Upper Urinary Tract Trauma: Difference between revisions
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=== <span style="color:#ff0000">Pathogenesis === | === <span style="color:#ff0000">Pathogenesis === | ||
* Acute ureteral injury results from (3): | * '''Acute ureteral injury results from (3):''' | ||
* | *# '''Iatrogenic injury''' (open surgery, laparoscopy, and endoscopic procedures) | ||
* | *# '''External violence''' from high-speed blunt mechanisms | ||
* | *##The presence of massive force injuries in the patient with blunt trauma should always increase the level of suspicion for ureteral injury | ||
* | *# '''Penetrating stab and gunshot wounds''' | ||
* Iatrogenic injury | * '''Iatrogenic injury''' | ||
** Procedures most commonly associated with iatrogenic ureteral injuries: | ** '''Procedures most commonly associated with iatrogenic ureteral injuries:''' | ||
*** Hysterectomy (54%) | *** '''Hysterectomy (54%)''' | ||
*** Colorectal surgery (14%) | *** Colorectal surgery (14%) | ||
*** Ovarian tumor removal (8%) | *** Ovarian tumor removal (8%) | ||
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** Compared to open surgery, ureteral injuries during laparoscopic surgery are less likely to be recognized immediately. | ** Compared to open surgery, ureteral injuries during laparoscopic surgery are less likely to be recognized immediately. | ||
*** During laparoscopy/robotic surgery, a high index of suspicion for ureteral injury is required. | *** During laparoscopy/robotic surgery, a high index of suspicion for ureteral injury is required. | ||
*** In open surgery, 1/3 of ureteral injuries are recognized immediately. | *** In open surgery, 1/3 of ureteral injuries are recognized immediately. | ||
*** Intraoperative assessment of ureters | *** Intraoperative assessment of ureters | ||
**** Some have advocated maneuvers to check the patency of the ureter after all surgeries in which ureteric injury is commonly reported (e.g., hysterectomy). | **** Some have advocated maneuvers to check the patency of the ureter after all surgeries in which ureteric injury is commonly reported (e.g., hysterectomy). | ||
**** Options (3): | **** Options (3): | ||
***** Direct inspection | ***** Direct inspection | ||
****** Purposefully opening the retroperitoneum before or after hysterectomy has been advocated to avoid ureteral injury or at least allow intraoperative detection. | ****** Purposefully opening the retroperitoneum before or after hysterectomy has been advocated to avoid ureteral injury or at least allow intraoperative detection. | ||
***** Injection of 5-10 mL of IV methylene blue or indigo carmine dye followed by cystoscopy | ***** Injection of 5-10 mL of IV methylene blue or indigo carmine dye followed by cystoscopy | ||
****** Poor predictor of injury | ****** Poor predictor of injury | ||
****** Goal of cystoscopy is to document the absence of hematuria and the presence of bilateral ureteral jets | ****** Goal of cystoscopy is to document the absence of hematuria and the presence of bilateral ureteral jets | ||
****** IV methylene blue and indigo carmine are generally considered to be benign drugs, but their use has resulted in patient deaths and fetal deaths when used in pregnant women. | ****** IV methylene blue and indigo carmine are generally considered to be benign drugs, but their use has resulted in patient deaths and fetal deaths when used in pregnant women. | ||
******* Contraindications for IV methylene blue (3): | ******* Contraindications for IV methylene blue (3): | ||
******** Pregnancy | ******** Pregnancy | ||
******** Use of selective (e.g., paroxetine, sertraline, fluoxetine, fluvoxamine, citalopram) or nonselective (e.g., imipramine) serotonin reuptake inhibitors | ******** Use of selective (e.g., paroxetine, sertraline, fluoxetine, fluvoxamine, citalopram) or nonselective (e.g., imipramine) serotonin reuptake inhibitors | ||
********* Methylene blue is a potent monoamine oxidase inhibitor and has caused deaths from serotonin toxicity in patients taking medications that increase serotonin levels | ********* Methylene blue is a potent monoamine oxidase inhibitor and has caused deaths from serotonin toxicity in patients taking medications that increase serotonin levels | ||
******** Glucose-6-phosphate dehydrogenase deficiency | ******** Glucose-6-phosphate dehydrogenase deficiency | ||
********* Causes methemoglobinemia and hemolysis | ********* Causes methemoglobinemia and hemolysis | ||
******* Contraindications for IV indigo carmine: | ******* Contraindications for IV indigo carmine: | ||
******** Pregnancy | ******** Pregnancy | ||
******** IV indigo carmine has been implicated in rare but serious cases of bronchospasm, bradycardia, hypertension, hypotension (most common), and anaphylactoid reactions. | ******** IV indigo carmine has been implicated in rare but serious cases of bronchospasm, bradycardia, hypertension, hypotension (most common), and anaphylactoid reactions. | ||
**** Retrograde pyelography | **** Retrograde pyelography | ||
**** Not effective | **** Not effective | ||
***** Intraooperative single-shot IVP | ***** Intraooperative single-shot IVP | ||
***** Intraoperative hydration or diuretic administration | ***** Intraoperative hydration or diuretic administration | ||
****** Has been suggested to enhance ureteral visualization and potentially decrease the risk for injury | ****** Has been suggested to enhance ureteral visualization and potentially decrease the risk for injury | ||
****** No data to support this method | ****** No data to support this method | ||
***** Digital palpation of the ureter | ***** Digital palpation of the ureter | ||
****** Appears to be ineffective | ****** Appears to be ineffective | ||
***** Grasping the ureter with forceps to evoke ureteral peristalsis | ***** Grasping the ureter with forceps to evoke ureteral peristalsis | ||
****** Highly ineffective; should never be relied upon. | ****** Highly ineffective; should never be relied upon. | ||
* Preoperative ureteral stenting | * Preoperative ureteral stenting | ||