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Purpose: To describe urologic complications associated with the surgical management of placenta accreta spectrum and determine their risk factors., Methods: A retrospective study was conducted on all patients diagnosed with abnormal invasive placentation who underwent surgery and delivered between 2002 and 2023 at a single expert maternity centre. Intra-operative and post-operative complications were described, with a special focus on urologic intra-operative injuries, including vesical or ureteral injuries. Univariate and multivariate analyses were performed to determine risk factors of intra-operative urologic injuries associated with placenta accreta spectrum surgical management. Additionally, using the Clavien-Dindo classification, the effects of intra-operative urologic injury and ureteral stent placement on post-operative outcome were evaluated., Results: A total of 216 patients were included, of which 47 (21.48%) had an intra-operative bladder and/or ureteral injury. Placenta percreta was associated with a higher rate of intra-operative urologic injury than placenta accreta (72.34% vs. 6.38%, p < 0.001). Multivariate analyses showed that patients who had placenta percreta and bladder invasion or emergency hysterectomy were associated with more intra-operative urologic injuries (OR = 8.07, 95% CI [2.44-26.75] and OR = 3.87, 95% CI [1.09-13.72], respectively). Patients with intra-operative urologic injuries had significantly more severe post-operative complications, which corresponds to a Clavien-Dindo score of 3 or more, at 90 days (21.28% vs. 5.92%, p = 0.004)., Conclusion: Surgical management of placenta accreta spectrum is associated with significant urologic morbidity, with a major impact on post-operative outcomes. Urologic complications seem to be correlated with the depth of invasion and the emergency of the hysterectomy., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The benefits of prophylactic ureteral stent placement during colorectal surgery remain controversial. This study aimed to determine the incidence of ureteral injury in colorectal operations, assess the complications associated with stent usage, and determine whether their use leads to earlier identification and treatment of injury., Methods: This was a retrospective study of patients undergoing colorectal abdominal operations between 2015 and 2021. Variables were examined for possible association with ureteral stent placement. The primary study endpoint was ureteral injury identified within 30 days postoperatively., Results: Of 6481 patients who underwent colorectal surgery, 970 (15%) underwent preoperative ureteral stent placement. The use of stents was significantly associated with a higher American Society of Anesthesiologists classification, wound classification, and longer duration of surgery. A ureteral injury was identified in 28 patients (0.4%). Of these patients, 13 had no stent, and 15 had preoperative stents placed. After propensity matching, stent use was associated with an increased risk of hematuria and urinary tract infection. Ureteral injury was identified intraoperatively in 14 of 28 patients (50.0%) and was not associated with ureteral stent use (P = .45)., Conclusion: Iatrogenic ureteral injury was uncommon, whereas preoperative stent placement was relatively frequent. Earlier recognition of iatrogenic ureteral injury is not an expected advantage of preoperative ureteral stent placement., (Copyright © 2024. Published by Elsevier Inc.)

Iatrogenic ureteral injury (IUI) during colorectal surgery is a rare complication but related to a serious burden of morbidity. This comprehensive and systematic review aims to provide a critical overview of the most recent literature about IUI prevention techniques in colorectal surgery. We performed a comprehensive and systematic review of studies published from 2000 to 2022 and assessed the use of techniques for ureteral injury prevention and intraoperative localization. 26 publications were included, divided into stent-based (prophylactic/lighted ureteral stent and near-infrared fluorescent ureteral catheter [PUS/LUS/NIRFUC]) and fluorescent dye (FD) groups. Costs, the percentage and number of IUIs detected, reported limitations, complication rates and other outcome points were compared. The IUI incidence rate ranged from 0 to 1.9% (mean 0.5%) and 0 to 1.2% (mean 0.3%) in the PUS/LUS/NIRFUC and FD groups, respectively. The acute kidney injury (AKI) and urinary tact infection (UTI) incidence rate ranged from 0.4 to 32.6% and 0 to 17.3%, respectively, in the PUS/LUS/NIRFUC group and 0-15% and 0-6.3%, respectively, in the FD group. Many other complications were also compared and descriptively analyzed (length-of-stay, mortality, etc.). These techniques appear to be feasible and safe in select patients with a high risk of IUI, but the delineation of reliable guidelines for preventing IUI will require more randomized controlled trials., (© 2023. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Introduction: Ureteral injury during pelvic surgery is a serious complication that requires special attention. The fluorescent ureteral catheter near-infrared ray catheter sets are 6.0F catheters containing fluorescent substances along their length that can be recognized by a laparoscopic indocyanine green camera. We present our experience using a near-infrared ray catheter in 6 consecutive patients who underwent surgery for recurrent pelvic tumors., Technique: The near-infrared ray catheters were inserted into the bilateral ureters in all patients, with the exception of patient 5 (left unilateral), by urologists using a cystoscope with the same technique as that commonly used in placing ureteral stents under general anesthesia. A laparoscopic indocyanine green camera was adapted to identify the ureters. From February 2020 to July 2020, 6 consecutive patients with recurrent pelvic tumors underwent surgery using a near-infrared ray catheter. In 3 patients, recurrent tumors were detected in the pelvic cavity after surgery for colon cancer (1 patient each of peritoneal recurrence behind the seminal vesicles, lymph node metastasis on the residual superior rectal artery, and peritoneal recurrence at the peritoneal reflection). Two patients had postoperative local recurrences of rectal cancer. The last patient had a recurrence of cervical carcinoma invading the rectum., Results: All patients underwent surgery under ureteral image navigation using near-infrared ray catheter not only for ureter preservation during the operation (4 patients) but also for the combined resection of the ureter with recurrent tumors (2 patients). One patient experienced postoperative ureteral stenosis on postoperative day 21 that required a ureteral double J-stent placement in the left ureter., Conclusion: Near-infrared ray catheter has the potential to reduce inadvertent periureteral dissection because the ureter can be identified before approaching it., (Copyright © The ASCRS 2021.)

Background: Ureteral identification is essential to performing safe colorectal surgery. Injected immunofluorescence may aid with ureteral identification, but feasibility without ureteral catheterization is not well described., Methods: Case series of robotic colorectal resections where indocyanine green (ICG) injection with or without ureteral catheter placement was performed. Imaging protocol, time to ureteral identification, and factors impacting visualization are reported., Results: From 2019 to 2020, 83 patients underwent ureteral ICG injection, 20 with catheterization and 63 with injection only. Main indications were diverticulitis (52%) and cancer (36%). Median time to instill ICG was faster with injection alone than with catheter placement (4min vs 13.5min, p < 0.001). Median time [IQR] to right ureter (0.3 [0.01-1.2] min after robot docking) and left ureter (5.5 [3.1-8.8] min after beginning dissection) visualization was not different between injection alone and catheterization., Conclusion: ICG injection alone is faster than with indwelling catheter placement and equally reliable at intraoperative ureteral identification., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To compare the oncological outcomes and major complications of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for stage IB1 cervical cancer (FIGO 2009) with a tumour size less than 2 cm., Methods: We retrospectively compared the oncological outcomes and major complications of 1207 stage IB1 cervical cancer patients with a tumour size less than 2 cm who received LRH (n = 546) or ARH (n = 661) in 37 hospitals., Results: (1) There was no significant difference in 3-year overall survival (OS; 97.3% vs. 98.5%, P = 0.288) or 3-year disease-free survival (DFS; 95.1% vs. 95.4%, P = 0.792) between LRH (n = 546) and ARH (n = 661).(2) The rate of any 1 complication refers to the incidence of one or more complications in a patient, which was higher with LRH than ARH (OR = 4.047, 95% CI = 2.035-8.048, P < 0.001). Additionally, intraoperative complications occurred with LRH (OR = 12.313, 95% confidence intervals [CI] = 1.571-96.493, P = 0.017), and postoperative complications (OR = 3.652, 95% CI = 1.763-7.562, P < 0.001) were higher with LRH than ARH. The ureteral injury rate was higher with LRH than with ARH (1.50% vs. 0.20%, OR = 9.814, 95% CI = 1.224-78.712, P = 0.032). The ureterovaginal fistula rate was higher with LRH than ARH. The rates of obturator nerve injury, bladder injury, vesicovaginal fistula, rectovaginal fistula, venous thromboembolism, bowel obstruction, chylous leakage, pelvic haematoma, and haemorrhage were similar between the groups., Conclusions: The oncological outcomes of LRH and ARH for stage IB1 cervical cancer patients with a tumour size less than 2 cm do not differ significantly. However, incidences of any 1 complication, intraoperative complications, and postoperative complications were higher with LRH than ARH, with complications manifesting mainly as ureteral injury and uterovaginal fistula., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Rationale: As the world's population ages, the number of surgical cases of colovesical fistulas secondary to colon diverticulitis is also expected to increase. The key issue while performing laparoscopic surgery for these fistulas is the avoidance of iatrogenic ureteral injury. There are no reports of Near-infrared Ray Catheter being used in surgery for diverticulitis, which is one of the diseases with the highest risk of ureteral injury. We present a case of a male patient with colovesical fistulas secondary to sigmoid colon diverticulitis who underwent laparoscopic surgery with visualization of the ureter using a new surgical technique in laparoscopic surgery., Patients Concern: An 82-year-old man presented to our urological department with general fatigue and air and fecal matter in the urine., Diagnoses: Cystography showed delineation of the sigmoid colon. Abdominal computed tomography findings revealed multiple sigmoid colon diverticula with thickened walls as well as large stones and a small amount of air in the bladder. He was diagnosed with a urinary tract infection with colovesical fistulas and bladder stones due to sigmoid diverticulitis., Interventions: After the creation of a transverse colostomy, we scheduled a laparoscopic anterior resection and cystolith removal., Outcomes: Severe inflammatory adhesions around the sigmoid colon and a high risk of ureteral injury were expected preoperatively. After induction of anesthesia, we inserted a Near-infrared Ray Catheter, a fluorescent ureteral catheter, which allowed us to easily identify and visualize the ureter in real-time. This allowed bowel dissection without concerns of ureteral injury. The operative time for the gastrointestinal part of the procedure was 150 minutes, and the patient was in a good general condition after the operation and was discharged on postoperative day 7., Lessons: The course of the ureter was easily and quickly identified by the green fluorescence from the ureteral catheter during laparoscopic surgery for fistulas associated with diverticulitis, where severe inflammation and dense fibrosis were present. Our technique is an easy and feasible approach that provides real-time urethral navigation during surgery for colovesical fistulas secondary to colon diverticulitis., Competing Interests: The authors report no conflicts of interest. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To report urologic outcomes from a series of IUIs, sustained during nonurologic procedures, with regards to timing of diagnosis and management of the injury. Iatrogenic ureteral injury (IUI) is the most common mechanism of ureteral trauma. Injuries can be intraoperatively diagnosed (IOD) or postoperatively diagnosed (POD)., Methods: This was a retrospective chart review of adult patients at a single institution who sustained an IUI from a non-urologic procedure between 2008 and 2019. Primary outcome was tube-dependence (ureter stent or nephrostomy tube) and nephrectomy rates at last follow-up. Secondary outcome was the number of additional urologic procedures required to manage subsequent complications of IUI., Results: There were 30 patients with IOD and 57 patients with POD. In the IOD group, at mean follow up of 6.3 months, 4 patients (14.3%) were tube dependent. In the POD group, at mean follow up of 13.1 months, 5 patients (10%) were tube dependent (P = .570). Rate of nephrectomy was higher in POD group compared to IOD, but the difference was not statistically significant (12.3% vs 6% respectively, P = .414). Additionally, in the POD group, 56% and 19.3% required a secondary and tertiary procedure to manage IUI complications, respectively. These rates were 16.7% (P < .001) and 3.3% (P = .002) in the IOD group., Conclusion: Delayed diagnosis of IUI was significantly associated with increased number of procedures needed to manage the injury. The rate of nephrectomy and tube dependence in this group was higher but not statistically significant. Delayed diagnosis of IUI is associated with higher treatment burden., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: We determined the association between ureteral diameter and ureteral injury during ureteral access sheath placement., Materials and Methods: Patients were prospectively enrolled in the study from July 2014 to September 2015. All patients underwent preoperative noncontrast computerized tomography and had a 12Fr to 14Fr ureteral access sheath placement without pre-stenting. A measurement of proximal ureteral diameter was carried out by 2 urologists and 1 radiologist. Ureteral wall injuries were evaluated by 2 endourologists using the 5-grade classification., Results: A total of 68 patients were included and the overall success rate for sheath placement was 94.1% (64). Among this group 46 patients (71.9%) had evidence of any type of injury to the ureter wall and the rate of high grade injuries was 26.1% (12). The ureteral diameter of patients who had a high grade injury was significantly smaller compared to those with low grade injuries (mean±SD 3.29±0.46 mm vs 4.5±0.97 mm, p <0.001). On multivariate analysis narrower proximal ureteral diameter was associated with a higher risk of high grade ureteral injury (OR 2.8, 95% CI 1.9-3.4, p <0.001), regardless of age, gender, body mass index, and middle and distal ureteral diameter., Conclusions: The proximal ureteral diameter is associated with high grade ureteral injury. A smaller ureteral diameter increases the risk and the severity of ureteral injury. Therefore, preoperative measurement of the ureteral diameter is recommended for ureteral access sheath placement to predict the risk of ureteral injury.

Objective: To analyze the etiology, characteristics, and ureteral reconstruction strategies of iatrogenic ureteric injuries in a high-volume center., Methods: Between September 2010 and August 2019, we retrospectively collected patients who underwent ureteral reconstruction due to iatrogenic ureteric injuries. Patient profiles, laboratory data, imaging studies, perioperative data, and complications were recorded., Results: Sixty-eight patients were enrolled in this study. The upper, middle, and lower thirds of the ureter were affected in 30, 2, and 36 cases, respectively. Of the 68 ureteric injuries, 69.1% occurred during urological procedures, followed by gynecological procedures, general surgery, radiotherapy, and orthopedic surgery. The majority of urological injuries (41, 87.2%) occurred due to stone removal. There was a significant difference in the age, sex, and location of ureteric injuries between the urological and nonurological groups. The median follow-up time was 17.9 months. The overall symptom remission rate was 91.2% and ranged from 87.5 to 100% for different reconstructive surgeries., Conclusions: Urological procedures were the most common cause of iatrogenic ureteric injury; thus, extra care should be taken. Timely detection and appropriate treatment of the ureteric injuries are necessary. Treatment strategies should be depended on the location and length of injury., (© 2021 S. Karger AG, Basel.)

Purpose: Hysterectomy (Hys) is the most common non-urologic surgery associated with iatrogenic genitourinary (GU) injury. We present the largest known population-based evaluation of GU injury related to benign Hys., Methods: The New York Statewide Planning and Research Cooperative System (SPARCS) was queried by ICD-9 and CPT codes. SPARCS for women from 1995 to 2014, who underwent laparoscopic or robotic Hys (minimally invasive surgery = MIS), abdominal Hys (AH), and vaginal Hys (VH) for benign diagnoses. Bladder and ureteral repairs were captured based on the procedure codes. Codes for ureteroneocystotomy (UNC) were compared to any other ureteral repairs, to elucidate injury patterns. Statistical analysis was conducted using Chi squared test, ANOVA, Mann-Whitney test and Poisson Regression and multivariable analysis were performed., Results: 516,340 women underwent Hys for a benign etiology. 69% were AH, 25% VH, and 6% were MIS. 7490 patients (1.45%) had a concomitant GU injury. Compared to VH, MIS and AH were associated with greater odds of bladder and ureteral injury (p < 0.001). MIS and AH, compared to VH, were associated with reduced odds of UNC compared to complex reconstruction (OR 0.27, p < 0.001 and OR 0.12, p < 0.00, respectively). The injured cohort had higher total mean charges ($29,889 vs $15,808) and length of hospitalization (6.32 vs 3.56 days) (p < 0.001)., Conclusions: Bladder and ureteral injuries during hysterectomy are uncommon in contemporary practice and are lower than historical rates. GU injury increases hospitalization cost. VH is associated with the lowest rate of GU injury, and thus appears to be a valuable approach, when feasible.

Objective: To evaluate the feasibility and effect of mesureteral preservation on urinary complications in the context of total mesometrial resection (TMMR), a surgical treatment for cervical cancer., Design: Retrospective cohort study with historic control., Setting: Single tertiary academic centre., Population: Women older than 18 with primary cervical cancer staged FIGO IB1-IIB enrolled in the prospective Leipzig School MMR study and underwent total mesometrial resection (TMMR) without adjuvant radiation., Method: We retrospectively analysed 100 consecutive TMMR procedures which were performed for cancer of the uterine cervix and in which the mesureter was preserved (intervention group, 01/2014-06/2017). We compared this group with the previous 100 consecutive TMMRs, which were performed before the introduction of mesureteral preservation (control group, 09/2010-01/2014)., Main Outcome Measures: The occurrence of urological and specifically ureteral complications., Results: Mesureteral preservation was feasible and was associated with a significant decrease in ureteral complications (11% without mesureteral preservation versus 3% with mesureteral preservation, P = 0.049). Furthermore, we found a significant decrease in the number of postoperative percutaneous nephrostomies and re-operations (7% versus none, P = 0.014). There was also a trend towards a decrease in other urinary complications such as postoperative bladder atony and uretero-vaginal fistulas., Conclusion: The mesureter constitutes a convenient dissection plane enabling the preservation of lateral ureteral blood supply during TMMR. In our study, maintenance of mesureteral integrity was associated with a significant reduction in ureteral complications. Mesureteral preservation might also be useful in other types of pelvic surgeries that carry a high risk of ureteral damage., Tweetable Abstract: Surgical preservation of the mesureter in cervical cancer patients was associated with a reduction in urinary complications., (© 2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Background: Caesarean section (CS) is usually perceived as a simple and safe alternative to natural birth, but in some instances can be technically difficult with consequent health hazards for both the mother and the fetus. We have proposed an evidence-based literature review of the most common difficult CS scenarios, with the aim to provide useful information about their management, possible prevention and resolution of complications., Methods: We identified articles through a reserch in PubMed, Scopus, Web of Science and Ovid MEDLINE for studies published between 1979 and 2019. We included the best available evidence, such as RCTs, non-randomised controlled clinical trials, case-control studies, cohort studies, and case series. About sixty articles were included in this review, four hundred and thirty-six were excluded after reviewing the title or abstract or because they weren't in English., Findings: The possible causes of "difficult" caesarean sections were divided into four categories: difficult access to the lower uterine segment; complicated fetal extraction, laceration or organ damage and abnormal placentation., Conclusions: Knowing in advance the potential technical difficulties and resulting risks allows the surgeon to plan appropriate strategies., Competing Interests: Declaration of Competing Interest The authors report no conflict of interest., (Published by Elsevier B.V.)

Objective: To compare the outcomes of patients who underwent early repair (≤7 days) of iatrogenic ureteral injury with ureteroneocystostomy and compare them to those repaired in a delayed fashion (>7 days)., Methods: A retrospective review of billing data between 2012 and 2018 identified patients who underwent ureteroneocystostomy for a benign ureteral disease. Inclusion criteria included all ureteral injuries related to a laparoscopic, robotic, or open surgical injury. Patients with ureteral injury related to radiation, stones, or reconstructive surgery were excluded. Patients undergoing reconstruction during the initial injury or within ≤7 days were designated as having undergone early repair, while the remaining were considered delayed repair. Demographics, as well as inpatient and postdischarge data were acquired, and statistical analysis was performed comparing the 2 groups., Results: Sixty-seven patients met inclusion criteria. Early repair was performed on 12 patients, while 55 underwent delayed repair. No significant difference in age, gender, Charlson Comorbidity Score, laterality, stricture location, or history of pelvic/abdominal radiation was noted. Inpatient complications were significantly higher in the immediate group (58 vs 18%, P =.004). Thirty- and 90-day complications were similar. Two patients in the delayed group and none in the immediate group demonstrated stricture recurrence (P =.710). A higher rate of Boari flap ureteral reconstruction was performed in the delayed cohort (P =.001)., Conclusion: In this cohort, there was no detectable difference in outcomes when comparing early and delayed ureteroneocystostomy for iatrogenic ureteral injuries., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To describe frequency and identify risk factors for urological lesions in patients undergoing obstetric hysterectomy secondary to abnormal placental insertion in a high specialty hospital., Material and Methods: Transversal, retrospective study of patients underwent hysterectomy due to abnormal placental insertion, from 2017 to 2019; age, obstetric antecedents, comorbidities, type of abnormal placental insertion type of hysterectomy, site of urinary lesion, anesthesia, surgery time and bleeding were studied. Analyses were made with ji square and Kruskal Wallis tests with SPSS V20.0 program considering significative p values p < 0.05., Results: Clinical records of 96 patients with age 32.6 ± 6.1 years were analyzed. Accretism was present in 38.5%, incretism in 19.8% and percretism in 18.8%. Total hysterectomy was accomplished in 78 (81.2%) cases. Urinary lesion was present in 27 (28.1%); vesical in 19 (19.8%), ureteral in 6 (6.5%) and both in 2 (2.0%). Urinary lesion was significantly more frequent in those patients with more pregnancies (median 4 [interquartile range (IQR): 3-4] vs. 3 [2-4]; p= 0.004), more caesarean sections (4 [3-4] vs. 2 [1-3]; p < 0.001), hemorrhage (3000 mL [2000-4800] vs. 2000 mL [1200-3000]; p = 0.001), and more surgery time (3.75 h [3.5-4.0] vs. 3.0 [2.0-3.5]; p < 0.001)., Conclusions: Urinary lesions in patients undergoing obstetric hysterectomy secondary to abnormal placental insertion are more frequent with higher number of pregnancies, caesarean sections, hemorrhage and surgery time., (Copyright: © 2020 Permanyer.)

Purpose: To analyze the trifecta outcome (functional, anatomical, and surgical aspects) of surgical reconstruction for ureteral lesions and investigate the factors affecting the success rate of such reconstruction., Methods: We retrospectively reviewed the data of patients who underwent ureteral reconstruction at our institute between March 2007 and November 2016. Patient profiles, surgical methods, complications, ureteral stenting, laboratory data, and image studies were collected. The trifecta outcome was defined as preserved renal function, no progression of hydronephrosis, and no long-term stenting. The primary endpoint was the percentage of patients who achieved the trifecta outcome. The secondary endpoint was risk factors for trifecta outcome failure., Results: We retrospectively reviewed 178 adult patients who had undergone ureteral reconstruction. The median follow-up period was 37.4 months. In total, 70 (39.3%) patients had iatrogenic ureteral injuries and 108 (60.7%) patients had non-iatrogenic ureteral lesions. Overall, 70% of the patients achieved the trifecta outcome after ureteral reconstruction. A multivariate analysis revealed that risk factors for trifecta failure were malignant diseases [odds ratio (OR) 2.93, p = 0.005], a history of pelvic radiation (OR 3.08, p = 0.032), preoperative estimated glomerular filtration rate < 60 (OR 2.52, p = 0.039), and a type of reconstruction ureteroureterostomy (OR 2.99, p = 0.014)., Conclusions: Trifecta outcome could be used to evaluate the ureteral reconstruction in iatrogenic injury and non-iatrogenic ureteral lesions. This study revealed several risk factors that affected the trifecta outcome.

Iatrogenic injury of the ureters is a feared complication of abdominal surgery. Zwitterionic near-infrared fluorophores are molecules with geometrically-balanced, electrically-neutral surface charge, which leads to renal-exclusive clearance and ultralow non-specific background binding. Such molecules could solve the ureter mapping problem by providing real-time anatomic and functional imaging, even through intact peritoneum. Here we present the first-in-human experience of this chemical class, as well as the efficacy study in patients undergoing laparoscopic abdominopelvic surgery. The zwitterionic near-infrared fluorophore ZW800-1 is safe, has pharmacokinetic properties consistent with an ideal blood pool agent, and rapid elimination into urine after a single low-dose intravenous injection. Visualization of structure and function of the ureters starts within minutes after ZW800-1 injection and lasts several hours. Zwitterionic near-infrared fluorophores add value during laparoscopic abdominopelvic surgeries and could potentially decrease iatrogenic urethral injury. Moreover, ZW800-1 is engineered for one-step covalent conjugatability, creating possibilities for developing novel targeted ligands.

Objectives: The aims of this study were to determine the efficacy of phenazopyridine when used intraoperatively to assess ureteral patency and to investigate factors that may influence its efficacy., Methods: This is a retrospective chart review performed at the Olive View-UCLA Medical Center, a Los Angeles County teaching hospital, from January 2014 through July 2016. Patients undergoing cystoscopy at the time of gynecologic surgery were identified via department case logs. All women receiving preoperative oral phenazopyridine were included. If ureteral flow was unable to be visualized with phenazopyridine alone, the medication was deemed ineffective, and sodium fluorescein was given intraoperatively. Patients were divided into a phenazopyridine effective or phenazopyridine ineffective group. Patient demographics, renal function, intraoperative fluids and urine output, estimated blood loss, timing and dose of medication administration, and complications were gathered from the chart and compared between groups using Fisher exact test, 2-sample t test, Wilcoxon test, and logistic regression for multivariable analysis. P < 0.05 was determined to be significant., Results: Preoperative phenazopyridine was effective in 190 (91.8%) of 207 patients. It was ineffective in 17 patients who then required intraoperative sodium fluorescein. The group in which phenazopyridine was effective was more likely to have been given a 200-mg (vs 100-mg) dose (P = 0.02) and had lower intraoperative urine output (median, 450 vs 800 mL; P = 0.002)., Conclusions: Preoperative oral phenazopyridine is effective in more than 90% of cases to detect during gynecologic surgery. A higher phenazopyridine dose and lower intraoperative urine output were associated with increased efficacy.

Aim: Iatrogenic ureteral injury (IUI) occurs rarely during colorectal surgery but is associated with significant mortality, morbidity and medicolegal issues. Few cases are reported, and recommendations regarding prevention are lacking. The aim of this study is to describe the current state of practice regarding IUI and its prevention among general surgeons in Switzerland., Method: All Swiss general surgeons who are members of either the Swiss Association of Laparoscopic and Thoracoscopic Surgery or the Swiss Surgical Society were invited to participate in an anonymous online survey. Demographics, surgical practice, rate of IUI and methods used to prevent IUI were investigated., Results: All participants were board-certified general surgeons, 63.4% were certified visceral surgeons and 17.9% were certified colorectal surgeons. The mean level of experience in colorectal surgery was 15.6 ± 9.2 years. Formal ureter identification was considered mandatory during sigmoid or rectal surgery by 83.7% of participants, and 31.7% considered identification of the right ureter during right colectomy to be mandatory. In total, 61.8% of the participants and 78.4% of surgeons with more than 20 years of experience had encountered at least one IUI. Prophylactic ureteral stenting was considered useful in complex procedures by 93.5% of participants, and 56.9% had used stents at least once in the past 12 months. Noninvasive techniques for identifying ureters would be considered in regular daily practice by 54.5% of the participants., Conclusion: Most general surgeons experience IUI. Ureter identification is widely integrated in colorectal procedures. Prophylactic stenting is widely used for difficult cases. Noninvasive methods to improve ureter identification are now needed., (Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.)

Background/objective: The purpose of this study is to evaluate the cases of lower urinary tract injuries during cesarean section with or without hysterectomy in cases with morbid placental adherence., Methods: This record based retrospective study was conducted at Ain Shams University Maternity Hospital in Cairo, Egypt during the period between January 2014 and December 2016. It included all patients who had urinary tract injuries during cesarean section with or without hysterectomy in the cases with morbid placental adherence and they were collected from files of pregnant women who were admitted at hospital planned for termination of pregnancy. Patients were enrolled in four groups, Group 1: cases without urinary tract injuries. Group 2: cases with injuries to the bladder. Group 3: cases with injuries of the ureter. Group 4: cases with injuries to the bladder and ureter., Results: This study gave us new information about the incidence of urinary tract injuries during cesarean section with morbid adherence placenta was 21.7% (Bladder 11.7%, Ureter 4.7%, and bladder with ureter 5.3%). There were various types of repair of urinary tract injury, as the following, bladder repair 10.8%, ureteric catheterization 0.9%, ureterovesical repair or reimplantation 1.5%, bladder repair and ureterovesical 1.2%, bladder repair and ureteric catheterization 2.3%, ureteric catheterization and ureterovesical 1.5 and 6.4% of cases needed urologic consultations. There is a real relation between urinary tract injury and obesity (55.3%). Bladder invasion was found in only 26.9% of all cases according to sonography findings. Most of the cases were delivered by cesarean section in 67.5%, and the remainders were delivered by cesarean hysterectomy 32.5%. About 96.5% of cases needed a blood transfusion., Conclusions: The morbid adherent placenta is still a challenge, which faces us as obstetricians, due to high morbidity and mortality. A multidisciplinary team is mandatory to avoid complications.

Background: Gynecologists debate the optimal use for intraoperative cystoscopy at the time of benign hysterectomy. Although adding cystoscopy leads to additional up-front cost, it may also enable intraoperative detection of a urinary tract injury that may otherwise go unnoticed. Prompt injury detection and intraoperative repair decreases morbidity and is less costly than postoperative diagnosis and treatment. Because urinary tract injury is rare and not easily studied in a prospective fashion, decision analysis provides a method for evaluating the cost associated with varying strategies for use of cystoscopy., Objective: The objective of the study was to quantify costs of routine cystoscopy, selective cystoscopy, or no cystoscopy with benign hysterectomy., Study Design: We created a decision analysis model using TreeAge Pro. Separate models evaluated cystoscopy following abdominal, laparoscopic/robotic, and vaginal hysterectomy from the perspective of a third-party payer. We modeled bladder and ureteral injuries detected intraoperatively and postoperatively. Ureteral injury detection included false-positive and false-negative results. Potential costs included diagnostics (imaging, repeat cystoscopy) and treatment (office/emergency room visits, readmission, ureteral stenting, cystotomy closure, ureteral reimplantation). Our model included costs of peritonitis, urinoma, and vesicovaginal/ureterovaginal fistula. Complication rates were determined from published literature. Costs were gathered from Medicare reimbursement as well as published literature when procedure codes could not accurately capture additional length of stay or work-up related to complications., Results: From prior studies, bladder injury incidence was 1.75%, 0.93%, and 2.91% for abdominal, laparoscopic/robotic, and vaginal hysterectomy, respectively. Ureteral injury incidence was 1.61%, 0.46%, and 0.46%, respectively. Hysterectomy costs without cystoscopy varied from $884.89 to $1121.91. Selective cystoscopy added $13.20-26.13 compared with no cystoscopy. Routine cystoscopy added $51.39-57.86 compared with selective cystoscopy. With the increasing risk of injury, selective cystoscopy becomes cost saving. When bladder injury exceeds 4.48-11.44% (based on surgical route) or ureteral injury exceeds 3.96-8.95%, selective cystoscopy costs less than no cystoscopy. Therefore, if surgeons estimate the risk of injury has exceeded these thresholds, cystoscopy may be cost saving. However, for routine cystoscopy to be cost saving, the risk of bladder injury would need to exceed 20.59-47.24% and ureteral injury 27.22-37.72%. Model robustness was checked with multiple 1-way sensitivity analyses, and no relevant thresholds for model variables other than injury rates were identified., Conclusion: While routine cystoscopy increased the cost $64.59-83.99, selective cystoscopy had lower increases ($13.20-26.13). These costs are reduced/eliminated with increasing risk of injury. Even a modest increase in suspicion for injury should prompt selective cystoscopy with benign hysterectomy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Studies indicate that with a safety wire in the ureter, an increased amount of force is necessary to advance ureteral access sheaths up to the proximal ureter. Theoretically, the compression of the ureter with the wire could lead to an increase in number and severity of ureteral injuries secondary to placement of a sheath. This prospective study aims to evaluate if there is a correlation between the use of a safety wire and ureteral injury from sheath placement by evaluating the location of the wire in relation to the injury after ureteroscopy., Materials and Methods: Fifty-nine consecutive patients underwent ureteroscopy for upper tract urinary stone disease. A 12/14 French ureteral access sheath was used with a safety wire in place. Ureteroscopy during withdrawal of the sheath was video recorded and reviewed by a blinded observer. Visible ureteral injuries were graded per the Traxer ureteral injury scale and the proximity of the wire to the injury was noted., Results: Thirty-one of 59 patients (52.4%) had a ureteral injury secondary to access sheath placement. Eighteen (30.5%) injuries were low-grade, 13 (22.0%) were high-grade (grade 2 and 3) and there were no grade 4 injuries. A total of 10 (32.3%) injuries occurred on the same side as the wire while 67.7% were on the contralateral side of the ureter. Of the injuries that occurred on the same side as the wire, 80% were grade 1 injuries and 2 (20%) were grade 3. Statistical analysis did not show a significant relationship between high/low injury grade and side of injury (p value = 0.088). This suggests that there is no association of between the safety wire and development of high injury., Conclusion: There is no association between the location of the safety wire and ureteral injury if injury occurs during the placement of a ureteral access sheath. This suggests that the use of a safety wire does not add significant morbidity to the procedure.

Gynecologic surgery is associated with various perioperative complications, especially urinary tract injuries. Intraoperative cystoscopy plays an important role in allowing assessment of the bladder to ensure the absence of injuries. Verification of the urinary jets from the ureters is a fundamental step that is not always easy to accomplish. Dyes are frequently used, but these are not always available and are associated with adverse effects. The present study aimed to demonstrate the use of CO 2 as a medium for distension during cystoscopy. A total of 47 patients underwent CO 2 cystoscopy after laparoscopic hysterectomy (n = 26) or bladder endometriosis nodule resection (n = 21). In all patients, the ureteral jets were readily identified, leaving no doubt as to their patency. The median interval between the onset of cystoscopy and the view of jetting from both ureteral ostia was 145 seconds (range, 80-300 seconds). All cystoscopies were normal, and no patient had any signs of accidental urinary tract injury in the follow-up period. Two patients experienced mild urinary tract infection. This cystoscopy technique using CO 2 is fast, easy, safe, and efficient. We recommend bladder distension with CO 2 as a reasonable alternative technique when cystoscopy is required during gynecologic procedures., (Copyright © 2018 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: Prophylactic placement of ureteral stents is performed during open colectomy to aid in ureteral identification and to enhance detection of injury. The effects of this practice in laparoscopic colectomy are unknown. This study compares outcomes of patients undergoing laparoscopic colectomy with and without prophylactic ureteral stenting., Methods: A retrospective cohort study at a tertiary academic medical center was performed. The primary outcome measure was the incidence of ureteral injury. Secondary outcomes evaluated included mortality, length of stay, procedural duration, and new-onset urinary complication (hematuria, dysuria, and urinary tract infection)., Results: In 702 consecutive patients undergoing elective laparoscopic colectomy from 2013 to 2016, prophylactic stents were placed in 261 (37%) patients. Two ureteral injuries occurred (0.3%), both in patients who underwent ureteral stent placement (P = 0.07) and were found and repaired intraoperatively. There was no in-hospital mortality. When accounting for age-adjusted Charlson comorbidity score, procedural indication, gender, BMI, and extent of resection, no difference in hospital length of stay (P = 0.79) was noted comparing patients with and without stenting. However, stent placement prolonged operating time (P = 0.03) and increased the risk of new-onset urinary complications (P = 0.04)., Conclusions: In this study, ureteral injuries only occurred in those with stent placement. Prophylactic ureteral stents in laparoscopic colectomy are associated with increased operative time and urologic morbidity. Owing to the low prevalence of ureteral injury in the elective setting and the increased risk of urinary complications, use of prophylactic ureteral stenting should be highly selective., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Determining the incidence and causes of lower urinary tract injury in patients undergoing total laparoscopic hysterectomy and examining the procedures applied for management., Methods: Patients who underwent total laparoscopic hysterectomy in a large referral center between 1 January 2015 and 31 October 2017 for benign gynecological reasons were included in the study. Patients who underwent laparoscopic supracervical hysterectomy, laparoscopy-assisted vaginal hysterectomy and robot-assisted laparoscopic hysterectomy were not included in this study. The hospital records of all patients included in the study were examined and the incidence, causes and management of lower urinary tract injuries were reviewed., Results: Total lower urinary tract injury rate was found as 2.01%, and these injuries were evaluated separately as bladder and ureter injuries. All the bladder injuries had occurred on the posterior wall of the bladder during vesicouterine dissection; six cases were intraoperatively detected and one case was detected on the first postoperative day. Most of ureteral injury cases were detected in the early postoperative period (75%). The rates of previous cesarean section and endometriosis were significantly higher in patients with injury to the bladder and ureter than in the control group (p<0,001). There was no significant difference between the patients with lower urinary tract injury and the control group regarding uterine weight, estimated blood loss, bilateral salpingo-oophorectomy, the presence and location of fibroids, and laparoscopic or vaginal closure of the vaginal cuff., Conclusion: Laparoscopic hysterectomy may be a good option in appropriate patients, but in case of previous cesarean section and endometriosis cases, patients should be informed about the possible complications in detail before the operation and care should be taken during dissection., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

The presentation and management of bladder, ureteric and urethral injuries during and following urogynaecology surgery are discussed. Applied anatomy is reviewed, and the surgical management of injuries diagnosed intra- and post-operatively is discussed., (Copyright © 2018. Published by Elsevier Ltd.)

Introduction: Benign prostatic hyperplasia (BPH) can be associated with marked intravesical protrusion, placing ureteral orifices at risk for injury during bladder outlet procedures., Aim: To determine whether ureteral stenting is necessary in cases of ureteral orifice injury during laser enucleation., Materials and Methods: Retrospective study included 465 patients with bladder outlet obstruction (IPSS > 20, Qmax < 10) secondary to BPH who were managed with thulium fiber laser (ThuFLEP) or holmium laser enucleation of the prostate (HoLEP). In seven patients, the ureteral orifices were injured during surgery (3-HoLEP; 4-ThuFLEP). Three of the seven patients underwent intraoperative stenting of the upper urinary tract (1-HoLEP; 2-ThuFLEP). In four cases, stenting was not performed (2-HoLEP; 2-ThuFLEP). The follow-up period was 6 months., Results: Postoperatively, none of the patients with a stent in the upper urinary tract exhibited signs of pelvicalyceal system (PCS) dilatation or inhibited urine flow from the kidney (assessed with abdominal ultrasound at 1, 3, 10, and 30 days after surgery). In two patients without stents, follow-up revealed no dilatation of the PCS. The other two patients without stents developed asymptomatic dilatation of the PCS (the pelvis-up to 1.5 cm; the calyx-up to 0.5 cm). At 1 month after surgery, no patients had dilatation of the PCS., Conclusions: Upper urinary tract stenting in cases of intraoperative ureteral orifice injury during laser enucleation of the prostate for BPH may not be warranted.

Study Objective: To evaluate rates of urologic injury in patients who underwent robotic hysterectomy compared with laparoscopic, vaginal, and open hysterectomy., Design: A retrospective analysis (Canadian Task Force classification II-2)., Setting: Henry Ford Health System, 2013 to 2016., Patients: Women who underwent robotic, vaginal, laparoscopic, and open abdominal hysterectomy., Interventions: Robotic hysterectomy, laparoscopic-assisted vaginal hysterectomy, total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, vaginal hysterectomy, and abdominal hysterectomy., Measurements and Main Results: To identify patients with urologic injury, a departmental database for quality improvement was searched for reported urologic injuries. In addition, patients who had urology consultation within 90 days of hysterectomy were screened for injury. A total of 3114 hysterectomies were identified by retrospective chart review. One thousand eighty-eight robotic, 782 laparoscopic, 304 vaginal, and 940 abdominal hysterectomies were analyzed for urologic complications. A total of 27 injuries were confirmed (7 during laparoscopic hysterectomy, 10 during robotic hysterectomy, 1 during vaginal hysterectomy, and 9 during abdominal hysterectomy). The overall rate of urologic injury was 0.87% with a 0.55% risk of bladder injury and a 0.32% risk of injury to the ureter. When the route of hysterectomy was taken into account, the risk of urologic injury was 0.92% for robotic hysterectomy, 0.90% for laparoscopic hysterectomy, 0.33% for vaginal hysterectomy, and 0.96% for open hysterectomy. The mean body mass index (BMI) for all patients was 32.7 kg/m 2 ; injured patients had a mean BMI of 34.6 kg/m 2 , and noninjured patients had a mean BMI of 32.0 kg/m 2 (p = .10)., Conclusion: Rates of urologic injury with robotic hysterectomy are similar to those of laparoscopic hysterectomy in our population. BMI was not significantly different in patients who had urologic injuries. Surgeon volume was not associated with risk for urologic injury., (Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Laparoscopic hysterectomy poses the risk of lower urinary tract injury, and intraoperative recognition of urinary tract injury is often difficult. We sought to evaluate sodium fluorescein coloration of ureteral jets during cystoscopy after laparoscopic hysterectomy and to evaluate surgeons' satisfaction with this method of injury detection., Methods: This was an observational study, in which data were collected prospectively. A total of 30 women who underwent laparoscopic hysterectomy from August 2016 to February 2017 at the Centre Hospitalier de l'Université Laval (CHUL) de Québec. Twenty-five milligrams of 10% intravenous sodium fluorescein was administered after vaginal cuff closure. Cystoscopy was then systematically performed, and the time to visualization (time from injection to coloration of ureteral jet), the quality of coloration, and the duration of cystoscopy were recorded. Side effects were systematically recorded and rigorously analyzed., Results: Most frequent indications for hysterectomy were fibroids and endometriosis with uterine weight from 76 to 885 g. Ninety-three percent of patients (n = 28) had bilateral ureteral jet coloration, whereas 1 patient had no coloration bilaterally, and another patient had a complete unilateral obstruction immediately diagnosed and resolved intraoperatively after removal of the vaginal sutures. In 90% of cases (n = 27), surgeons were highly satisfied with the use of sodium fluorescein. The average time between visualization of both left and right ureteral jets was 1 minute. Side effects included hypotension (n = 3) and yellow coloration of urine (n = 15)., Conclusion: Our study suggests that sodium fluorescein is an effective dye for documenting ureteral patency and improving visualization of ureteral jets during cystoscopy upon completion of laparoscopic hysterectomy.

Injury to the bladder and/or ureters is the cause of significant morbidity, and efforts to reduce these injuries are important. This debate presents arguments that both support, and refute, the value of routine cystoscopy at the time of benign hysterectomy. Proponents of routine cystoscopy state that injuries are more likely to be detected and repaired when cystoscopy is routinely performed. Dissenters counter that the available evidence does not support routine cystoscopy at the current rates of lower urinary tract injury, and the cystoscopy should be performed only when injury is suspected or when performing hysterectomy with concurrent procedures that increase the risk of lower urinary tract injury., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Accidental ureteral injury with gynaecologic surgery, especially hysterectomy, represents a high risk of patient morbidity. The incidence may vary from centre to centre. As the introduction of new minimally invasive surgical techniques and instruments may have affected the incidence of ureteral injury, we de novo analysed the incidence data for the last seven years., Study Design: Incidence of ureteral injury was analysed stratifying the data according to the type of hysterectomy (n = 3071). The incidence rate was reported as a confidence interval (CI). Ureteral injuries were classified as direct or indirect., Results: Fifteen ureteral injuries were registered. The highest incidence was evidenced for radical hysterectomy (CI: 0.82-3.99), followed by laparoscopic radical hysterectomy (CI: 0-11.9). The incidence of direct ureteral injury was 26.6%, half of which were identified during the operative procedure. In 26.7% of the operations resulting in ureteral injury, heat-generating instruments were used., Conclusions: The incidence of ureteral injury during different types of hysterectomy was low. The majority of injuries were indirect. These were injuries which resulted from a micro-trauma, and developed due to the delayed necrosis of the ureteral wall. Laparoscopic approach to radical and simple hysterectomy didn't substantially raise the incidence of ureteral injury., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Purpose: Excessive bulking force during primary access of the ureteral access sheath may induce ureteral injury. We investigated the efficacy of preoperative α-blockade to reduce ureteral access sheath insertion force and determine the upper limit required to avoid ureteral injury., Materials and Methods: In this randomized controlled trial 135 patients from a single institution who had ureteropelvic junction or renal pelvis stones and were scheduled to undergo retrograde intrarenal surgery were prospectively enrolled from December 2015 to January 2017. Of the patients 41 and 42 were randomly assigned to the control and experimental groups, respectively. The experimental group received α-blockade preoperatively. The 21 patients who were pre-stented were assessed separately. We developed a homemade device to measure maximal ureteral access sheath insertion force., Results: Our ureteral access sheath insertion force measurement device showed excellent reproducibility. Higher insertion velocity resulted in greater maximal sheath insertion force. Maximal insertion force in the α-blockade group was significantly lower than in the control group at the ureterovesical junction (p = 0.008) and the proximal ureter (p = 0.036). Maximal insertion force in the α-blockade group was comparable to that in pre-stented patients. Female patients and patients 70 years old or older showed a lower maximal ureteral access sheath insertion force than their counterparts. The rate of grade 2 or greater ureteral injury was lower in the α-blockade group than in controls (p = 0.038). No injury occurred in any case in which ureteral access sheath insertion force did not exceed 600 G., Conclusions: Preoperative α-blockade and slow sheath placement may reduce maximal ureteral access sheath insertion force. If the force exceeds 600 G, a smaller diameter sheath may be an alternative. Alternatively the procedure can be terminated and followed later by pre-stented retrograde intrarenal surgery., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: Bladder and ureteral lesions are the most common urologic complications occurring during pelvic surgery with 1% and 0.5% to 3%, respectively. These lesions are rarely recognized intraoperatively and pose a major problem to urologists, gynecologists, and general surgeons., Objective: To study the factors favoring urologic complications following pelvic surgery at the University Hospital Point-G., Patients and Method: We conducted a retrospective study at the University Hospital Point-G between 2006 and 2015. It involved 23 patients with a whole urological lesion following pelvic surgery. These patients underwent a clinical and para-clinical examination (intravenous urography, methylene blue test) to confirm the urological lesion and to determine its management., Results: The average age of our patients was 32.00 years with extremes of 18 and 40 years old. The leakage of urine was found in 82.6% (19/23). Interventions that caused urologic injury were: caesarean section 52.2% (12/23), hysterectomy 30.4% (7/23), as well as a caesarean section and hysterectomy 17.4% (4/23). Methylene blue was performed in 19 patients, it was positive in 52.2% (12/23) and intravenous urography (IVU) in 7 patients. The lesions encountered were: retrotrigonal fistula vesico-vaginal 10 cases, vesico-vaginal fistula under trigonal 2 cases, uretero-vaginal fistula 7 cases, and bilateral ureteral ligation 4 cases. Fistulorraphy was performed in 52.2% followed by direct ureterovesical reimplantation. The postoperative outcome was satisfactory in 100% of cases with obtaining a good bladder tightness. The average duration of hospitalization was 12 days (+/- 4 days)., Conclusion: Pelvic surgery results in urological injuries. Caesarean section and hysterectomy are contributing factors. Vesico-vaginal fistula or ureteral lesions are common., (Le comitée de rédaction se réserve le droit de revoyer aux auteurs avant toute soumission à l'avis des lecteurs les manuscrits qui ne seraient pas conformes à ces modalités de présentation. En outre il leur conseille de sonserver un examplaire du manuscrit, des figures et des tableaux.)

Background: Cesarean delivery is performed frequently worldwide, and follow-up studies that report complications at subsequent surgery are warranted., Objectives: The aim of the study was to investigate the association between a previous abdominal delivery and complications during a subsequent hysterectomy and to estimate the fraction of complications that are driven by the presence of adhesions., Study Design: This was a longitudinal population-based register study of 25354 women who underwent a benign hysterectomy at 46 hospital units in Sweden 2000-2014., Results: Adhesions were found in 45% of the women with a history of cesarean delivery. Organ injury affected 2.2% of the women. The risk of organ injury (adjusted odds ratio, 1.74; 95% confidence interval, 1.41-2.15) and postoperative infection (adjusted odds ratio, 1.26; 95% confidence interval, 1.15-1.39) was increased with previous cesarean delivery, irrespective of whether adhesions were present or not. The direct effect on organ injury by a personal history of cesarean delivery was estimated to 73%, and only 27% was mediated by the presence of adhesions. Previous cesarean delivery was a predictor of bladder injury (adjusted odds ratio, 1.86; 95% confidence interval, 1.40-2.47) and bowel injury (adjusted odds ratio, 1.83; 95% confidence interval, 1.10-3.03), but not ureter injury. A personal history of other abdominal surgeries was associated with bowel injury (adjusted odds ratio, 2.27; 95% confidence interval, 1.37-3.78), and the presence of endometriosis increased the risk of ureter injury (adjusted odds ratio, 2.15; 95% confidence interval, 1.34-3.44)., Conclusion: Previous cesarean delivery is associated with an increased risk of complications during a subsequent hysterectomy, but the risk is only partly attributable to the presence of adhesions. Previous cesarean delivery and presence of endometriosis were major predisposing factors of organ injury at the time of the hysterectomy, whereas background and perioperative characteristics were of minor importance., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Complications from lateral lumbar interbody fusion procedures range from neurologic deficits to organ and blood vessel injuries. Injury to the ureter has been reported though uncommon. The present study was performed to elucidate the anatomic relationship of the ureter to this surgical approach., Methods: Eight adult cadavers (16 sides) were placed in the full lateral position, and the distal ureter was cannulated with a metal wire that was passed up to the kidney. Fluoroscopy was used to establish the position of the ureter in relation to the bony anatomy in this region., Results: In the lumbar region, there was a posterior to anterior course of the left and right ureter. From the direct lateral position, the ureter was found to lie at or posterior to the anterior edge of the lumbar vertebral bodies. On 87.5% of sides, the ureter was on average 2.5 cm posterior to the anterior border of the vertebral bodies at L2, 3 cm posterior at L3, 1.0 cm posterior at L4, and on the margin of the anterior vertebral bodies at L5. In general, the ureter, from a lateral perspective, crossed the posterior third of the upper lumbar vertebrae, approached the middle third at L3, and reached the anterior third at L4/L5 before descending into the pelvis., Conclusions: Owing to the proximity of the ureter to the lumbar vertebral bodies, it is imperative to verify that this structure is not in the surgical trajectory during lateral lumbar interbody fusion procedures if injury is to be avoided., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Performing the minimally invasive lateral lumbar interbody fusion (LIF), such as the extreme lateral interbody fusion (XLIF) and oblique lateral interbody fusion (OLIF), through a retroperitoneal approach has become increasingly popular. Although urological injury is a major complication of LIF, the anatomical location of the ureter and its risk of injury have not been assessed. The purpose of this study was to evaluate the efficacy of dual-phase contrast-enhanced computed tomography for assessing the location of the ureter and risk of its injury in consecutive LIF cases., Methods: 27 cases (12 men and 15 women) were enrolled in the study. Dual-phase contrast-enhanced CT was performed preoperatively, and the risk of ureteral injury was assessed. The location of the ureter was classified using the psoas muscle and vertebral body as reference structures for OLIF and XLIF procedures, respectively. During the OLIF procedures, the location of the ureter was additionally assessed with direct vision and manual palpation in all cases. Simultaneously, potential vascular anomalies were assessed with both 3D and axial images of CT., Results: A total of 125 among 162 ureters, excluding 13 with insufficient enhancement and 24 (44.4%) within the kidney at the L2-L3 level, were assessed preoperatively; 113 ureters (90.4%) were classified as anatomically close to the surgical corridor for OLIF, and 20 ureters (16.0%) as having a potential risk of injury during XLIF. In one case, OLIF was converted to a conventional posterior procedure because of a vascular anomaly. Intraoperative findings showed that ureters moved anteriorly with the peritoneum in all cases, as assessed by manual palpation under direct vision., Conclusions: Dual-phase contrast-enhanced CT is useful in assessing the location of the ureter, kidney, and vascular structures simultaneously. Both OLIF and XLIF have a potential risk of urological injury., (Copyright © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Objectives: The most frequent ureteral lesions are iatrogenic, mainly due to gynecologic and urologic procedures. The resolution and repair of these lesions, when they require surgery, is often the performance of ureteroneocystostomy. We describe the technique for the repair of distal ureter lesions that preserves both anatomy and function of the urinary tract (1). The operation consists in dissection and extraction of the distal ureteral stump from its intramural tract to get at least 1 cm of free ureter, percutaneous insertion of a ureteral stent, checking the absence of tension between proximal ureter and distal dissected stump, end to end anastomosis and reinsertion of the distal ureter in the previously dissected bladder muscle layer. We present 4 cases of ureteral injury after laparoscopic simple total hysterectomy for uterine myomas with complete section of the distal ureter, that were operated 3-5 days after injury, performing laparoscopic repair surgery. We performed clinical and radiological control with intravenous urography demonstrating ureteral continuity normalization and good renal function. We believe that repair of the urinary tract with anatomical and physiological preservation must be the first option in the laparoscopic treatment of complete distal ureteral injuries, and intramural ureter dissection when needed avoids the performance of ureteroneocystostomy. It is necessary to keep progressing in the technique improvement, and to increase the number of cases and experience.

Introduction: Ureterorenoscopy (URS) is a popular and growing option for management of ureteric and renal stones. The CROES URS Global Study was set up to assess the outcomes of URS in a large worldwide cohort of patients involving multiple centres. In this paper, we analysed the database for intra-operative and post-operative complications associated with ureterorenoscopy., Methods: The CROES database was established via collaboration between 114 centres in 32 countries worldwide, and information on both intra-operative and post-operative complications was collected electronically between January 2010 and October 2012., Result: On analysis of a total of 11,885 patients, the overall complication and stone-free rates were found to be 7.4 and 85.6 %, respectively. The intra-operative and post-operative complication rates were 4.2 and 2.6 %, respectively, and in total 5 deaths were reported in the study period. Taking into account different world economies, there were no differences in the complication rates between the developing and developed nations or between different centres from different continents., Conclusion: Ureterorenoscopy is a safe and effective procedure for treatment of stones, the outcomes of which are broadly comparable in different parts of the world for similar patient and stone demographics.

Aims: The study was conducted to evaluate the incidence of urologic injuries during gynecologic surgery, study the management and outcome of such injuries, and identify risk factors that may be associated with urologic injuries., Methods: A case-control study was conducted in patients who underwent gynecologic surgery from 2005 to 2014 in the university hospital. The study cases referred to patients who had urologic injury during gynecologic surgery and the control cases referred to patients who had gynecologic surgery matching the same period, type of procedure, and etiological disease leading to surgery. The medical records were reviewed and analyzed. Odds ratios (ORs) and 95% confidence intervals (CI) were used to identify risk factors associated with urologic injury., Results: During the study period, there were 86 cases of urologic injuries from a total of 28 819 cases. The overall 10-year incidence was 0.30%. The incidence of bladder injury was 0.18%, (0.083% for ureteric and 0.014% for combined ureter and bladder injury). Among 80 cases with complete data, 52 (65%) had bladder injury and 48 (92.3%) were recognized the time of surgery and underwent primary repair with successful outcome, whereas 18 (75%) of 24 ureteric injury were detected intraoperatively. Previous pelvic surgery and the presence of adhesion were significant risk factors of urologic injury with OR 3.436, 95% CI 2.037-5.796 and OR 2.185, 95% CI 1.319-3.621, respectively., Conclusion: Urinary bladder injury was the most common urinary tract injury during gynecologic surgery. Previous pelvic surgery and the presence of adhesion were significant risk factors., (© 2017 Japan Society of Obstetrics and Gynecology.)

Laparoscopic radical hysterectomy has been widely performed for patients with early-stage cervical cancer. The operative techniques for nerve-sparing to avoid bladder dysfunction have been established during the past three decades in abdominal radical hysterectomy, but how these techniques can be applied to laparoscopic surgery has not been fully discussed. Prolonged operation time or decreased radicality due to less accessibility via a limited number of trocars may be a disadvantage of the laparoscopic approach, but the magnified visual field in laparoscopy may enable fine manipulation, especially for preserving autonomic nerve tracts. The present review article introduces the practical techniques for sparing bladder branches of pelvic nerves in laparoscopic radical hysterectomy based on understanding of the pelvic anatomy, clearly focusing on the differences from the techniques in abdominal hysterectomy., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: To compare different modalities to aid in the evaluation of intraoperative ureteral patency on cystoscopy in the postindigo carmine era., Methods: In a randomized controlled trial, participants undergoing pelvic surgery were randomized into one of four groups: saline distention (control), 10% dextrose distention, oral phenazopyridine, or intravenous sodium fluorescein. Our primary outcome was visibility of the ureteral jets. Secondary outcomes included surgeon satisfaction; adverse reactions including allergies, urinary tract infections, urinary retention, cystoscopy times, and ureteral obstruction; and delayed diagnosis. Participants were followed for 6 weeks. A sample size of 176 participants was planned to demonstrate a 30% difference in the visibility scale. All analyses were performed in an intention-to-treat fashion., Results: From February 25, 2015, through August 2015, 176 participants were enrolled; 174 completed the trial, and two did not undergo intervention. Forty-four participants were included in the phenazopyridine, dextrose, saline, and sodium fluorescein groups. Sodium fluorescein and 10% dextrose resulted in significantly improved visibility and satisfaction when compared with the control group (P<.001 and P=.004, respectively). Dextrose provided the highest satisfaction and phenazopyridine provided lowest, but visibility was not statistically different between the two groups (P=.101). Three ureteral obstructions were identified intraoperatively and none in the postoperative period. Mean total cystoscopy time varied between 4.0 and 4.8 minutes and postoperative urinary retention rate was 50% across all groups. Overall urinary tract infection rate was 24.1%, which was similar between interventions. There were no related adverse events., Conclusion: Compared with the control, 10% dextrose and sodium fluorescein resulted in improved visibility and provided significantly more satisfaction in the evaluation for ureteral patency with no considerable increase in operative time or morbidity., Clinical Trial Registration: ClinicalTrials.gov, https://clinicaltrials.gov, NCT02476448.

Introduction: Iatrogenic ureteral injury is a rare but potentially devastating complication of colorectal surgery. We evaluated the incidence and management of iatrogenic ureteral injuries in colorectal surgery during the transition phase from open to laparoscopic surgery., Materials and Methods: We conducted a retrospective single center study. All patients who underwent colorectal surgery between 2004 and 2014 were evaluated by collecting data of electronic patient charts. Both acute and elective procedures were included., Results: A total of 3302 colorectal procedures were performed in the study period. Of these, 2817 operations were performed open and 484 laparoscopically. A total of 23 iatrogenic ureteral injuries were identified, of which 5 were found during laparoscopic surgery. The cumulative incidence of ureteral injuries was 0.6% for open procedures and 1.0% for laparoscopic procedures., Conclusions: Ureteral injury is a rare complication of colorectal surgery. The incidence might rise with the increasing use of laparoscopy.

Objective: To identify risk factors for ureteral injury during hysterectomy and to assess outcomes of concurrent minimally invasive vs converted to open repairs., Methods: We queried the American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2013 to identify abdominal hysterectomy (AH), minimally invasive hysterectomy (MIH), or vaginal hysterectomy. Ureteral injury was identified based on intraoperative or delayed management. Multivariate logistic regression was performed to assess the effect of hysterectomy approach on risk of ureteral injury while controlling for covariates. For patients with ureteral injury during MIH, we compared 30-day outcomes following minimally invasive vs converted open repairs., Results: There were 302 iatrogenic ureteral injuries from 96,538 hysterectomies, with 0.18%, 0.48%, and 0.04% from AH, MIH, and vaginal hysterectomy, respectively. Patients who underwent MIH were younger and had decreased comorbidities compared to patients who underwent AH (all P < .001). MIH resulted in lower overall complications (6.6% vs 14.8%, P < .001) but higher ureteral injury rate (0.48% vs 0.18%, P < .001) compared to AH. On multivariate analysis, the minimally invasive approach was associated with increased risk of ureteral injury (odds ratio 4.2, P < .001). Patients undergoing minimally invasive ureteral repairs (89%) during MIH had shorter operating room time and length of stay but similar overall perioperative complications compared to those with converted open repairs (11%)., Conclusion: Using a large national series, we show that the minimally invasive approach for hysterectomy is an independent risk factor for iatrogenic ureteral injuries. During MIH, concurrent minimally invasive ureteral repairs resulted in comparable 30-day outcomes compared to converted to open repairs., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Ureteral injury during laparoscopic surgery is rare, but when it occurs, it can be a serious problem. Near-infrared fluorescence (NIRF) with methylene blue (MB) administration is a promising technique for easier and potentially earlier intraoperative visualization of the ureter. Aim of this prospective study was to assess the feasibility of NIRF imaging of the ureter during laparoscopic colorectal surgery, using MB., Methods: Patients undergoing laparoscopic colorectal surgery were included and received intravenous injection of MB preoperatively. The ureter was visualized using a laparoscope, which offered both conventional and fluorescence imaging. Intraoperative recognition of the ureter was registered. The precision of ureter distinction with MB imaging was compared to the conventional laparoscopic view., Results: Ten patients were included. All procedures were initially performed using a laparoscopic approach. Dose per injection ranged between 0.125 mg/kg and 1.0 mg/kg bodyweight. There were no adverse effects attributable to MB administration. The ureter was successfully detected in five patients, with highest contrast between ureter and surrounding tissue at an administered dose of 0.75-1.0 mg/kg. The fluorescent signal was only picked up after the ureter was already visible in the conventional white light mode., Conclusion: Ureteral fluorescence imaging using MB proved to be safe and feasible. However, the present technique does not provide practical advantage over conventional laparoscopic imaging for identification of the ureter during laparoscopic colorectal surgery. Future research is necessary to explore more extensive dose finding, alternative fluorescent dyes, or improvement of the imaging system to make this application clinically beneficial.

Ureteral injury is one of the possible complications of distal colectomies. It may be caused by misidentification of the anatomic landmarks during the left lateral dissection, due to factor pertaining to the patient, the disease, and the surgeon. The only way to reduce the risk of this avoidable complication is the perfect knowledge and identification of the anatomy of the left ureter. In this article, we describe an anatomic triangle that can be a valid help in the identification of the ureter in the area where higher is the risk of iatrogenic injury. The left ureteric triangle can be prepared after the dissection of the left Toldt plane, as soon as the dissection reaches the superior mesorectum. Sides of this triangle are (a) superiorly, the dissected mesosigmoid, (b) right side, upper mesorectum and sacral promontorium, and (c) inferiorly, the margin of the incised posterior parietal peritoneum. The left ureter runs within this triangle.

Objectives: To analyze the robotic approach as treatment of iatrogenic ureteral injuries., Methods: Medical records were reviewed for patients undergoing robotic-assisted laparoscopic ureteral reimplantation at the University of Missouri from 2009 to 2014. Patient charts were analyzed for demographics, prior abdominal surgeries, circumstances of injury, outcomes, and other relevant information., Results: Nine patients met inclusion criteria. The average age was 44.6. Patients had an average of 4.3 abdominal surgeries. Injury occurred during hysterectomy (open, laparoscopic, or vaginal) in eight patients (88.9 %), five cases were laparoscopic, two utilized robotic assistance, and one injury occurred during uterosacral vault suspension. All cases were related to gynecological procedures. On average, ureteral injury was detected 17.2 days after the initial surgery and repaired 62.3 days after initial operation. The average surgical repair time was 295.9 min (range 168-498) with an average blood loss of 77.2 mL (range 20-150). Four patients required a psoas hitch, with one receiving both a psoas hitch and a Boari flap. Postoperatively, patients had an average hospital stay of 2.7 days. One patient had ileus for greater than 3 days, and another was readmitted within 30 days for pain control and antiemetics following stent removal. One patient underwent open reimplantation 3 years after original surgery for development of ureteral stricture. At follow-up, all patients had returned to baseline renal function., Conclusions: Robotic approach is feasible and a safe option for distal iatrogenic ureteral injuries occurring during gynecological procedures. Prior abdominal surgery or delayed repair does not preclude a robotic approach.

Objective: To evaluate the usefulness of phenazopyridine for confirmation of ureteral patency during intraoperative cystoscopy., Methods: We conducted a randomized controlled trial comparing use of phenazopyridine with no medications for evaluation of ureteral patency during intraoperative cystoscopy in women undergoing pelvic surgery. The primary study outcome was time to visualize ureteral urine efflux. To detect a 3-minute difference with α of 0.05 using a two-sided, two-sample t test and β 0.80 required 98 patients equally divided into two groups., Results: A total of 104 women were randomized from April to December 2015. Patients in the treatment group tended to be older (P=.02); otherwise, study groups were similar. Time to visualize ureteral urine efflux did not differ between study groups with a mean time of 2 minutes 40 seconds (±2 minutes 38 seconds) in the control group and 2 minutes 53 seconds (±4 minutes 35 seconds) in the treatment group (P=.77). Regarding the surgeon survey, surgeons felt less frustrated and impatient in visualization of ureteral urine efflux in the treatment group compared with the control group (mean response 1.5±0.8 in treatment compared with 2.0±1.0 in control, P=.007), and surgeons felt that the cystoscopy took too long more often in the control than in the treatment group (1.7±0.9 in treatment compared with 2.1±1.0 in control, P=.02). Trial of void result differed significantly between groups with fewer patients in the treatment group failing a void trial (P=.04). There were no adverse events related to phenazopyridine use., Conclusion: Preoperative phenazopyridine is a useful and cost-saving medication for use in planned cystoscopy for evaluation of ureteral patency., Clinical Trial Registration: ClinicalTrials.gov, https://clinicaltrials.gov/, NCT02424149.