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Ureteral Stricture

Steis Ureteral

Ureteral stricture denotes stenosis of the ureteral lumen, most commonly due to iatrogenic causes, and symptoms of obstruction are most frequently observed.


Presentation

The post-operative appearance of fever, flank abdominal pain, leukocytosis and even peritonitis are hallmarks of ureteral stricture and if such symptoms are present after gynecological or colorectal surgery, a high dose of clinical suspicion toward this disorder should be made [2].

Asymptomatic
  • Patient was asymptomatic during the follow-up. However, a urinary ultrasound disclosed important pielocalyceal dilation, and further investigation demonstrated extensive proximal ureteral stricture.[ncbi.nlm.nih.gov]
  • The patient remains asymptomatic, with normal renal sonogram, 6 months after the procedure.[ncbi.nlm.nih.gov]
  • Asymptomatic urinary tract infection developed in two other patients, with no renal function impairment.[ncbi.nlm.nih.gov]
  • Although most strictures are either asymptomatic or easily dilated, there are some strictures that result in progressive ureteral obstruction, do not respond to ureteral dilation and require operative intervention.[ncbi.nlm.nih.gov]
  • At a mean follow-up of 8 mo, all patients were asymptomatic. The main limitations were the short follow-up and the small sample size. CONCLUSIONS: RAUU is feasible and safe for repairing iatrogenic lumbar and iliac ureteral strictures.[ncbi.nlm.nih.gov]
Suggestibility
  • Various procedures have been suggested, but endoureterotomy, balloon dilation, and open surgical repair are most commonly performed.[symptoma.com]
  • To improve the functional outcome of this operation 2 main technical modifications were suggested: tailoring the bowel segment and non-refluxing ileovesical anastomosis (17). These two main rules were not respected by the surgeon in our case.[latunisiemedicale.com]
Flank Pain
  • Several months later the flank pain recurred, and IVP now showed a calcified stone midway in the left ureter. Ureterolithotomy was performed, and a 3 cm long stone embedded in the mucosa was removed.[ncbi.nlm.nih.gov]
  • The left renal function, glomerular filtration rate, had a recovery from 9.6 ml/min preoperatively to 14.0 ml/min at 6-month follow-up, and the patient has no complaints about the donor site and flank pain.[ncbi.nlm.nih.gov]
  • From above condition if any of these conditions restricted or compress the ureter enough to block pee flow, you may feel signs, (for example, flank pain or blood in the pee) and you are at danger for infections, kidney stones, or kidney harm.[roboticsurgeonindia.com]
  • The patient is asked to uncap the tube if flank pain, fever, or drainage around the catheter develops. The stent is exchanged for a nephrostomy catheter at the end of six to eight weeks.[alpfmedical.info]
Ureteral Disorder
  • Disorders Your kidneys make urine by filtering wastes and extra water from your blood.[icdlist.com]
Ureteral Disorder
  • Disorders Your kidneys make urine by filtering wastes and extra water from your blood.[icdlist.com]

Workup

Abdominal ultrasonography may be initially used to detect hydronephrosis that can suggest the presence of the stricture, but either cystoscopy or a retrograde pyelogram are recommended diagnostic procedures [2]. CT-IVP is an alternative method to detect strictures, but the use of a contrast is necessary in this case [2].

Treatment

Various procedures have been suggested, but endoureterotomy, balloon dilation, and open surgical repair are most commonly performed [1]. The choice somewhat depends on the location of injury [2], however, as laparoscopic ureteral reimplantation has shown excellent results in managing distal strictures [3] [7], whereas robot-assisted ureteral reimplantation showed equal efficacy for both middle and distal strictures [4].

Prognosis

Between 50-70% of ureteral injuries are not diagnosed during procedures that caused it and require further diagnostic workup [2], but the prognosis is good with early recognition of injury.

Etiology

Several causes have been recognized [1] [2] [5]:

  • Iatrogenic - In the vast majority of cases, the ureteral stricture is the result of injury after various procedures, including endoscopic, laparoscopic or open surgery, renal transplantation, or endoscopy of the upper GI tract.
  • Congenital strictures - Most commonly seen at the ureteropelvic junction.
  • Passage of renal calculi.

Epidemiology

It is estimated that gynecologic surgery is responsible for 75% of all ureteral iatrogenic injuries and estimated rates are 0.2 per 1000 cases in the setting of vaginal hysterectomy and 1.3 per 1000 cases for total abdominal hysterectomy [2]. 9% of cases are seen after colorectal surgery, while less than 1% of cases are seen after renal procedures [2]. Renal calculi and their descent through the ureter are recognized risk factors, as ureteral perforation was strongly correlated with the formation of a stricture at that site [5]. Moreover, endourological treatment of ureteral stones is also described as a procedure that can induce stricture and between 14-24% of patients develop this complication [6].

Sex distribution
Age distribution

Pathophysiology

Iatrogenic injury to the ureter can cause ischemia associated with fibrosis and scarring of the ureter, or other conditions such as renal calculi or congenital abnormalities are the underlying cause [1]. These events, accompanied by narrowing of the ureteral lumen, induce typical signs and symptoms.

Prevention

By far the most significant preventive strategy is avoiding ureteral injury, meaning that surgeons must pay attention not to damage the ureter when performing gynecological or colorectal surgery.

Summary

Ureteral stricture - pathological narrowing of the lumen of the ureter, is almost always induced by iatrogenic causes, with several forms of surgery (endoscopic/open) and renal transplantation being most frequently mentioned [1]. Malignant tumors, congenital stricture, and certain infections are other notable causes [1], and symptoms such as abdominal pain, leukocytosis and a sense of fullness are primarily encountered [2]. Cystoscopy or a retrograde pyelogram are recommended for the diagnosis of ureteral stricture, while computed tomography with intravenous pyelogram (CT-IVP) is a good alternative method [2]. Endoureterotomy, balloon dilation and either laparoscopic or open reconstruction, which carries the highest success rates, may be performed in order to repair the stricture [1] [3] [4].

Patient Information

Ureteral stricture is a term describing the pathological narrowing of the lumen of the ureter, which connects the kidneys and the bladder. In most cases, this condition is caused by damage of the ureter during surgical procedures (mainly gynecological and colorectal) or other diagnostic procedures in the abdominal area, such as endoscopy of the upper gastrointestinal tract. Symptoms include the post-operative development of fever, increased white blood cell count and abdominal pain with a sense of fullness. The diagnosis can be made by conducting imaging studies that will visualize the narrowed ureter and several surgical approaches exist. Depending on the location of stricture, both invasive (open surgery) or minimally invasive (endoscopic surgery) may be performed to repair the injury.

References

Article

  1. Hafez KS, Wolf JS Jr. Update on minimally invasive management of ureteral strictures. J Endourol. 2003;17(7):453-464.
  2. Burks FN, Santucci RA. Management of iatrogenic ureteral injury. Ther Adv Urol. 2014;6(3):115-124.
  3. Abraham GP, Das K, Siddiaiah AT, Ramaswami K, George PD, Abraham JJ. Laparoscopic reconstruction of ureteral strictures involving solitary renal units-1 year and 5 year outcomes. J Minim Access Surg. 2015;11(4):236-240.
  4. Kozinn SI, Canes D, Sorcini A, Moinzadeh A. Robotic versus open distal ureteral reconstruction and reimplantation for benign stricture disease. J Endourol. 2012;26(2):147-151.
  5. Roberts WW1, Cadeddu JA, Micali S, Kavoussi LR, Moore RG. Ureteral stricture formation after removal of impacted calculi. J Urol. 1998;159(3):723-726.
  6. Fam XI, Singam P, Ho CCK, et al. Ureteral stricture formation after ureteroscope treatment of impacted calculi: A prospective study. Korean J Urol. 2015;56(1):63-67.
  7. Ogan K, Abbott JT, Wilmot C, Pattaras JG. Laparoscopic Ureteral Reimplant for Distal Ureteral Strictures. JSLS. 2008;12(1):13-17.

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Last updated: 2018-06-22 05:40