The Clinical Research Of Iatrogenic Ureteral Injury Complicating Ureteral Stricture

Introduction:To investigate the ureteroscopic feature and the pathological basis of the iatrogenic ureteric lesion complicating upper tract obstruction and to evaluate the efficacy of different surgical strategies in different cases.Material and method:From February 2007 to April 2009,16 cases with iatrogenic ureteric lesion complicating upper tract obstruction were enrolled in this retrospective study. The average age of the patients was 49 years old. After the endourologic trauma, a D-J stent had been set in place for 4-6 weeks in all the cases. The length of the obstructive portion and the thickness of the ureteric scar were evaluated by MRU. The STORZ 7.9F semi-rigid ureteroscope was used to observe the altered ureter. For the patients without any obstruction found by the ureteroscopy, an open surgery was carried out to remove the stricture part and the specimen was examined by a pathologist. For the rest of the cases, we tried the internal ureterotomy with holium laser under the ureteroscope. After all the procedure, a 7F D-J stent was indwelled for 6 weeks. An intravenous urography was done 6 months after the procedure to evaluate the results.Result:The semi-rigid ureteroscope could advance without any difficulty in 4 patients, in whom the involved mucosa were flat and the lumen were unobstructed. The surgical specimen showed a thickening of the whole ureteric wall with chronic inflammation and interlace of smooth muscle cell while the mucosa was intact. In the other 12 patients, we gave up the ureteroscopy for the tight stenosis with the guide wire set in place and a holium laser endoureterotomy was carried out. In all the 4 patients with open surgery,6 month after the surgery, the IVU showed there was no more obstruction in the altered ureter while in 3 cases treated by internal incision had a recurrence of ureteric stricture and hydronephrosis. We have removed the obstructive part in these 3 patients and the follow-up at 6 months after the second surgery demonstrated the ureter intact.Conclusion:In some of the patients with iatrogenic ureter lesion, the ureteric mucosa could be intact while there is a thickening of the sub-mucosa, the mucucularis and the peri-ureteric tissue. For the patients the ureteral kinetic obstruction was probably the main cause and the surgical removal of the altered segment might be the reasonable choice. For the patients with a tight and relatively short stricture (<2cm) confirmed by the ureteroscopy, the holium laser endoureterotomy or the ballon dilation could be proposed with a relatively high late recurrence rate. The urine extravasation might enhance the fibrosis of the ureter and for the cases with an important urinoma, the PCN drainage might be a good solution.