Complications of Ureterscopy

COMPLICATIONS AND MANAGEMENT OF
URETERSCOPIC SURGERY
by
Hassaan Ali Gad
Assistant lecturer of urology
Aswan University, Egypt
hassaan.ali@aswu.edu.eg
2019

AGENDA
• INTRODUCTION
• INTRAOPERATIVE COMPLICATIONS
• POSTOPERATIVE COMPLICATIONS
EARLY POSTOPERATIVE COMPLICATIONS
LATE POSTOPERATIVE COMPLICATIONS

• INTRODUCTION
• INTRAOPERATIVE COMPLICATIONS
• POSTOPERATIVE COMPLICATIONS

INTRODUCTION
• Ureteroscopy has gained a place as a primary treatment
modality for many urologic applications including stone
diseases, ureteropelvic junction obstruction, and upper
urinary tract transitional cell carcinoma with high success
rates
• With increased surgical experience and improvements in
endoscopic equipment the number of overall and severe
complications has decreased.

CLSSIFICATION COMPLICATIONS
• Minor complications can be effectively managed by
non operative means with minimal sequelae.
• Major complications are injuries that need operative
intervention or are life threatening condition.

CLSSIFICATION
INTRAOPERATIVE COMPLICATIONS
Minor Complications
Major Complications
Minor Complications
Major Complications
Minor Complications
Major Complication

INTRAOPERATIVE COMPLICATIONS
Minor Complications
Difficult Access of ureter or pathological site
Mucosal Abrasion
False Passage
Perforation
Extravasations
Thermal Injury
Bleeding
Proximal Calculus Migration
Extrusion of Calculi.

Difficult Access
• Inability to inter through the ureteric orifice or reached the target site of
the ureter.
Situations preventing access ureteric orifice
• Pinpoint
• Trabeculated Bladder
• UV Junction calculus
• Large median lobe
• Ectopic orifice
• Duplex system
• Ureterocoele
• Diverticulum
• Tumor

Situations preventing access trget site
• edema surrounding the stone,
• tortuous ureter
• stricture,,
• trauma causing obstruction
• mucosal flaps
• false passages.

Minor Complications
Mucosal Abrasion
False Passage
Perforation
Extravasations
Thermal Injury
Bleeding

Mucosal Abrasion
Any instrument passed through the ureter can
cause mucosal abrasions up to 4%.
• The larger the instrument, the more is the friction
applied to the ureteral mucosa.
• These lesions generally have no significant
consequence.
• observation
• ureteral stent

False Passage
Perforation of the ureteral mucosa and submucosal
without full penetration of the ureteral wall.
• guidewire does not travel up the ureter smoothly
• lack of guide wire coil in the renal pelvis or calyces
Diagnosis by retrograde pyelogram
Management
ureteral stenting for two to four weeks.
conservatively for small false passage

Perforation
full penetration of the ureteral wall up to2%
patient movement during a cough
Ureterscopy, Lithotreptor, guidewires, baskets,
balloon,or ureteral catheters dilation
Management
small perforations conservatively managed with
ureteral stent for 4 to 6 weeks
large perforations ; open or laparoscopic repair

Extravasation
Is result of perforations or avulsions
• it maybe irrigant fluid, contrast, or blood into the
retroperitoneal space
• Diagnosis by retrograde pyelography
• Management
small perforations no clinical significance.
urinoma infected necessitating percutaneous or open
drainag
large disruptions of the ureter may need surgical
exploration

Thermal Injury
• lasers, electrocautery, and EHL,ultrasonic
lithotripter probes.
• EHL coagulative necrosis
• laser has a smaller depth of penetration of 0.5
mm but extensive use can damage to adjacent
organ
• Management
Minimal thermal damage conservative
or short-term stent placement.

Bleeding
• trauma to the ureteral orifice ,abrasions ,perforation, or over
distention of the collecting system,.
• bleeding is affect visibility.
• can cause termination of the procedure.
• Most bleeding is self-limiting ,severe bleeding lead clot formation
• stent placement. a tamponade balloon catheter
• Persistent hemorrhage :invasive surgery or emboliztion in extreme
cases.

Minor Complications
Mucosal Abrasion
False Passage
Perforation
Extravasations
Thermal Injury
Bleeding

Iatrogenic displacement of a ureteral stone into the wall of the ureter,
is up to 2%.
Submucosal Stone migrates s, it is difficult to remove, and increase the
risk of ureteral stricture formation.
laser excision followed by ureteral stent placement is recommended.
• Complete extrusion “lost stone,”
it can be left in place..
Antibiotics to decrease the risk of abscess formation
it is important for the patient to be aware of this condition

PROXIMAL STONE MIGRATION
•Proximal stone migration is no longer considered a
treatment failure
Prevention of stone migration
• surgeon experience
• Location
• size of the stone
• patient positioning
• Irrigation pressures
• energy source

(A) Cook N-Trap,
(B) PercSys Accordion,
(C) Microvasive 10-mm Stone Con
(D) 7-mm Microvasive Stone Cone.

Major Complications
• Avulsion of the ureter
• Intussusceptions
• Equipment Breakdown

Avulsion of the ureter
• Complete avulsion of the ureter is serious complication
(0% to 0.5%)
Mechanisms:
forceful removal of a stone by dormia basket through
a segment of ureter with a diameter smaller than the
stone itself.
high risk in lumber ureter due to less muscle support
and thinner mucosa
.

Dignosis :
the ureter is seen with the stone as it is
extracted from the patient or a portion of the
ureter is seen in the bladder.

• fevers, flank pain, or mass due to a urinoma or an abscess
• Retrograde pyelography is diagnostic
• open or laparoscopic repair is the mainstay of treatment
• The type of repair is dependent location ,length of devitalized
ureter, patient age ,comorbidities, and renal function.
• PCN for unstable patient

Intussusception
• typically arises during basket extraction of a
large stone.
• spontaneous due to a ureteral tumor
• difficulty placing a stent, obstruction persists

It can occur in both an antegrade and retrograde direction

TREATMENT :
Stent placement over the safety wire is only
a temporizing measure as the injury is
devitalized
open or laparoscopic surgical excision of the
intussuscepted segment

Equipment Breakdown
• The current state of ureteroscopy is entirely
dependent on complex and costly equipment.
• Poor vision or a malfunctioning accessory can result
in patient injury.
• Proper inspection and care of instruments are
essential in minimizing intraoperative equipment
failure.

• Ureteral Obstruction
• Acute Urinary Retention
• Renal Colic
• Infection and Fever

Infection and Fever
• Infectious ranged from low-grade fever to septic shock.
Etiology
• instrumentation
• Stones, encrusted ureteral stents
Precautions
• Sterile urine or culture
• Drainage of obstructed infected collecting system .
• antibiotic prophylaxis,
• low-pressure irrigation

Ureteral Obstruction and Acute
• edema, clot, trauma, stone fragments, Ureteral dilation
• and stent Obstruction or migration
• postoperative obstruction is self-limiting.
• Conservative treatment of pain medications or intravenous
fluids.
• persistent obstruction require a shorter duration of stenting.

Acute urinary retention
• It is cited to occur in <1% after ureteroscopy.
increased risks
• symptomatic prostatic enlargement,
• Complicated ureteroscopy by hematuria or
clot retention

Renal Colic
• transient obstruction from ureteral edema,
clots, or stone fragments. 3.5 to 9.0%
• oral analgesics.
• stent placement :frequent colic and urinary
symptoms

• Ureteral Stricture
• Ureteral Necrosis
• Vesicoureteral Reflux

Ureteral Stricture
• Stricture can present months to years. Ranges( 0% to 3.3%)
CAUSES
• larger ureteroscopes
• Impacted stones ,ureteral perforation and extravasation, ureteral
ischemia, and thermal injury
• stone granuloma .
TREATMENT
• balloon dilation
• endoureterotomy and stenting for 8 to 10 weeks
• open or laparoscopic resection and repair.

Ureteral Necrosis
• Ureteral necrosis rare but major complication
• CAUSES
• intussusceptions,
• thermal injury,
• mucosal dissection.
• perforation
• submucosal irrigation.

Vesicoureteral Reflux
VUR has been described as a late complication of ureteroscopy.
of little clinical significance
incidence
up to 20% after ureteral dilation to 24 Fr.
and 10% after 14 Fr.
complete resolution of reflux at 2 weeks postoperatively

Thank you for your attention

Complications of Ureterscopy

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