Presentación sobre complicaciones asociadas al abordaje quirúrgico de la litiasis ureteral, mediante ureteroscopia semirrígida y flexible.

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Riesgos y
complicaciones en
ureteroscopia por litiasis
ureteral impactada
Dr. Alfonso Montes de Oca Guzmán R3U
Hospital Regional de Monterrey
ISSSTE

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TEMPORALIDAD
 Las complicaciones se pueden englobar en relación al tiempo
como
 INTRAOPERATORIAS
 POSTOPERATORIO INMEDIATO
 POSTOPERATORIO TARDIO

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INTRAOPERATORIAS

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POSTOPERATORIAS INMEDIATAS

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POSTOPERATORIAS TARDIAS

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 Once access was obtained,
fragmentation was performed principally
using a laser device (49.0%) or a
pneumatic device (30.3%).
 Operative procedures were considered
uneventful in the majority of patients
(93.7%).
 There was a low incidence of significant
bleeding (1.4%), perforation (1.0%), and
failure to complete the operation (1.6%)

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 A high stone-free rate (85.6%) was achieved, but
stones were impacted in 27.2% of patients and the
intraoperative migration rate was 9.5%.
 Ureteral stents were inserted in the majority of
patients (81.4%).

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 The postoperative complication rate was low (3.5%).
 The most frequent complication was
 fever (1.8%);
 The majority of complications were Clavien grade I or II
(2.8% of patients)
 Five patients had a Clavien grade V; causes of death were
 sepsis, lung embolism, cardiac death, multiorgan dysfunction,
and sudden death from arrhythmia.
 At 3 months, 8.4% of patients were readmitted to the
hospital for a range of complications, including flank pain
and ureteral stent discomfort

11. z  The reported rate of intraoperative stone migration in the current
study was 9.5%.
 A number of techniques have been introduced to reduce the rate of
migration.
 In the majority of patients, stone fragmentation was achieved
using lasers (49%) or pneumatic disruption (30.3%).
 The primary intraoperative complications reported were
 bleeding (1.4%)
 perforation (1.0%)
 ureteral avulsion (0.1%).
 Five patients died after URS.

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 The postoperative complication rate was low at 3.5%
 Fever (1.8%) of patients and was comparable to that in other
studies.27
 The rate of bleeding at 0.4% was lower than the 2% rate of
persistent hematuria previously published.27
 Notably, 96% of patients had no reported complications
(Clavien grade 0).

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 Showed a 30% complication rate at a
resident training center
 98% of these were grade 1–3
 < 2% were grade 4.
 A stricture rate of 0.3% resulted in
hospital readmission.
 Again, ureteral stricture has previously been
reported as a late complication in 0%–4% of
cases, with comparable rates of < 1% in the
more recent studies, and may be due to
ureteral trauma from instrumentation or
calculus impaction

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 Intraoperative complications
 The overall incidence of intraoperative complications was 12.6 %.
 The most common complications
 proximal stone migration (3.9 %),
 mucosal injury (2.8 %)
 bleeding (1.9 %),
 inability to reach stone (1.8 %)
 malfunctioning or breakage of instruments (0.8 %)
 extraureteral stone migration (0.33 %)
 ureteral perforation (0.8 %)
 ureteral avulsion (0.16 %).
 According to modified Satava classification system, there were
 4.5 % grade 1
 4.4 % grade 2a
 3.2 % grade 2b
 0.57 % grade 3

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 Significantly more operations failed in patients who had proximal
stones ,and there was significantly more bleeding during surgery
in the multiple locations group.
 Perforation was significantly more likely to occur when the stone
was located in the midureter, and conversions were also more
common in this group.
 There is no significant difference in perforation rates during the
procedure between patients treated with semirigid ureteroscopy
(1% [84 of 8221]) and patients treated with flexible ureteroscopy
(0.6% [3 of 540]).

19. z  Of the patients who had a perforation and a stone in the
midureter, 64% had an impacted stone versus 36% in the total
group.
 An additional analysis on preoperative stent use showed that
patients who had had any preoperative stent had a higher
chance of bleeding 1.9%.

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• More than 92% of procedures
were not associated with any
intraoperative complications
• Intraoperatively, ureteral
perforation is reportedly the most
common complication of
ureteroscopy.
• midureter, where the
perforation rate was highest,
64% of the stones were
impacted among patients who
had a perforation
• Although rare, one of the most
serious complications of
ureteroscopy is complete ureteral
avulsion.
• The most common
postoperative complication
was fever, with a rate of 1.3–
3.0%, followed by urinary tract
infection (UTI) at 0.6–1.8% and
bladder cramps at 0.2–0.7%.

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No differences were observed in stone burden and stone-free rates in patients
treated with semirigid or flexible ureteroscopy; only in the midureter group was the
stone-free rate higher among patients treated with semirigid ureteroscopy (90.2%)
compared with flexible ureteroscopy (80.9%)

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Garduño-Arteaga LM, et al. Ureteroscopia: Experiencia de 20 años del
Hospital General de México , Rev Mex Urol 2011;71(6):325-330

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