Iatrogenic upper urinary tract injuries

Definition

Iatrogenic injuries of the renal collecting system and ureter may occur during endoscopic, laparoscopic, open, and image-guided endovascular procedures.

Early recognition reduces the risk of stricture, fistula, infection, and loss of kidney function.

When to suspect it

• Flank pain, fever, reduced urine output.
• Urinary infiltration of tissues, unexplained rise in creatinine.
• Urine appearing in a drain after surgery.
• After endoscopy: a change in the pattern of pain and failure of urine output to recover as expected.

Diagnosis

• Initial assessment: CBC, creatinine, electrolytes, urinalysis, and culture if infection is suspected.
• Ultrasonography: hydronephrosis, fluid.
• CT with a urographic phase is the key investigation in a stable patient.
• Retrograde pyelography is used to plan stent placement.

Emergency management

• Partial injury with preserved patency: stenting.
• Complete transection or inability to obtain retrograde access: nephrostomy.
• Intraoperative recognition: immediate reconstruction.

Algorithm