure and double J Stent was inserted on table. Another patient underwent RGP f/b stenting on Right side, but on Left, PCN was done, f/b antegrade stenting. 3 patients presented with pyonephrosis after 2 weeks of primary surgery, managed with PCN, f/b ureteric reimplantation. In remaining 8 cases RGP was done f/b double J Stenting in 3 cases (presented within 10 days of injury) and in 5 cases (which shows complete cut off in RGP) open ureteric reimplantation was done. All reimplantation was extravesical, refluxing (Leich- Gregor technique) and stented; among them 8 in open method and 3 laparoscopically. Follow up were done on post op 6 weeks, 2 month, 6 month and after yearly up to 2 year. In total 11 reimplantation there was reflux and hydronephrosis in 2 cases in imaging studies and all patients were asymptomatic. Only 1 patient managed by antegrade stenting showed lower ureteric stricture in 1 year follow up later managed successfully with laparoscopic extravesical ureteric reimplantation.CONCLUSION: Earliest intervention within 10 days of injury gives best result even with endoscopic intervention of least morbidity. The cases which present as uretero- vaginal fistula after 2 weeks of injury are best managed by open or laparoscopic extravesical non refluxing ureteric reimplantation.

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