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1.  CT scanning for diagnosing blunt ureteral and ureteropelvic junction injuries 
BMC Urology  2008;8:3.
Blunt ureteral and ureteropelvic (UPJ) injuries are extremely rare and very difficult to diagnose. Many of these injuries are missed by the initial trauma evaluation.
Trauma registry data was used to identify all blunt trauma patients with ureteral or UPJ injuries, from 1 April 2001 to 30 November 2006. Demographics, injury information and outcomes were determined. Chart review was then performed to record initial clinical and all CT findings.
Eight patients had ureteral or UPJ injuries. Subtle findings such as perinephric stranding and hematomas, and low density retroperitoneal fluid were evident on all initial scans, and prompted delayed excretory scans in 7/8 cases. As a result, ureteral and UPJ injuries were diagnosed immediately for these seven patients. These findings were initially missed in the eighth patient because significant associated visceral findings mandated emergency laparotomy. All ureteral and UPJ injuries have completely healed except for the case with the delay in diagnosis.
Most blunt ureteral and UPJ injuries can be identified if delayed excretory CT scans are performed based on initial CT findings of perinephric stranding and hematomas, or the finding of low density retroperitoneal fluid.
PMCID: PMC2258295  PMID: 18257927
2.  Ureteral injuries from gunshots and shells of explosive devices 
Urology Annals  2010;2(1):17-20.
Penetrating rather than blunt trauma is the most common cause of ureteral injuries. The approach to management differs from the far more common iatrogenic injury.
The purpose of this series is to report our experience in ureteral trauma management, with attention to the diagnosis, repair, and outcome of these injuries.
Materials and Methods:
From April 2003 to October 2009, all abdominal trauma cases received alive, reviewed for penetrating ureteric injuries
A total of twenty (fifteen male, five female) penetrating ureteral injuries were evaluated. All penetrating ureteric injuries were due to (9 gunshot and 11 shells from explosive devices). Since the patients had a clear indication for surgery, no IVU or CT scan was done preoperatively, major intra-abdominal injuries were often associated. The diagnosis of ureteric injury was made intraoperatively in 8 cases (40%) While, twelve cases (60%) were diagnosed postoperatively. Eight ureteric injuries (40%) were proximal 1/3, 4 (20%) to middle 1/3 and 8 (40%) to the distal 1/3. Management was with stenting in 2 patients, ureteroureterostomy in 8, ureteroneocystostomy in 6, and nephrectomy in 4.
In this study, a delay in diagnosis was a contributory factor in morbidity related to ureteral injury, the need for second operation in already compromised patients from associated injuries, The presence of shock on admission, delayed diagnosis, and colon injuries were associated with a high complication rate. Ureteral injuries must be considered early during the evaluation of penetrating abdominal injuries.
PMCID: PMC2934583  PMID: 20842252
Gunshot; penetrating injury; shells of explosive devices; ureter
3.  Isolated renal pelvis rupture secondary to blunt trauma: Case report 
•A case, with isolated renal pelvis rupture due to blunt abdominal trauma.•Clear urine output from the urinary catheter was seen in patient.•Diagnosed a large rupture of renal pelvis by abdominal contrast enhanced CT.•Isolated rupture of the renal pelvis causes delays in the diagnosis of the rupture.•Only a few isolated cases of pelvis rupture with resultant extravasation have been described previously in literature.•Surgical intervention should be warranted in emergency cases.
Isolated rupture of the renal pelvis is a very rare condition and thus causes delays in the diagnosis of the rupture. It is most commonly seen in the setting of obstructive ureteric calculus. Other rare causes include neoplasms, trauma, and iatrogenic procedures. Diagnosis is usually established on computed tomography (CT) which demonstrates the extravasation of the contrast in the peripelvic, perinephric, or retroperitoneal collections.
Presentation of case
A 27-year-old male patient was admitted to our hospital due to multiple traumas associated with motor vehicle accidents. The patient had clear urine output. A large pelvic rupture was detected by abdominal contrast-enhanced CT and after consulting with other departments, emergency repair of the renal pelvis was performed and a ureteral stent was implanted.
Only a few isolated cases of pelvis rupture with resultant extravasation have been reported in the literature. The treatment of pelvic rupture should be preceded by the removal of underlying causes, followed by conservative management. However, surgical intervention should be warranted in the emergency cases presenting with the symptoms that may impede the decision-making process and in the cases whose diagnosis cannot be clarified by radiological techniques.
Renal pelvic injury must be considered in the differential diagnosis of blunt trauma. Surgical intervention may be necessary in some cases. We present a case who underwent surgery due to isolated renal pelvis rupture caused by blunt abdominal trauma.
PMCID: PMC4392341  PMID: 25734319
Renal pelvis rupture; Blunt trauma; Surgery
4.  A review of ureteral injuries after external trauma 
Ureteral trauma is rare, accounting for less than 1% of all urologic traumas. However, a missed ureteral injury can result in significant morbidity and mortality. The purpose of this article is to review the literature since 1961 with the primary objective to present the largest medical literature review, to date, regarding ureteral trauma. Several anatomic and physiologic considerations are paramount regarding ureteral injuries management.
Literature review
Eighty-one articles pertaining to traumatic ureteral injuries were reviewed. Data from these studies were compiled and analyzed. The majority of the study population was young males. The proximal ureter was the most frequently injured portion. Associated injuries were present in 90.4% of patients. Admission urinalysis demonstrated hematuria in only 44.4% patients. Intravenous ureterogram (IVU) failed to diagnose ureteral injuries either upon admission or in the operating room in 42.8% of cases. Ureteroureterostomy, with or without indwelling stent, was the surgical procedure of choice for both trauma surgeons and urologists (59%). Complications occurred in 36.2% of cases. The mortality rate was 17%.
The mechanism for ureteral injuries in adults is more commonly penetrating than blunt. The upper third of the ureter is more often injured than the middle and lower thirds. Associated injuries are frequently present. CT scan and retrograde pyelography accurately identify ureteral injuries when performed together. Ureteroureterostomy, with or without indwelling stent, is the surgical procedure of choice of both trauma surgeons and urologists alike. Delay in diagnosis is correlated with a poor prognosis.
PMCID: PMC2830948  PMID: 20128905
5.  Partial Ureteropelvic Junction Disruption after Blunt Trauma: Case Report 
Case Reports in Urology  2011;2011:541705.
Partial ureteropelvic junction disruption as a result of blunt trauma is rare and frequently missed by the initial trauma evaluation. Delays in diagnosis have also been associated with significant morbidity. A high index of suspicion should lead to appropriate investigations, and the management will be determined by the severity of the disruption. We present herein a 24-year-old man who was admitted to the Emergency Room with multiple organ injuries caused by a severe blunt trauma. Emergency celiotomy was performed for massive hemoperitoneum and shattered spleen which led to splenectomy. The diagnosis of partial UPJ disruption was missed preoperatively and suspected in CT scan after appearance of flank tender mass. Confirmation was obtained in retrograde ureteropyelography and treated conservatively with indwelling ureteral stent. We present herein an extensive review of the literature to examine the current status of this entity and to determine if improvements could be made in the diagnosis and treatment.
PMCID: PMC3350049  PMID: 22606618
6.  Prognostic factors in retroperitoneal fibrosis  
Journal of Medicine and Life  2010;3(1):19-25.
The aim of this study is to evaluate effective prognostic factors in the evolution of patients with retroperitoneal fibrosis and to establish the validity of fractal analysis in determining the disease severity in these patients.
Material and Methods: This study included 19 patients (M/F: 5/14) treated for idiopathic retroperitoneal fibrosis and bilateral obstructive renal failure between Jan 2004–Dec 2008. Patients were identified retrospectively, searching for patients diagnosed with IRF, after retroperitoneal biopsy or, in most cases the diagnosis rested on radiological findings, especially CT, with identification of a retroperitoneal mass, the absence of other demonstrable renal or ureteric disease or any other pathology that could explain the findings. CT was very useful in describing the retroperitoneal mass around the aorta and inferior vena cava, the extent of the lesion and for monitoring the response to surgical treatment during the follow–up. The data were evaluated about medical history, physical examination findings, laboratory tests (serum urea and creatinine, blood sugar, sodium, potassium, bicarbonate levels, serum pH, uric acid, haematocrit, white blood cell count), imaging methods (renal ultrasound, abdominal CT–scan, MRI). At admission all patients had active disease with obstructive renal failure and underwent bilateral ureteric stenting in order to normalize the BUN levels. After normalizing of BUN levels, ureterolysis and omental wrapping was performed. Postoperatively, ureteric stents were removed after 1 month and remission of renal disfunction was obtained in approximately 5 months (range 2–10 months). All patients were followed for at least 1 year. Patients were regularly checked every 3 months.
Results: Of the 19 patients, there were 5 men and 14 women. The median age at diagnosis of RF was 50 years (range 42–64 years). The most frequent presenting symptoms were back or abdominal pain, weakness, weight loss, oligoanuria, arterial hypertension and mild fever. The duration of symptoms before diagnosis ranged from 6 to 18 months. At presentation all patients had active disease, presenting renal dysfunction with a median serum creatinine of 5.18 mg/dl (range 1–15.4 mg/dl). Most of the patients had moderate bilateral hydronephrosis (2nd degree hydronephrosis). In our study, all patients had excellent prognosis, with full recovery of renal function in 78% of cases (15 patients). The fractal dimension of the fibrosis mass contour correlates with level of renal function impairment. Even more, the fractal dimension seems to slightly variate between CT evaluations (1.30±0.1), suggesting a non aggressive pattern of extension of the fibrotic mass characteristic for benign lesions.
Conclusions: The imaging parameters did not predict the disease severity, except the increase in fractal dimension of fibrosis surface area. Efficacy of bilateral ureteric stenting in improving renal function is limited in most of the cases. Dispite the level of renal function impairment at admission, full recovery can be achieved after bilateral ureteric stenting/nephrostomy and ureterolisis.
PMCID: PMC3019032  PMID: 20302193
idiopathic retroperitoneal fibrosis; ureterolysis; fractal; obstructive renal failure
7.  Hand-assisted laparoscopic ureteroureterostomy with renal mobilization for delayed recognition of a proximal ureteral injury after lumbar disk surgery 
We present hand-assisted laparoscopic ureteroureterostomy (HALUU) with renal mobilization as a novel approach to the management of proximal ureteral injury after lumbar disk surgery. A 63-year-old female underwent L4-L5 diskectomy and facetectomy with cage placement for back and leg pain. Postoperatively, she developed fever, nausea, abdominal pain, ileus and leukocytosis. A computed tomography scan of the abdomen and pelvis with intravenous contrast and delayed imaging demonstrated a left proximal ureteral injury with contrast extravasation. Retrograde and antegrade ureteral stent placement was unsuccessful; a nephrostomy tube was placed. Antegrade and retrograde ureterograms revealed a 3-cm proximal ureteral defect. All treatment options were discussed, and the patient chose to undergo hand-assisted laparoscopic renal mobilization with ureteroureterostomy, which was completed successfully without complications. Operative time was 381 minutes; estimated blood loss was 50 mL. The patient was discharged after 2 days, her ureteral stent was removed in 8 weeks, and follow-up with furosemide-mercaptoacetyltriglycine (MAG-3) renal scan demonstrated 30% function without evidence of obstruction. Hand-assisted laparoscopic ureteroureterostomy with renal mobilization can be performed as definitive management of a medium-length proximal ureteral injury. This is the first case describing this management technique after lumbar disk surgery.
PMCID: PMC3499927  PMID: 23293695
8.  Imaging in renal trauma 
World Journal of Radiology  2013;5(8):275-284.
Renal injuries are classified, based on the American Association for the Surgery of Trauma classification, in to five grades of injury. Several imaging modalities have been available for assessing the grade of renal injury, each with their usefulness and limitations. Currently, plain radiographs and intravenous urography have no role in the evaluation of patients with suspected renal injury. Ultrasonography (USG) has a limited role in evaluating patients with suspected retroperitoneal injury; however, it plays an important role during follow up in patients with urinoma formation. USG helps to monitor the size of a urinoma and also for the drainage procedure. The role of selective renal arteriography is mainly limited to an interventional purpose rather than for diagnostic utility. Retrograde pyelography is useful in assessing ureteral and renal pelvis integrity in suspected ureteropelvic junction injury and for an interventional purpose, like placing a stent across the site of ureteric injury. Magnetic resonance imaging has no role in acute renal injuries. Multidetector computed tomography is the modality of choice in the evaluation of renal injuries. It is also useful in evaluating traumatic injuries to kidneys with preexisting abnormalities and can help to define the extent of penetrating injuries in patients with stab wounds in the flank region. The combination of imaging findings along with clinical information is important in the management of the individual patient. This article will describe a spectrum of renal injuries encountered in a trauma setting.
PMCID: PMC3758495  PMID: 24003353
Trauma; Renal injury; Imaging; Focused abdominal sonography for trauma; Multidetector computed tomography; Contrast-enhanced computed tomography; Grading; American Association for the Surgery of Trauma classification; Vascular injury; Revision of American Association for the Surgery of Trauma
9.  The Implications of Lighted Ureteral Stenting in Laparoscopic Colectomy 
The placement of indwelling ureteral catheters during colorectal surgery has been recommended for prevention of ureteral injuries. With the advent of laparoscopic colectomy (LCo), the role of preoperative placement of lighted ureteral stents (LUS) has also become commonplace. We sought to evaluate the value of lighted ureteral stent placement in laparoscopic colectomy.
Sixty-six patients underwent LCo with LUS inserted preoperatively. Stents were removed in the immediate postoperative period. Two surgeons performed all the colectomies; 32 patients were males and 34 were females. Fifty patients underwent sigmoid colectomy, 4 had abdominoperineal resection, 4 had right colectomy, and 1 each had transverse or subtotal colectomy. Eighteen patients had a diagnosis of cancer, 34 had diverticular disease, and 14 had neoplastic polyps. Forty patients had bilateral and 26 had unilateral stent placement. A review of the incidence of ureteral injuries, hematuria, and anuria as the cause of acute renal failure was accomplished, comparing the unilateral and bilateral stented groups.
One (1.5%) patient suffered a left ureteral laceration during sigmoid colectomy. This was managed successfully with stent reinsertion. Sixty-five (98.4%) patients had gross hematuria lasting 2.93 days (1 to 6 days). The cost of bilateral stent placement was $1504.32. A statistically significant difference occurred in the duration of hematuria (days) between patients who had unilateral (2.5 ± 0.82) and bilateral stent placement (3.37 ± 1.05), (P < 0.001). Four patients suffered from anuria, 2 required renal support needing hemodialysis for 3 to 6 days, 3 (75%) had bilateral stents, and 1 (25%) had a unilateral stent.
We recommend the placement of lighted ureteral stents as a valuable adjunct to laparoscopic colectomy to safeguard ureteral integrity. Transient hematuria is common but requires no intervention. Reflux anuria occurs infrequently and is reversible.
PMCID: PMC3043401  PMID: 12002296
Laparoscopy; Colectomy; Lighted Ureteral Stent (LUS); Hematuria
10.  Iatrogenic ureteric injuries following abdomino-pelvic operations: a 10-year tertiary care hospital experience in Tanzania 
Iatrogenic ureteric injuries are rare complications of abdomino-pelvic surgery but associated with high morbidity and even mortality. There is paucity of data regarding iatrogenic ureteric injuries in Tanzania and Bugando Medical Centre in particular. This study describes our experience in the management and outcome of ureteric injuries following abdomino-pelvic operations outlining the causes, clinical presentation and outcome of management of this condition in our local setting.
This was a retrospective descriptive study of patients with iatrogenic ureteric injuries following abdomino-pelvic operations that were managed in Bugando Medical Centre between July 2004 and June 2014.
A total of 164 patients (M: F = 1: 1.6) were studied. Of these, 154 (93.9%) were referred to Bugando Medical Centre having had their initial surgeries performed at other hospitals, whereas 10 (6.1%) patients sustained ureteric injuries during abdomino-pelvic surgery at Bugando Medical Centre. The median age at presentation was 36 years. The most common cause of iatrogenic ureteric injuries was total abdominal hysterectomy occurring in 69.2% of cases. The distal ureter was more frequently injured in 75.6% of cases. Suture ligation was the commonest type of injury accounting for 36.6% of patients. One hundred and sixteen (70.7%) patients had delayed diagnosis but underwent immediate repair. Ureteroneocystostomy was the most frequent reconstructive surgery performed in 58.0% of cases. Of the 164 patients, 152 (92.7%) were treated successfully. Twelve (7.3%) patients died in hospital. The main predictors of deaths were delayed presentation, deranged renal function tests on admission, missed ureteric injuries and surgical site infections (P < 0.001). The overall median length of hospital stay was 12 days. Follow up of patients was generally poor as more than half of patients were lost to follow up.
Total abdominal hysterectomy still accounts for most cases of iatrogenic ureteric injuries in our environment. Meticulous surgical technique as well as identification of the course of the ureter and associated anatomic locations where injury is most likely to occur is important to decrease the risk of ureteric injury. Timely recognition of ureteric injury and its management is associated with good outcome.
PMCID: PMC4359460  PMID: 25774212
Ureteric injuries; Iatrogenic; Abdomino-pelvic operations; Management; Outcome; Tanzania
11.  Distal ureteral atresia with ureteropelvic junction obstruction in a female child: a rare case 
This case report describes a distal ureteral atresia along with ureteropelvic junction obstruction which occurred in a 19-month-old female child. It is easily to be misdiagnosed as mere ureteropelvic junction obstruction and omitted the combined diagnosis of distal ureteral atresia. Dismembered pyeloplasty was done in local hospital after admission, however with the result of recurrent fever when clamp the left nephrostomy tube and Antegrade urography demonstrated distal ureteral atresia. After two months, boari flap reconstruction was performed for the patient in the Second Xiangya Hospital of Central South University, and the child had good rehabilitation in the end. To our knowledge, this is the first case report on distal ureteral atresia associated with ureteropelvic junction obstruction.
PMCID: PMC4358612  PMID: 25785157
Distal ureteral atresia; ureteropelvic junction obstruction; rare entity
12.  Percutaneous Management of Ureteral Injuries that are Diagnosed Late After Cesarean Section 
Korean Journal of Radiology  2008;9(4):348-353.
We wanted to present the results of percutaneous management of ureteral injuries that were diagnosed late after cesarean sections (CS).
Materials and Methods
Twenty-two cases with 24 ureteral injuries that were diagnosed late after CS underwent percutaneous nephrostomy (PN), antegrade double J (DJ) catheter placement and balloon dilatation or a combination of these. The time for making the diagnosis was 21 ± 50.1 days. The injury site was the distal ureter in all cases (the left ureter: 13, the right ureter: 7 and bilateral: 2). Fifteen complete ureteral obstructions were detected in 13 cases. Ureteral leakage due to partial (n = 4) or complete (n = 3) rupture was noted in seven cases. Two cases had ureterovaginal fistula. All the cases were initially confirmed with antegrade pyelography and afterwards they underwent percutaneous nephrostomy. Balloon dilatation was needed in three cases. Antegrade DJ stents were placed in 10 cases, including the three cases with balloon dilatation. Repetititon of percutaneous nephrostomy with balloon dilatation and DJ stent placement was needed in one case with complete obstruction. All the cases were followed-up with US in their first week and then monthly thereafter for up to two years.
Eighteen ureters (75%) were managed by percutaneous procedures alone. A total of six ureter injuries had to undergo surgery (25%).
Percutaneous management is a good alternative for the treatment of post-CS ureteral injuries that are diagnosed late after CS. Percutaneous management is at least preparatory for a quarter of the cases where surgery is unavoidable.
PMCID: PMC2627270  PMID: 18682673
Ureter injury; Cesarean section; Percutaneous nephrostomy; Balloon dialatation; Ureteric stent
13.  Urologic Complications Following Obstetric and Gynecologic Surgery 
Korean Journal of Urology  2012;53(11):795-799.
Urologic injuries occur frequently during surgery in the pelvic cavity. Inadequate diagnosis and treatment may lead to severe complications and side effects. This investigation examined the clinical features of urologic complications following obstetric and gynecologic surgery.
Materials and Methods
We accumulated 47,318 obstetric and gynecologic surgery cases from 2007 to 2011. Ninety-seven patients with urological complications were enrolled. This study assessed the causative disease and surgical approach, type, and treatment method of the urologic injury.
Of these 97 patients, 69 had bladder injury, 23 had ureteral injury, 2 had vesicovaginal fistula, 2 had ureterovaginal fistula, and 1 had renal injury. With respect to injury rate by specific surgery, laparoscopic-assisted radical vaginal hysterectomy was the highest with 3 of 98 cases, followed by radical abdominal hysterectomy with 15 of 539 cases. All 69 cases of bladder injury underwent primary suturing during surgery without complications. Of 14 cases with an early diagnosis of ureteral injury, 7 had a ureteral catheter inserted, 5 underwent ureteroureterostomy, and 2 underwent ureteroneocystostomy. Of nine cases with a delayed diagnosis of ureteral injury, ureteral catheter insertion was carried out in three cases, four cases underwent ureteroureterostomy, and two cases underwent ureteroneocystostomy.
Bladder injury was the most common urological injury during obstetric and gynecologic surgery, followed by ureteral injury. The variety of injured states, difficulty of diagnosis, and time to complete cure were much greater among patients with ureteral injuries. Early diagnosis and urologic intervention is important for better outcomes.
PMCID: PMC3502740  PMID: 23185673
Gynecologic surgical procedures; Iatrogenic disease; Urinary tract; Wounds and injuries
14.  Robotic-Assisted Repair of Iatrogenic Ureteral Ligation Following Robotic-Assisted Hysterectomy 
Background and Objectives:
Ureteral injuries, while rare, do occur during gynecologic procedures. The expansion of laparoscopic and robotic pelvic surgical procedures increases the risk of ureteral injury from these procedures and suggests a role for minimally invasive approaches to the delayed repair of ureteral injuries. We present, to our knowledge, the first case of delayed robotic-assisted ureteral deligation and ureterolysis following iatrogenic ureteral injury occurring during a robotic abdominal hysterectomy.
We present a case report and review of the literature.
A 57-year-old female underwent a seemingly uncomplicated robotic-assisted laparoscopic total abdominal hysterectomy and bilateral oophorectomy for symptomatic fibroids. On postoperative day 8, she presented with persistent right flank pain. Imaging studies revealed high-grade ureteral obstruction consistent with suture ligation of the right ureter. She underwent successful robotic-assisted ureteral deligation and ureterolysis. Her postoperative course was unremarkable, and she was discharged home on postoperative day 1 from the deligation.
Robotic-assisted management of complications from urologic or gynecologic surgery is technically feasible. This can potentially preserve the advantages to the patient that are being seen from the initial less-invasive surgery.
PMCID: PMC3016006  PMID: 19275861
Robotics; Ureter; Gynecologic surgical procedure
15.  Spontaneous splenic rupture due to uremic coagulopathy and mortal sepsis after splenectomy 
Nontraumatic spontaneous splenic rupture (NSSR) has been encountered much more rarely compared with the traumatic splenic rupture. Although NSSR generally emerges in dialysis patients on account of such causes as the use of heparin during hemodialysis, uremic coagulopathy, infections, and secondary amyloidosis. Herein, we aimed to present a case of spontaneous splenic rupture which had developed soon after the inclusion of the case suffering from end-stage renal disease in routine hemodialysis program in the absence of any trauma or other prespecified risk factors for splenic rupture. A 55-year-old male patient was admitted to our hospital to have the ureteral double J stent removed. The operation was completed without any complication. Complaining an abdominal pain more prominent in the left upper abdominal quadrant in the first postoperative day, the patient underwent a through physical examination which disclosed abdominal distension, widespread tenderness, and rebound and defense positivity. The abdominal tomography depicted 122 × 114 × 95 mm lesion compatible with a hematoma. On the basis of these findings, an emergency exploratory operation was decided to be performed. Following clearance of the retroperitoneal hematoma, splenectomy was implemented. Experiencing progressive deterioration in his clinical status despite antibiotherapy, the patient unfortunately died of sepsis with multiorgan failure on the 25th postoperative day. In conclusion, NSSR is such an entity that may be missed out, can pursue variable clinical courses, and requires emergency therapy upon definitive diagnosis. The possibility of spontaneous bleedings should be kept in mind in any case with the history of hyperuricemia even in the absence of overt trauma, no matter if they are included in routine hemodialysis or not.
PMCID: PMC4477390  PMID: 26157658
Coagulopathy; splenectomy; splenic rupture; spontaneous; uremia
16.  A trial placement of a prophylactic ureteral catheter during the excision of a huge pelvic mass with incidental cystotomy 
Ureteral injuries are one of the major complications following gynecologic surgeries. They are serious, troublesome, often associated with significant morbidity, and are one of the most common causes for legal action against gynecologic surgeons. The reported rates of injury depend on the vigilance of diagnosis, type of surgery and other risk factors. We present a case of a 48 year old obese Caucasian female with no significant past medical history who came in with back pain and progressive abdominal swelling for the past three months and was found to have a very large pelvic mass. After preoperative evaluation, including: medical history, physical exam, and imaging studies showing a heterogenous mass 24.6 x 33.0 x 43.1, we predicted that the risk of urinary tract injuries was very high. We used preoperative prophylactic bilateral ureteral catheters to prevent injury. A surgical oncologist was consulted and an exploratory laparotomy was performed with removal of the large multi–lobulated pelvic mass + total abdominal hysterectomy, bilateral salpingo–oophorectomy, and appendectomy all performed at the same time. Patient had an incidental cystotomy during the procedure, which was repaired intra–operatively. The ureters remained intact with no injuries. The importance of thorough preoperative identification, evaluation and anticipation of ureteral injuries will be discussed in detail.
PMCID: PMC3974465  PMID: 24707391
ureter; catheter; injury; prophylactic
17.  Delayed Recognition of Bilateral Ureteral Injury after Gyneacological Surgery 
Ghana Medical Journal  2008;42(4):133-136.
Iatrogenic bilateral ureteric injury is a rare complication of pelvic surgery, which if not recognised immediately results in significant morbidity and even mortality
To describe the presentation, aetiology and treatment of iatrogenic bilateral ureteric injuries recognised late following gynaecological surgery.
The case notes of 14 consecutive cases of bilateral ureteric injury managed between October 2000 and January 2007 were studied.
Thirteen cases resulted from abdominal hysterectomy and one from vaginal repair of vesicovaginal fistula. Excessive bleeding with difficult haemostasis was the predominant predisposing factor. The indication for referral included oliguria, anuria, and urinary ascites or azotaemia. The time interval between the original surgery and the recognition of the injury ranged between 1 and 92 days. Patients in whom deterioration in renal function was ascribed to obstructive uropathy from bilateral ligation (postrenal renal failure) were referred much earlier than those in whom a diagnosis of prerenal renal failure was made (mean of 2 vs. 10 days). Five patients (36%) required dialyses before repair. All the repairs were done at open surgery. Thirteen survived with no loss of kidney. One patient died of overwhelming sepsis.
Late recognition and referral of bilateral ureteric injury was associated with serious complications. Post operative deterioration in a patient's renal function following pelvic surgery should be assumed to be due to ureteric obstruction until proven otherwise. Such patients should be promptly referred to centres with the facility for further investigation and management. Early open repair for these injuries is advocated.
PMCID: PMC2673835  PMID: 19452019
ureteral injury; renal failure; gynaecological surgery; anuria; hydronephrosis
18.  Delayed Presentation of Isolated Complete Pancreatic Transection as a Result of Sport-Related Blunt Trauma to the Abdomen 
Blunt abdominal trauma is a rare but well-recognized cause of pancreatic transection. A delayed presentation of pancreatic fracture following sport-related blunt trauma with the coexisting diagnostic pitfalls is presented.
Case Report
A 17-year-old rugby player was referred to our specialist unit after having been diagnosed with traumatic pancreatic transection, having presented 24 h after a sporting injury. Despite haemodynamic stability, at laparotomy he was found to have a diffuse mesenteric hematoma involving the large and small bowel mesentery, extending down to the sigmoid colon from the splenic flexure, and a large retroperitoneal hematoma arising from the pancreas. The pancreas was completely severed with the superior border of the distal segment remaining attached to the splenic vein that was intact. A distal pancreatectomy with spleen preservation and evacuation of the retroperitoneal hematoma was performed.
Blunt pancreatic trauma is a serious condition. Diagnosis and treatment may often be delayed, which in turn may drastically increase morbidity and mortality. Diagnostic difficulties apply to both paraclinical and radiological diagnostic methods. A high index of suspicion should be maintained in such cases, with a multi-modality diagnostic approach and prompt surgical intervention as required.
PMCID: PMC3075161  PMID: 21490833
Pancreatectomy; Pancreatic transection; Mesenteric hematoma
19.  Ureteral Injury in Gynecologic Surgery: A 5-Year Review in A Community Hospital 
Korean Journal of Urology  2012;53(2):120-125.
We reviewed the cases of ureteral injury during gynecologic surgeries in a community hospital and attempted to find possible options for alleviating these distressing situations.
Materials and Methods
A total of 2,927 patients underwent gynecologic surgeries in the last 5 years at our hospital. We retrospectively analyzed the cases, particularly the possible risk factors and management according to the time of detection of the injury. Thirty-five cases (1.2%) were identified with ureteral injury in a total of 2,927 gynecologic surgeries. Risk factors included endometriosis, pelvic inflammatory disease, previous pelvic surgery, history of pelvic radiation, and congenital anomalies. Among 2,927 patients, 522 had predisposing factors for ureteral injuries.
The incidence of ureteral injury in laparoscopic cases was 1.1%, similar to the cases of laparotomy (1.2%). The rate of ureteral injury was significantly higher in the group with risk factors (2.7%) than in the group without risk factors (0.9%; p=0.002). Prophylactic ureteral stenting was performed in 101 of 522 patients with risk factors according to the gynecologic surgeon's preference. The injury rate (1.0%) in the stenting group was lower than that in the non-stenting group (3.1%; p=0.324). Management of ureteral injuries was successful in all cases. Of the patients with postoperatively diagnosed injuries, two patients were managed with secondary procedures, such as retrograde balloon dilatation or ureteroneocystostomy.
The incidence of ureteral injury was significantly higher in cases having risk factors than in cases without risk factors. Surgeons should be cautious to avoid ureteral injury during gynecologic surgery, especially in patients with risk factors.
PMCID: PMC3285707  PMID: 22379592
Gynecologic surgical procedures; Laparotomy; Stents; Ureter; Wounds and injuries
20.  Extensive Retroperitoneal Fibrosis with Duodenal and Ureteral Obstruction Associated with Giant Inflammatory Aneurysm of the Abdominal Aorta 
Texas Heart Institute Journal  2003;30(4):311-313.
We report a case of abdominal aortic aneurysm complicated by retroperitoneal fibrosis with both duodenal and bilateral ureteral obstruction. The patient underwent successful bilateral transurethral ureteral stenting, and then he was referred for surgical treatment of the aneurysm. Massive retroperitoneal fibrosis was found at surgery, and the mass was removed along with the diseased aorta, which was replaced by a bifurcated Dacron prosthesis; duodenolysis and ureterolysis were concomitantly performed. Ureteral stents were removed on the 8th postoperative day. Follow-up assessment at 1 year showed normalization of the urinary tract structure at echography and good hemodynamic performance of the vascular prosthesis at Doppler examination. To our knowledge, no other case of duodenal and bilateral ureteral stenosis secondary to massive retroperitoneal reactive fibrosis in association with abdominal aortic aneurysm has been reported. (Tex Heart Inst J 2003;30:311–3)
PMCID: PMC307718  PMID: 14677743
Anuria/etiology; aortic aneurysm, abdominal/complications; blood vessel prosthesis; case report; duodenal obstruction/etiology; retroperitoneal fibrosis/complications; tomography, x-ray computed; ultrasonography; ureteral obstruction/etiology
21.  Combined Y-shaped common channel transureteroureterostomy with Boari flap to treat bilateral long-segment ureteral strictures 
BMC Research Notes  2014;7:550.
Ureteral stricture is a complication of several etiologies including idiopathic retroperitoneal fibrosis, infection, radiotherapy, instrumentation, and surgical procedures. A variety of techniques have been reported for management. The transureteroureterostomy and bladder flap have been the standard procedures for repairing distal ureteral defects of unilateral ureter. Bilateral ureteral stricture is an uncommon condition that challenges usual reconstructive procedures. It is a difficult task to reconstruct the complex situation of bilateral ureteral strictures.
Case presentation
A 54-year-old female underwent concurrent chemoradiotherapy for stage IVB squamous cell carcinoma of cervix. Subsequently, she had stricture of bilateral distal ureters with bilateral hydroureteronephrosis which was found by computed tomography. The renal function deteriorated during the follow-up period. She had periodic change of double-J stents and percutaneous nephrostomy. However, the renal function still deteriorated. We performed a combined Y-shaped common channel transureteroureterostomy with Boari flap to reconstruct bilateral long-segment ureteral strictures. The patient recovered uneventfully.
Reconstruction of bilateral ureteral strictures is a difficult treatment. We developed a modified technique for the complex situation of bilateral ureteral strictures. To our knowledge, this has not been previously reported in the scientific literature and it is a feasible procedure to treat bilateral long-segment ureteral strictures.
PMCID: PMC4150947  PMID: 25138268
Boari flap; Double-J catheter; Radiation; Transureteroureterostomy; Ureteral stricture
22.  A Rare Presentation of AKI: Gastric Infiltration of the Bladder Wall 
Case reports in nephrology  2011;2011:387649.
We describe the case of a man who presented with back pain and acute kidney injury and was found to have bilateral ureteral obstruction, which initially corrected with ureteral stents. Imaging studies showed thickening of the bladder. Shortly thereafter, he developed obstructive jaundice, pancreatitis, recurrence of renal failure, and was diagnosed with advanced gastric cancer after a laparotomy revealed peritoneal carcinomatosis. The patient deteriorated rapidly after diagnosis. While peritoneal carcinomatosis, ureteral metastases, and extrinsic ureteral compression have been recognized in gastric cancer, obstructive renal failure due to tumor infiltration of the bladder wall is seldom described. We present this case as an unusual cause of acute renal failure and presentation of gastric cancer.
PMCID: PMC3914133  PMID: 24533190
23.  Diaphragmatic Hernia: An Uncommon Cause of Dyspepsia 
Adult onset diaphragmatic hernia is a rare condition with variable clinical manifestations. The majority of adult-onset diaphragmatic hernia is associated with trauma. Blunt thoracic and abdominal trauma associated with a 5% to 7% incidence of diaphragmatic injury, and in 3% to 15% for those with penetrating injury. These injuries may be left unrecognized when they occur but often are uncovered months later during work up for related symptoms. Prompt diagnosis and surgical repair is recommended by most authorities. Traditionally, diaphragmatic hernia is repaired by laparotomy or thoracotomy, or both. Herein, we report a case of adult onset diaphragmatic hernia presented with dyspepsia that was successfully repaired via laparoscopy. Operative approach and technique of diaphragmatic defect closure is elucidated.
PMCID: PMC3015605  PMID: 16121887
Hernia; Diaphragmatic hernia; Laparoscopy
24.  Review of 9 Cases of Diaphragmatic Injury Following Blunt Trauma Chest; 3 Years Experience 
The Indian Journal of Surgery  2012;76(4):261-264.
Diaphragmatic injuries can occur with both blunt and penetrating trauma which can be associated with herniation of abdominal viscera into the thoracic cavity. Diaphragmatic injuries can occur with blunt trauma chest in 1–7 % of patients. Retrospectively for last 3 years all cases blunt trauma chest admitted to surgery were reviewed and a study of cases of diaphragmatic rupture was done. We analysed 496 patients of blunt trauma chest retrospectively for period of three years. Nine patients have diaphragmatic injuries, all were males, six presented acutely three were chronic. In six patients laparotomy was done, four subcostal and two midline incisions were preferred. In chronic cases thoracotomy was done. Left sided injury predominates and rib fractures are most common associated finding. Diagnosis in majority of cases is made by Computerised tomography scan. Subcostal incision may be used in patients with isolated diaphragmatic injury in acute presentation while thoracotomy is preferred in late cases. Most common morbidity is pulmonary complications
PMCID: PMC4175668  PMID: 25278647
Blunt trauma chest; Diaphragmatic injuries; Subcostal incision
25.  Ureteral Injury with Delayed Massive Hematuria after Transvaginal Ultrasound-Guided Oocyte Retrieval 
We report a case of ureteral injury with delayed hematuria after transvaginal oocyte retrieval. A 28-year-old infertile patient with a history of previous laparoscopic resection of endometriotic nodes of both sacrouterine ligaments presented with abdominal pain one day after oocyte retrieval. Four days after oocyte retrieval, she presented with massive hematuria that reappeared 6 days after oocyte retrieval. Monopolar coagulation with wire electrode and insertion of a double-J-stent was performed during operative cystoscopy. The patient recovered completely after transfusion and had no signs of renal impairment after ureteric stent removal. This is the first report of ureteral injury after oocyte retrieval presenting itself with delayed massive hematuria and no signs of renal dysfunction or urinary leakage into retroperitoneal space.
PMCID: PMC4471305  PMID: 26146577

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