A panel of three experts will discuss intraoperative consults for ureteral injuries during Tuesday’s Plenary I program. The 30-minute presentation, titled Intraoperative Consult for Ureteral Injury, which will illustrate different types and severities of ureteral injuries that typically occur during surgery, begins at 9:25 a.m. in Hall A in the San Diego Convention Center.
“This plenary is about the acutely recognized ureteral injury and the algorithm you can use to evaluate the injury and manage it,” said Sean P. Elliott, MD, associate professor and Director of Reconstructive Urology at the University of Minnesota. “Much of the emphasis will be on damage control in certain situations, appropriate evaluation in other circumstances or temporizing maneuvers such that the patient can later undergo a formal repair. And in some circumstances, you repair things then and there.”
Dr. Elliott will be joined on the panel by Lee C. Zhao, MD, assistant professor of Urology at New York University, and Hadley M. Wood, MD, assistant professor of Urology at Case-Lerner College of Medicine and staff surgeon at the Glickman Urological and Kidney Institute Center for Genitourinary Reconstruction at the Cleveland Clinic.
While there are no good data on the frequency of intraoperative consults, the two broad categories of ureteral injuries that generate most intraoperative calls are laparoscopic injuries and open surgical injuries. Although ureteroscopic injuries are not uncommon, Tuesday’s presentation will focus on consultation for injuries encountered during non-urological surgery.
“Before jumping into the repair, stop and consider a few things first,” Dr. Elliott advised. “Patient medical history, positioning such as supine versus lithotomy, surgical instrumentation and how the type of surgery being done during the injury will affect the approach to the injury.
“When you see a ureteroscopic injury, nine times out of 10 you are going to stent it and wait to see what happens,” he continued. “Most of the time, these injuries heal and only occasionally do they need a reconstruction. The patient’s abdomen isn’t open, so there is no harm and a lot of potential value in stenting and waiting to see what happens. You only want to reconstruct if you have to.”
With the advent of laparoscopic and robotic procedures, most open surgeries today are major procedures, such as a large colon resection or cervical cancer resection. “The surgeon may be more likely to incidentally injure the ureter because these procedures are so challenging,” Dr. Elliott said.
Being able to insert a stent makes most ureteroscopic injuries relatively easy to manage. The next easiest cases involve very distal ureteral injuries, such as those that can occur during a hysterectomy. Most distal injuries can be treated by ureteral reimplantation with or without a psoas hitch of the bladder. This can be an effective strategy for ureteral injuries almost to the midpoint of the ureter.
Proximal ureteral injuries are the most challenging. They are too far from the bladder for a simple ureteral implant, and the closer the injury is to the kidney, the more major vessels may be involved. Proximal injuries often call for major reconstruction that will require a separate surgery.
“If it’s not easily reconstructable and it’s not stentable for some reason, the first thing I think about is damage control,” Dr. Elliott said. “The safest approach is often to tie off the ureter so there is no urine leakage into the peritoneum, then get a nephrostomy tube inserted and come back another day for the reconstruction.
“The most important difference between even the most challenging reconstruction and an intraoperative consult is time,” he continued. “No matter how complex an elective reconstruction, the surgeon has time to study and plan. When the call comes intraoperatively, the time to act is now. You can’t decide when that intraoperative consult is going to happen. It is going to surprise you. You want to be ready to go on the spot, know what to do, what to evaluate and how to proceed. We are going to provide the tools.”
Plenary I Preview
Intraoperative Consult for Ureteral Injury
Presenter: Sean P. Elliott, MD
9:25 – 9:55 a.m. Tuesday
Hall A, San Diego Convention Center