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Ureteral Diameter as Predictor of Ureteral Injury during Ureteral Access Sheath Placement

DOI: 10.1097/JU.0000000000001299
Reference: JU-20-1119

Background and significance: Flexible ureteroscopy (URSf) has been the most developed endourological procedure in recent years (1). This has to do with the massive access to disposable ureteroscopes and for its better results compared to extracorporeal lithotripsy. With the increase of URSf, and therefore, an increase in the use of ureteral access sheaths, we began to see complications that were not frequent in our clinical practice. Post-urethroscopy, ureteral strictures are widely described in the literature, reaching up to 4% (2). These types of complications are serious, since their resolution, depending on which segment of the ureter they occur, implies a major surgical challenge. The urological community began to look at this phenomenon with attention the year 2012, when Traxer published its classification of damage to the ureteral wall (Grade 0 to Grade 4) and suggested the treatment that should be carried out in any case. Many other publications show that when there are high grade ureteral lesions due to the use of access sheaths, the possibility of late ureteral stenosis is greater. How can we prevent or sense this type of damage?

The work to be reviewed, tries in a simple and intelligent way to define risk factors in patients who will have an URSf performed with the use of an access sheath and in this way plan the surgery better, even indicating the previous installation of a ureteral catheter to prevent the eventual stenosis of the ureter.

Summary: This is a prospective work developed in one year. Sixty-eight patients were enrolled to have a URSf for renal lithiasis and therefore had ureters without previous dilation. Only in 64 patients was possible to install an access sheath, which leaves us with a first important message; the need for a ureteral catheter prior to an URSf in almost 10% of cases, which should be informed to the patient before surgery. Of the 64 patients with access sheath (12/14 fr.), 70% (46 patients) presented some degree of ureteral injury. Patients with grade 4 lesions were not consigned, however, there were 12 patients (25%) who presented grade 3 lesions, considered to be high grade and that could eventually develop a late ureteral stenosis. Most of the high-grade lesions were in the proximal ureter (80%); second relevant message; ureteral lesions when using access sheath are more frequent than we think and in a not lesser percentage they can be serious. All patients enrolled in the study were requested a non-contrast CT scan days prior to surgery and following a strict protocol the width of the ureter was measured at the proximal, medial, and distal levels. There are several findings to highlight, mainly if we focus on high-grade lesions. Most high-grade lesions are produced in the proximal ureter and in the male gender. A smaller proximal ureter diameter is directly related to the possibility of having a high-grade proximal ureteral lesion; in this work the average diameter of proximal ureters that had high-grade lesions was 3.29 mm. (Table 1).

Personal Assessment

Strengths

  • Very well done work, in a simple and intelligent way.
  • It shows us that at least 10% of the patients in a URSf will not be able to install an access sheath, which must be known by the patient
  • It provides tools to prevent ureteral damage when u.sing access sheaths, allowing the use of a shorter access sheath to be planned prior to surgery, or simply not to use an access sheath.

Weaknesses

  • There may be subjectivity in the measurement of ureteral diameter and degree of damage after surgery, as they are dependent operators.

Dr. Fernando Marchant G.
Prof. Asociado Universidad de Chile
Unidad de Endourología Hospital Clínico
Universidad de Chile

Bibliography

  1. Trends in Upper Tract Stone Disease in England: Evidence from the Hospital Episodes Statistics (HES) Database. Rukin N, Siddiqui Z, Chedgy E, Somani BK. Urol Int. 2017; 98:391–396. 
  2. The development of ureteric strictures after ureteroscopic treatment for ureteric calculi: A long-term study at two academic centres. El-Abd AS, Suliman MG, Abo Farha MO, Ramadan AR, El-Tatawy HH, El-Gamal OM, et al. Arab J Urol. 2014;12:168–72
  3. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. Olivier Traxer 1, Alexandre Thomas. J Urol  2013 Feb;189(2):580-4

151 replies on “Ureteral Diameter as Predictor of Ureteral Injury during Ureteral Access Sheath Placement”

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