356 | Prevalence and Management of Complications of Ureteroscopy A Seven-Year Experience With Introduction of a New Maneuver to Prevent Ureteral Avulsion Karim Taie,1 Majid Jasemi,1 Dinyar Khazaeli,2 Ali Fatholahi 2 Purpose: To evaluate the prevalence and type of rigid ureteroscopy complications and suggest a new method for ureteral avulsion prevention. Materials and Methods: Between March 2002 and March 2009, we retrospec- tively evaluated 2955 patients who had undergone diagnostic or therapeutic ure- teroscopy for asymptomatic hematuria, migrated ureteral stent, or transurethral lithotripsy. They were enrolled from four hospitals in Ahvaz, Iran. Results: Complications were encountered in 241 (8%) patients, including tran- sient hematuria (4.2%), mucosal erosion (1.4%), stone migration (1.3%), ureteral perforation (1.2%), and fever and/or sepsis (1.0%). Ureteral avulsion occurred in 6 (0.2%) patients. Mostly, complications were managed conservatively, using ure- teral stenting. Ureteral avulsions were managed using a new technique. Conclusion: In our series, the complication rate is comparable with the literature. A new technique was used in case of ureteroscope entrapment in the ureter, to lessen the occurrence of ureteral avulsion. Keywords: ureteroscopy, ureteral calculi, treatment outcome, lithotripsy, intraop- erative complications Corresponding Author: Karim Taie, MD Department of Urology, Imam Khomeini Grand Hospital, Jondishapour University of Medical Sci- ences, Ahvaz, Iran Tel: +98 916 111 0545 Fax: +98 611 222 2229 E-mail: ktaee@yahoo.com Received April 2010 Accepted March 2011 1 Department of Urology, Imam Khomeini Grand Hospital, Jondishapour University of Medical Sci- ences, Ahvaz, Iran 2 Department of Urology, Golestan Grand Hospital, Jondishapour University of Medical Sciences, Ahvaz, Iran Endourology and Stone Disease Endourology and Stone Disease 357Vol. 9 | No. 1 | Winter 2012 |U R O LO G Y J O U R N A L Complications of Ureteroscopy | Taie et al INTRODUCTION Transurethral lithotripsy (TUL) is the treat-ment of choice for lower and middle ureter-al calculi.(1-4) It has also been used for treat- ment of upper ureteral and renal stones. Based on recent studies, its use as a treatment modality for upper third ureteral stones has become popular;(1-3) however, extracorporeal shockwave lithotripsy (SWL) is still the treatment of choice.(3) Besides its therapeutic benefits, TUL may be as- sociated with some minor or major complications, which may range from a subtle flank pain and transient hematuria to ureteral perforation, ureteral avulsion, and sepsis.(5,6) Recently, these complica- tions have become less prevalent due to the intro- duction of semi-rigid and flexible ureteroscopes and increasing experience and familiarity of sur- geons with TUL.(6) Nonetheless, ureteroscopy is still the most common cause of ureteral injury.(7) Therefore, surgeons should be aware of potential complications and their management strategies. In this study, we evaluated the prevalence and type of these complications and also suggested a method to prevent ureteral avulsion. MATERIALS AND METHODS A total of 2955 patients who had undergone di- agnostic ureteroscopy were retrospectively evalu- ated. They were recruited from four hospitals namely, Golestan, Imam Khomeini, Arvand, and Apadana, in Ahvaz, Iran. The indications for ureteroscopy were asymptomatic hematuria, ureteral stent mi- gration, and TUL. Ureteroscopies were performed by eight urologists who had at least ten years of experience. In all the subjects, procedures were performed using a rigid ureteroscope 6.75 to 9.0F, and TUL was carried out by pneumatic Swiss Lithoclast lithotripter. The pre-operative urine culture was negative and prophylactic antibiotics were administered to all the subjects. The following data were obtained from medical records: age, gender, stone charac- teristics (volume and location), complications, and management strategies. RESULTS Of participants, 2165 and 790 were male and fe- male, respectively. The mean age of the patients was 38 years (range, 3 to 80 years). The mean stone diameter was 11.5 mm (range, 4 to 20 mm). More than one ureteral stone was treated in 24% of patients and stone street was encountered in 57 (2%). The locations of stones were upper, mid- dle, and lower third of the ureter, in 8%, 25%, and 66.8%, respectively. Renal pelvic stone accounted for 0.2% of cases. Bilateral TUL was performed in 3% of patients. Stones were not amenable to TUL in 7 patients; hence, ureterolithotomy and/or dou- ble-J ureteral stent insertion were performed. Complications included fever and/or sepsis, tran- sient hematuria (lasting less than 4 days), stone mi- gration, ureteral mucosal injury (abrasion and false passage formation), ureteral perforation, and ure- Table 1. Distribution of urologists and study population in different hospitals Hospitals Urologists (n = 8)* Study population (n = 2955) Male (n = 2165) Female (n = 790) Imam Khomeini 3 867 (29.34%) 316 (10.69%) Golestan 5 822 (27.82%) 300 (10.15%) Apadana 3 195 (6.60%) 71 (2.40%) Arvand 4 281 (9.51%) 103 (3.48%) * Some of the urologists work in more than one hospital 358 | teral avulsion (Table 2). Death, severe hemorrhage, stone expulsion to retroperitoneum, urinoma, or abscess formation did not occur in any patient. Up- ward stone migration occurred mostly in patients with upper third ureteral stones and those with se- vere hydroureteronephrosis. All cases of fever and hematuria were managed successfully using conservative management. Ureteral perforation, ureteral mucosal trauma, and false passage formation were also successfully managed with double-J ureteral stent insertion for 4 to 6 weeks in all of the patients except one, who underwent open surgery since ureteral stenting was impossible. Ureteral avulsion occurred in 6 patients (1 woman and 5 men), of whom 4 had upper third ureteral stones, one had impacted ureteral stone, and one had large stone. In all subjects with ureteral avul- sion, the avulsed ureter exited from the urethral meatus, coating the ureteroscope, while the sur- geon was attempting to pull back the ureteroscope with force. The ureter has been detached from ureterovesical junction (UVJ) in 1 patient; and in 5 patients si- multaneous UVJ and ureteropelvic junction (UPJ) avulsion occurred. Management consisted of ne- phrectomy (1 patient), ureteral re-implantation (1 patient), using Boari flap (2 patients), and ileal in- terposition (1 patient). In a patient with complete ureteral avulsion, we performed proximal anas- tomosis and distal refluxing ureteral re-implan- tation. Double-J ureteral stent was inserted in all the 6 patients. The last patient, who had undergone proximal anastomosis with distal re-implantation, underwent SWL consequently due to renal stones, but unfortunately, stone fragments did not pass completely. Double-J stent was inserted for the pa- tient and was replaced every 3 to 6 months. The Table 2. Demographic and clinical characteristics of study population Variables Male (n = 2165) Female (n = 790) Age (mean ± SD), y 38.1 ± 10.2 37.5 ± 9.8 Indications, No (%) Calculus 2081 (70.42%) 758 (25.65%) Diagnostic 65 (2.20%) 23 (0.78%) Retained or migrated stent 22 (0.74%) 8 (0.27%) Complications, No (%)* Hematuria 66 (2.23%) 58 (1.96%) Stricture 0 (0%) 0 (0%) Perforation 21 (0.71%) 14 (0.47%) Avulsion 5 (0.17%) 1 (0.03%) Mucosal erosion/False passages 23 (0.78%) 17 (0.58%) Fever/Sepsis 16 (0.54%) 13 (0.44%) Stone Migration 12 (0.41%) 26 (0.88%) Total 143 (4.84%) 129 (4.37%) * Some cases showed more than one complication; overall complication rate was 8.1%. Endourology and Stone Disease 359Vol. 9 | No. 1 | Winter 2012 |U R O LO G Y J O U R N A L Complications of Ureteroscopy | Taie et al patient was followed up for 2 years, but he was not compliant enough. He did not return for fur- ther follow-up; therefore, he missed the chance of reconstructive surgery and finally underwent ne- phrectomy in another center because of ureteral stricture and severe renal damage. DISCUSSION Compared with SWL, TUL is more effective in treatment of the lower third ureteral stones.(1-3) Al- though SWL is still the modality of choice in the treatment of upper and middle third ureteral stones, TUL is being performed increasingly with the same efficacy.(1-4,8) Today, open surgery is rarely done for treating ureteral and renal stones, since these may also be treated with flexible ureteroscopy and hol- mium laser. Besides its therapeutic benefits and despite its widespread use, TUL may be associated with a number of complications, especially when used for treating proximal ureteral stones.(4,9) Di- agnosing these complications and managing them have utmost importance for surgeons undertaking this procedure. In a study by Gleavlete and associates, 2735 TUL procedures were assessed with regards to the rate and type of complications. Immediate complications occurred in 10.64% of patients, including fever and sepsis (1.13%), persistent he- maturia (2.04%), renal colic (2.23%), transient vesicoureteral reflux (4.58%), and ureteral stent migration (0.66%). Intra-operative complications happened in 3.6% of subjects and included ureteral mucosal trauma (false passage formation) (1.0%), abrasion (1.50%), ureteral perforation (0.65%), stone expulsion (0.18%), bleeding (0.10%), and ureteral avulsion (0.11%).(5) In another study, Elashry and colleagues stated that with increasing surgeon’s experience and evolving devices, the rate of ureteral perforation and avul- sion have decreased from 3.3% to 0.5% and from 1.3% to 0.1%, respectively.(6) In a study of 2273 patients who had undergone ureteroscopy, Bultler reported 1% complication rate, which was mostly ureteral trauma and managed conservatively while 22% required open surgery due to ureteral perfora- tion or avulsion.(10) In our study, 8% of patients developed complica- tion, which were mostly minor complications, in- cluding transient hematuria, stone migration, false passage formation, and ureteral mucosal trauma. Except for one patient, all the cases of ureteral per- foration were managed by ureteral double-J stent insertion for 6 weeks. Fever and sepsis were also treated with conservative therapy. Ureteral avul- sion was the most serious complication, which occurred in 0.2% of patients, and resulted in ne- phrectomy in 1 out of 6 subjects. The affected kid- ney was salvaged in the other 5 patients with open surgery. Our complication rate is comparable with previ- ous studies. The most catastrophic complication of ureteroscopy is ureteral avulsion. Although it oc- curred in only 0.2% of patients, appropriate strate- gies should be considered to prevent it due to its serious consequences and potential sequel. Once it occurs, however, proximal anastomosis and distal re-implantation of the avulsed ureter may be done as a temporary option until further reconstructive procedures can be undertaken in more suitable set- tings. If ureteroscope is trapped in the ureter, it cannot be taken out and ureteral avulsion may occur in case of excessive force. The authors suggest the follow- ing maneuver to prevent ureteral avulsion: a. Increase irrigation pressure in the ureter; hence, the ureteral mucosa would be released from the ureteroscope. b. Perform rectal examination in men with your left index finger or insert two fingers in the vagi- nal fornix in women, and try to push UVJ and the lower ureteral segment upward and against the ureteroscope’s sheath. While the ureter is dilated, wave and rotate the ureteroscope 45º clockwise and counter clockwise gently and remove it if no resistance is encountered. At the same time, control 360 | REFERENCES 1. Anagnostou T, Tolley D. Management of ureteric stones. Eur Urol. 2004;45:714-21. 2. Wolf JS, Jr. Treatment selection and outcomes: ureteral calculi. Urol Clin North Am. 2007;34:421-30. 3. Nikoobakht MR, Emamzadeh A, Abedi AR, Moradi K, Mehr- sai A. 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Urol J. 2006;3:75-8. ureteral mucosal movement proximally against the direction of ureteroscope. Retry if it was not suc- cessful. Writers of this study have tried this maneuver in many cases, and in all cases ureteroscope could be released easily. CONCLUSION In case of ureteral avulsion, proximal anastomosis and distal refluxing re-implantation of the avulsed ureter and double-J stent insertion can buy the pa- tient’s time for reconstructive surgery in a more suitable situation. CONFLICT OF INTEREST None declared. Endourology and Stone Disease 9. Francesca F, Scattoni V, Nava L, Pompa P, Grasso M, Rigatti P. Failures and complications of transurethral ureteroscopy in 297 cases: conventional rigid instruments vs. small caliber semirigid ureteroscopes. Eur Urol. 1995;28:112-5. 10. Butler MR, Power RE, Thornhill JA, et al. An audit of 2273 ureteroscopies--a focus on intra-operative complications to justify proactive management of ureteric calculi. Surgeon. 2004;2:42-6.