Search

Iatrogenic ureteral injury, an uncommon entity, is primarily caused by complications of gynecologic surgery. This report describes a case of ureterovaginal fistula discovered 13 days after a vaginal hysterectomy. Ureteroscopy was performed, with passage of an indwelling ureteral stent for 6 weeks. The patient immediately became continent of urine and the fistula healed, thus avoiding the need for further surgery.

Indwelling self-retaining ureteral stents are important for the maintenance of urinary drainage in the ureter threatened by obstruction by neoplasm, edema, or calculus. Proximal migration of the stent into the ureter prevents simple cystoscopic retrieval and necessitates removal by other techniques. In this series both rigid and flexible ureteroscopes were used to remove stents from locations ranging from the renal pelvis to the distal ureter in 16 patients. Three-pronged wire graspers was the retrieval instrument most frequently used. Stents were removed in all patients without complication. Ureteroscopy provides the most convenient and least invasive technique for removing stents proximally located in the upper urinary system.

Balloon dilation catheters have been used extensively for percutaneous transluminal dilation of vascular narrowings. A recent urological application has been the use of a balloon to dilate acutely the normal ureteral orifice and intramural ureter for the purpose of performing transurethral ureteroscopy. Complications of balloon dilation may result if over inflation and bursting of the balloon occur followed by ureteral injury. We report the pressure needed to dilate the ureter adequately in 122 patients during an 18-month period. Adequate dilation was achieved in 93 patients (78 per cent) at pressures of 8 atmospheres or less, while 27 (22 per cent) required more than 10 atmospheres of pressure. Balloon dilation was not satisfactory in 2 patients (2 per cent) but it was accomplished by metal bougies. Our results confirm the safety and efficiency of balloon dilation to facilitate ureteroscopy. Important safeguards when using this method include the use of balloons designed specifically for ureteral dilation, slow balloon inflation to allow for ureteral accommodation and the use of fluoroscopy to judge the end point of dilation.

Kaufman reported a severe ureteral injury following ureteroscopy in 1984. His commentary summarizes the important messages in this article well: The intent of this report is not to denegrate the splendid advances in nephroscopy and ureteroscopy, but rather to introduce a sobering message that the patient must be informed of the inherent risk of such procedures and that the urologist must be wary of the problems that might occur. Problems have been known ever since endoscopic instrumentation was first introduced, and every experienced urologist has had his share of problems associated with stone extraction and other endoscopic procedures. Traditional teaching in urology has been to eschew manipulation of stones in the upper two thirds of the ureter because the lumbar ureter is mobile and more easily damaged by instrumentation than the pelvic segment. Endoscopic visualization of stones in the upper ureter allowing accurate grasping of calculi would appear at first to provide an element of security heretofore unachievable, but urologists nonetheless should be mindful of the hazards of any type of stone extraction from the upper ureter. Urologists must be ready and equipped to handle emergencies associated with new instruments and techniques, and the patients must be apprised of the exigencies. "Caveat emptor" (buyer beware) could not be a more apt or timely maxim in our specialty. Ureteroscopy has greatly aided many patients, and a large number of urologists have integrated this procedure into their daily practices.(ABSTRACT TRUNCATED AT 250 WORDS)

Upper tract tumors may be diagnostic problems, and the importance of obtaining tissue in a closed fashion has been illustrated. This is probably the most important advantage of the ureteroscopic approach to these tumors. Ureteroscopy is safe and reliable and allows examination of about 95 per cent of all patients evaluated. Success rates will continue to improve with the expanded use of flexible instruments. Ureteroscopy may also be used for treatment. However, before this mode of therapy can be accepted, further work must be done comparing the findings of the endoscopic biopsy with the pathologic stage of the cancer. Nevertheless, it does appear that low-grade localized distal ureteral tumors can be managed effectively by ureteroscopic means. Possibly low-grade tumors in the renal pelvis can also be managed by this method (see also following article). Again, methods of surveillance such as radiographic studies and urinary cytology must be used in addition to endoscopic examination for follow-up (Table 2). Extensive pyelocaliceal tumors, high-grade pelvic tumors, and high-grade ureteral tumors probably cannot be managed effectively by ureteroscopic means. Either polychronotropism or failure to control a primary tumor may prove an indication for adjuvant topical therapy. Potential side effects such as systemic absorption resulting in myelosuppression need to be considered. However, if standard dosages known to be relatively safe intravesically are employed, there should be no significant problems.