Stesura Seveso


Archivio Italiano di Urologia e Andrologia 2021; 93, 2248

CASE REPORT

No conflict of interest declared.

CASE REPORT
We present the case of a female patient aged 72-year-old
who previously underwent sacral-colpopexy because of
anterior vaginal compartment prolapse. The patient
underwent surgery to remove the mesh, due to the pain
she had had since it was placed. A mid-line laparotomy
was performed removing completely the mesh. 
At 48 hours after intervention, the patient started feeling
an intense pain in the left renal fossa that was not
relieved with anti-inflammatories and morphic drugs, as
well as nausea and vomiting. CT scan showed left
uretero-hydronephrosis with complete ureteral dilation
from a few centimetres above the bladder. Moreover, it
was observed free perirenal fluid. Based on these find-
ings, it was decided emergency surgery performing ret-
rograde pyelography.
During pyelography (Figure 1), it was checked stop in
retrograde pass contrast about 4 cm from the bladder.
With the increase of the instillation pressure of contrast
in the ureter, a filiform passage of contrast was observed
through the stop area. At that time, a ureteroscopy was
decided, introducing a 9.5 F semi-rigid instrument to
the problem area (Figure 2). Under direct vision, con-
centric closure of the ureter lumen could be observed,
suspecting iatrogenic suture of the ureter. A guide pass
was achieved through the central area of the stenotic
area, verifying its correct location with intraoperative
fluoroscopy. Due to the availability of holmium laser, an
endoureterotomy was performed in the 12h central posi-
tion on the tip, with laser parameters of 1J-10Hz. Almost
instantaneously, the stenotic area was opened, showing
the polyglactin suture that entered from the outside of
the ureter to the inside and leaving the ureter tract with
a good caliber without resistance to the passage of the
ureteroscope. In the rest of the ureter no injuries were
evidenced.
A 6 F ureteral stent was maintained for one month.
During follow-up, the patient remained asymptomatic
and without dilation of the left system on imaging tests.

DISCUSSION
The use of holmium laser for the endoscopic treatment
of intraluminal ureteral sutures has been previously
described, with correct resolution in all cases. 
The summary of the published literature is summarized
in Table 1 (2-5).

Although reconstructive surgery is the most
accepted treatment for ureteral injury, there

are reports of cases where endourologic treatment led to cor-
rect resolution of the problem. We present the case of a female
patient aged 72-year-old who was previously underwent sacral-
colpopexy because of anterior vaginal compartment prolapse.
The patient underwent surgery to remove the mesh, due to the
pain she had had since it was placed. A mid-line laparotomy
was performed removing completely the mesh. At 48 hours
after intervention, the patient started feeling an intense pain in
the left renal fossa that was not relieved with anti-inflammato-
ries and morphic drugs. In the diagnostic ureteroscopy, it was
found iatrogenic suture of the ureter. Due to the availability of
holmium laser, an endoureterotomy was performed in the 12h
central position on the tip, with laser parameters of 1J-10Hz. 
A 6F ureteral stent was maintained for one month. During 
follow-up, the patient remained asymptomatic and without 
dilation of the left system on imaging tests. Although we accept
that open reconstruction is the gold standard treatment for
ureteral trauma, we describe holmium laser endoureterotomy
as a promising technique to consider in the event of ureteral
intraluminal ligation. 

KEY WORDS: Ureteral trauma; Endourology; Holmium laser.

Submitted 2 February 2021; Accepted 5 February 2021  

INTRODUCTION
Ureteral injury represents only 1-2,5% of urologic trau-
ma. The main cause of ureteral injury is in 75% of the
cases iatrogenic by urologic, gynaecologic, or colorectal
surgery. Ureteral injury diagnosis must be suspected
since there are no specific signs to identify it. Patient
symptoms will depend on the degree of the wound, loca-
tion, or the type of damage (perforation, ligation, tran-
section). Computed tomography urography (CTU) and
anterograde or retrograde pyelography presents high
sensibility for ureteral trauma diagnosis (1). 
Although reconstructive surgery is the most accepted treat-
ment for ureteral injury, there are reports of cases where
endourologic treatment led to correct resolution of the
problem. Various procedures have been described from
resolution of urinary leak by means of ureteral stent to
ureteral realignment in case of complete transection (1). In
this study, we present a case of an iatrogenic ureteral liga-
tion with an intraluminal suture resolved by laser
endoureterotomy. Here we describe the key points of the
surgery as well as review similar cases reported in literature. 

Endoscopic treatment of intraluminal ureteral suture 
with holmium laser

Jorge Panach-Navarrete, María Negueroles-García, José María Martínez-Jabaloyas

Department of Urology, University Clinic Hospital of Valencia, Facultat de Medicina i Odontologia, Universitat de València,
Valencia, Spain.

DOI: 10.4081/aiua.2021.2.248

Summary



249Archivio Italiano di Urologia e Andrologia 2021; 93, 2

Treatment of intraluminal ureteral suture

As can be seen in the review, endoscopic
ureterotomy is a successful surgery which
can prevent the patient from a more aggres-
sive surgery. 
As shown in Table 1, the use of the balloon
dilatation catheter or the weeks of perma-
nence of the stent are not clearly defined.
In our experience, the clinical course of the
patient was optimal without the use of a
balloon and with maintenance of the stent
for 4 weeks. From our point of view, it is a
simple endourological procedure if you are
used to ureteroscopy. 
The main limiting factor could be the
availability of laser in case of emergency
surgery, so the possibility of its use must
be foreseen. Although we accept that
open reconstruction is the gold standard
treatment for ureteral trauma, we describe
a promising technique to consider in the
context of ureteral intraluminal ligation.

REFERENCES
1. Bryk DJ, Zhao LC. Guideline of guidelines: a
review of urological trauma guidelines. BJU Int.
2016; 117:226-34.

2. Hao Z, Zhang L, Zhou J, et al. Minimally Invasive
Management of Iatrogenic Ureteral Injuries with
Ureteroscope Facilitated by Holmium Yttrium-
Aluminum-Garnet Laser. Int Sch Res Notices. 2014;
2014:307963.

3. Bagley DH, Schultz E, Conlin MJ. Laser division
of intraluminal sutures. J Endourol. 1998; 12:355-7.

4. Lawrentschuk N, Rogerson J, Bolton DM. Use of
holmium laser for removal of an intraluminal
ureteric suture. Int J Urol. 2004; 11:916-8.

5. Klett DE, Mazzone A, Summers SJ. Endoscopic
Management of Iatrogenic Ureteral Injury: A Case
Report and Review of the Literature. J Endourol
Case Reports. 2019; 142-144. 

Table 1. 
Endoscopic treatment of intraluminal sutures, summary of published cases.

Figure 1. 
Retrograde pyelography where 
a retrograde stop in the contrast 
passage was found about 4 cm 
from the bladder. 
By increasing the instillation 
pressure of contrast in the ureter, 
a filiform passage (white arrow) 
of contrast was observed through 
the stop area.

Figure 2. 
Image of ureteroscopy. 
(A) Guide passage through the stenotic area. 
(B) Endoureterotomy with holmium laser in position 12h on the guide. 
(C) Image of the injured area once the stenosis has been incised. 
The white arrow indicates the polyglactin suture, with the gray arrow the area 
of the ureter wall incised with laser.

Author Number Balloon Weeks Success Postoperative
of cases dilatation catheter of stent complication

Hao, Z. (2) 12 Yes 12 weeks 100% No

Bagley, D.H. (3) 1 No 6 weeks 100% No

Lawrentschuk (4) 1 No 2 weeks 100% No

Klett, D.E. (5) 1 No 8 weeks 100% No

Correspondence
Jorge Panach-Navarrete, MD (Corresponding Author)
jorge.panach@uv.es
María Negueroles-García, MD
maria.negueroles@gmail.com
José María Martínez-Jabaloyas, MD, PhD
marjabaloyas@gmail.com
Department of Urology, University Clinic Hospital of Valencia, 
Facultat de Medicina i Odontologia, Universitat de València, Valencia, Spain
Av Blasco Ibáñez, 17, CP 46010 Valencia, Spain