Iatrogenic ureteral injury during retroperitoneal laparoscopy for large renal cysts: What we learned and a review of the literature

Article type: Research Article

Authors: Zhang, Zejian^a | Chen, Dong^a | Deng, Ling^a | Li, Wei^a | Wang, Xisheng^{a; *} | Zhang, Yixiang^b | Liekui, Fang^{c; *} | Feloney, Michael P.^d | Zhang, Yuanyuan^{e; *}

Affiliations: [a] Department of Urology,Shenzhen Longhua District Central Hospital,The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, Guangdong Province,China | [b] Department of Urology, Shenzhen People’s Hospital,The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong Province,China | [c] Department of Urology, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen third people’s hospital, Shenzhen, Guangdong Province, China | [d] Department of Urology, Creighton University School of Medicine, Omaha, NE, USA | [e] Wake Forest Institute for Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA

Correspondence: [*] Corresponding author: Xisheng Wang, Department of Urology, Shenzhen Longhua District Central Hospital, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, Guangdong Province, China. E-mail: 18923877315@163.com and Liekui Fang, Department of Urology, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen third people’s hospital, Shenzhen, Guangdong Province, China. E-mail: fangliekui88@163.com and Yuanyuan Zhang, Wake Forest Institute for Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA. E-mail: yzhang@wakehealth.edu.

Abstract: PURPOSE:To avoid Iatrogenic ureteral injury during retroperitoneal laparoscopy for large renal cyst (diameter > 70 mm), we present two cases of iatrogenic ureteral injury and discuss their clinical courses and final outcomes. PATIENTS AND METHODS:Two male patients (47 years old and 74 years old) with large left simple renal cysts underwent a retroperitoneal laparoscopic operation to treat the cysts. In the first patient, the left proximal ureter was partially transected (Grade 3) during the operation. The injury was identified intraoperatively. The transection was managed with a primary ureteroureterostomy (end to end) along with a double J ureteral stent. In the second patient, the left proximalureter was partially transected (Grade 4). However, the injury was unrecognized postoperatively for two days. After recognition of the complication, the injury was managed with an early primary ureteroureterostomy, which followed a failed attempt to place ureteral stent endoscopically. RESULTS:In the first patient, a postoperative urinary leakage developed and lasted for 13 days. During long term follow-up of the first patient after the urine leak resolved, there were no reports of pain in the lumbar region or other discomfort. No recurrence of the renal cyst occurred, which was confirmed with an ultrasound at one year postoperatively. In the second patient a ureteral fistula and severe perirenal infection occurred and lasted for 86 days. The patient ultimately underwent a left nephrectomy after conservative management for this surgical complication failed. This patient developed a chronic wound infection that lasted for 3.14 months following the nephrectomy. During follow-up post nephrectomy, the patient developed stage 3B moderate chronic kidney disease (CKD) (GFR = 30 –44 ml/min). CONCLUSIONS:For single large (diameter > 70 mm) renal cysts located at the lower pole of the kidney, it is recommended to not completely dissect out and mobilize the entire renal cyst for cyst decortication in order to avoid injuring the ureter. Iatrogenic ureteral injury increases the risk of readmission and serious life-threatening complications. The immediate diagnosis and proper management ureteric injury can reduce complications and long term sequalae.

Keywords: Renal cyst, iatrogenic ureteral injury, laparoscopic renal cyst decortication

DOI: 10.3233/XST-200804

Journal: Journal of X-Ray Science and Technology, vol. 29, no. 1, pp. 185-196, 2021