Diagnosis and Treatment of Iatrogenic Injuries of the Ureter in Patients Undergoing Pelvic Surgery in a Resource Limited Setting: A 10-Year Multi-Institutional Review

Abstract

Background: Most ureteral injuries are iatrogenic, secondary to operative trauma. Iatrogenic ureteral injuries result from abdominopelvic surgery. The challenge is diagnosing these as early as possible so as to provide appropriate ureteral reconstruction early. The aim of this study was to summarize the etiologies, clinical features and general management of iatrogenic ureteral injury in a resource limited context of a low-income country.

Patients and methods: We carried out a multicentric study and reviewed all patients with iatrogenic ureteral injuries in three referral hospitals in Yaoundé, Cameroon, over a ten-year period.

Results: Overall, we recorded 38 cases of iatrogenic ureteral injuries out of 19053 pelvic surgeries performed during the study period. The average number of iatrogenic ureter injuries per year was 3.45 cases. The mean age was 46 ± 10.7 years; all were female. Hysterectomy accounted for 29 (76.3%) of the ureteral injuries. The majority, (34; 89.47%) of the cases, were diagnosed post-operatively. The most frequent symptoms were flank pain and vaginal urine leakage in 18 (47.4%) and 13 (34.2%) cases respectively. The most common imaging procedure was ultrasound showing dilation of the right ureter in 21 (55.2%) cases. Ureteral injuries were found to be located mostly at the right distal segment and the mid ureter with a frequency of 30 (78%) and 8 (22%) respectively. All the patients underwent surgical treatment including ureteroneocystostomy, uretero-ureterostomy, Boari flap reconstructions and nephrectomy. Seventy-four percent (n=28) of participants had a favorable outcome and 26.3% (n=10) developed postoperative complications.

Conclusion: In our setting, iatrogenic ureteral injuries are not uncommon in women undergoing pelvic surgery. In the absence of a high index of suspicion, diagnosis is delayed. Abdominal pelvic ultrasound usually shows the affected side. Ureteroneocystomy is commonly performed, with both minor and major complications.

Keywords: Iatrogenic Ureteral Injuries, Hysterectomy, Ureteroneocystostomy, Yaounde, Cameroon.