Iatrogenic Ureteral Injury in Abdominopelvic Surgery: Early Detection, Intraoperative Prevention, and Reconstructive Management
DOI:
https://doi.org/10.64784/328Palabras clave:
iatrogenic ureteral injury, ureteral trauma, abdominopelvic surgery, CT urography, prophylactic ureteral stenting, indocyanine green, fluorescence-guided surgery, ureteroneocystostomy, ureteroureterostomy, urinary diversion, reconstructive urologyResumen
Inadvertent ureteral injury is an uncommon but potentially severe complication of abdominopelvic surgery, particularly in complex colorectal, gynecological, oncological, and retroperitoneal procedures. Its clinical impact is strongly influenced by the timing of recognition, since delayed diagnosis may lead to urinary extravasation, urinoma, obstruction, infection, fistula formation, ureteral stricture, prolonged hospitalization, and loss of renal function. This study analyzed current evidence on intraoperative prevention, radiological diagnosis, and early therapeutic management of iatrogenic ureteral injury through a structured review of the literature. The findings showed that intraoperative recognition was associated with fewer secondary procedures, hospital readmissions, and hospitalization days compared with delayed diagnosis. Routine prophylactic ureteral stenting did not demonstrate a consistent reduction in ureteral injury rates, although it may facilitate anatomical identification in selected high-risk procedures. Fluorescence-guided visualization with indocyanine green significantly improved intraoperative ureteral identification, but current evidence has not confirmed a definitive reduction in injury incidence. Computed tomography urography with delayed excretory-phase acquisition was identified as a key diagnostic tool, particularly for demonstrating contrast extravasation, urinoma, hydronephrosis, and incomplete ureteral opacification. Management depended on injury location, severity, tissue viability, and timing of diagnosis. Endoscopic stenting and nephrostomy were useful in selected cases, while complete transection, devascularization, or extensive tissue loss generally required reconstructive surgery. Overall, the evidence supports a multidisciplinary approach integrating risk stratification, careful intraoperative identification, early imaging, prompt urinary diversion, and anatomy-adapted reconstruction to reduce morbidity and preserve renal function.
Referencias
• Ambani, S. N., Skupin, P., Malaeb, B. S., Barboglio-Romo, P., & Stoffel, J. T. (2020). Does early ureteroneocystostomy after iatrogenic ureteral injury jeopardize outcome? Urology, 136, 245–250. DOI: 10.1016/j.urology.2019.09.056.
• Blackwell, R. H., Kirshenbaum, E. J., Shah, A. S., Kuo, P. C., Gupta, G. N., & Turk, T. M. T. (2018). Complications of recognized and unrecognized iatrogenic ureteral injury at time of hysterectomy: A population-based analysis. The Journal of Urology, 199(6), 1540–1545. DOI: 10.1016/j.juro.2017.12.067.
• Brandes, S., Coburn, M., Armenakas, N., & McAninch, J. (2004). Diagnosis and management of ureteric injury: An evidence-based analysis. BJU International, 94(3), 277–289. DOI: 10.1111/j.1464-410X.2004.04978.x.
• Brollo, P. P., Puggioni, A., Tumminelli, F., Colangelo, A., Biddau, C., Cherchi, V., & Bresadola, V. (2024). Preventing iatrogenic ureteral injury in colorectal surgery: A comprehensive and systematic review of the last 2 decades of literature and future perspectives. Surgery Today, 54(4), 291–309. DOI: 10.1007/s00595-022-02639-9.
• Burks, F. N., & Santucci, R. A. (2014). Management of iatrogenic ureteral injury. Therapeutic Advances in Urology, 6(3), 115–124. DOI: 10.1177/1756287214526767.
• Croghan, S. M., Zaborowski, A., Mohan, H. M., Mulvin, D., McGuire, B. B., Murphy, M., Galvin, D. J., Lennon, G., Quinlan, D., & Winter, D. C. (2019). The sentinel stent? A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections. International Journal of Colorectal Disease, 34(7), 1161–1178. DOI: 10.1007/s00384-019-03314-1.
• European Association of Urology. (2026). EAU guidelines on urological trauma. EAU Guidelines Office.
• Esparaz, A. M., Pearl, J. A., Herts, B. R., LeBlanc, J., & Kapoor, B. (2015). Iatrogenic urinary tract injuries: Etiology, diagnosis, and management. Seminars in Interventional Radiology, 32(2), 195–208. DOI: 10.1055/s-0035-1549378.
• Ferrara, M., & Kann, B. R. (2019). Urological injuries during colorectal surgery. Clinics in Colon and Rectal Surgery, 32(3), 196–203. DOI: 10.1055/s-0038-1677026.
• Gild, P., Kluth, L. A., Vetterlein, M. W., Engel, O., Chun, F. K. H., & Fisch, M. (2018). Adult iatrogenic ureteral injury and stricture—Incidence and treatment strategies. Asian Journal of Urology, 5(2), 101–106. DOI: 10.1016/j.ajur.2018.02.003.
• Haroon, S. A., Rahimi, H., Merritt, A., Baghdanian, A., Baghdanian, A., & LeBedis, C. A. (2019). Computed tomography (CT) in the evaluation of bladder and ureteral trauma: Indications, technique, and diagnosis. Abdominal Radiology, 44(12), 3962–3977. DOI: 10.1007/s00261-019-02161-6.
• Hird, A. E., Nica, A., Coburn, N. G., Kulkarni, G. S., Nam, R. K., & Gien, L. T. (2021). Does prophylactic ureteric stenting at the time of colorectal surgery reduce the risk of ureteric injury? A systematic review and meta-analysis. Colorectal Disease, 23(5), 1060–1070. DOI: 10.1111/codi.15498.
• Kanabur, P., Chai, C., & Taylor, J. (2020). Use of indocyanine green for intraoperative ureteral identification in nonurologic surgery. JAMA Surgery, 155(6), 520–521. DOI: 10.1001/jamasurg.2020.0094.
• Litchinko, A., Denost, Q., Noiret, B., Ris, F., & Adamina, M. (2026). Fluorescence-guided ureter mapping in colorectal surgery: A systematic review of intraureteral ICG and emerging renal fluorophores. Frontiers in Surgery, 13, 1734869. DOI: 10.3389/fsurg.2026.1734869.
• Maheswaran, R., Beisland, C., Bergesen, A. K., & Almås, B. (2024). A delayed diagnosis of iatrogenic ureteral injury results in increased morbidity. Scientific Reports, 14(1), 13771. DOI: 10.1038/s41598-024-63847-6.
• Mazzarella, G., Muttillo, E. M., Picardi, B., Rossi, S., Rossi Del Monte, S., & Muttillo, I. A. (2022). Real-time intraoperative ureteral identification in minimally invasive colorectal surgery: A systematic review. Journal of Laparoendoscopic & Advanced Surgical Techniques, 32(6), 627–633. DOI: 10.1089/lap.2021.0292.
• Ould Ahmed, K., Jourdan, M., Baboudjian, M., Aubert, M., & Mege, D. (2025). Ureteral complications during colorectal surgery. Journal of Visceral Surgery, 162(5), 359–368. DOI: 10.1016/j.jviscsurg.2025.08.004.
• Souli, A., Alves, A., Tillou, X., & Menahem, B. (2024). Iatrogenic ureteral injury: What should the digestive surgeon know? Journal of Visceral Surgery, 161(1), 6–14. DOI: 10.1016/j.jviscsurg.2023.04.001.
• White, L. A., Joseph, J. P., Yang, D. Y., Kelley, S. R., Mathis, K. L., Behm, K., & Viers, B. R. (2021). Intraureteral indocyanine green augments ureteral identification and avoidance during complex robotic-assisted colorectal surgery. Colorectal Disease, 23(3), 718–723. DOI: 10.1111/codi.15407.
• Yanagisawa, T., Mori, K., Quhal, F., Kawada, T., Mostafaei, H., Laukhtina, E., Rajwa, P., Sari Motlagh, R., Aydh, A., König, F., Pallauf, M., Pradere, B., Miki, J., Kimura, T., Egawa, S., & Shariat, S. F. (2023). Iatrogenic ureteric injury during abdominal or pelvic surgery: A meta-analysis. BJU International, 131(5), 540–552. DOI: 10.1111/bju.15913.
