Management of ureteral avulsion as a complication of ureterorenoscopy

Objective: To review diagnostic and operative considerations in the management of ureteral avulsion resulting from ureterorenoscopy.

Materials and methods: Between 1999 and 2007, three cases of complete ureteral avulsion following ureteroscopic surgery were repaired. Avulsion was recognized perioperatively in two patients undergoing surgery for impacted distal and mid-ureteral stones, and was treated with end-to-end anastomosis in one case, and with psoas hitch in the other. One patient undergoing surgery for a proximal stone in another center was referred five days postoperatively with right flank pain, tenderness, and fever. A percutaneous nephrostomy was placed, and antegrade pyelogram showed a large defect of the mid-ureter. The avulsed ureter was repaired three weeks after the primary surgery with a Boari flap extending to the proximal ureter. In all cases, ureteral stent was removed within six weeks of surgery.

Results: Intravenous pyelogram obtained six months after surgery showed ureteral patency in all cases without evidence of dilatation or strictures. Ureteral stricture was not observed during a follow-up period of at least 18 months.

Conclusion: Repair of complete ureteral avulsion following endoscopic surgery is a challenging task which should be tailored according to the individual situation. Boari flap is a versatile technique in the repair of severe ureteral defects, and may eliminate the need for a possible ileal ureteric replacement. Proper ureteroscopic handling is the key to prevention of this catastrophic complication.