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Table of Contents
CASE REPORT
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 200-203  

Ureteric injury after lumbosacral microdiscectomy: A case report and review of literature


Department of Urology, PGIMER, Chandigarh, India

Date of Submission20-Apr-2015
Date of Acceptance20-Jun-2015
Date of Web Publication10-Apr-2017

Correspondence Address:
Nitin Garg
Department of Urology, PGIMER, Chandigarh
India
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DOI: 10.4103/0974-7796.204191

PMID: 28479779

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   Abstract 

Microdiscectomy is considered a very safe procedure with few serious complications. Ureteric injury following microdiscectomy is rarely reported in the literature. We report a rare case of iatrogenic ureteric injury following L5-S1 microdiscectomy for prolapsed intervertebral disc which was detected early and managed in time.

Keywords: Latrogenic, microdiscectomy, prolapsed intervertebral disc, ureteric injury


How to cite this article:
Garg N, Panwar P, Devana SK, Ravi Mohan S M, Mandal A K. Ureteric injury after lumbosacral microdiscectomy: A case report and review of literature. Urol Ann 2017;9:200-3

How to cite this URL:
Garg N, Panwar P, Devana SK, Ravi Mohan S M, Mandal A K. Ureteric injury after lumbosacral microdiscectomy: A case report and review of literature. Urol Ann [serial online] 2017 [cited 2020 Jan 27];9:200-3. Available from: http://www.urologyannals.com/text.asp?2017/9/2/200/204191


   Introduction Top


Iatrogenic injuries account for the majority of ureteric injuries.[1] The most common location is distal one-third of the ureter, and most common causes are gynecologic and colorectal surgeries.[2] Ureteric injuries are also known to occur after lumbar spine surgeries.[3] Microdiscectomy, presently, is the standard treatment for herniation of lumbosacral disc material. The microsurgical approach through the “interlaminar window” is synonymous with the terms “microdiscectomy” or “microsurgical discectomy.” The goal of this surgical procedure is the removal of slipped disc material (nucleus, endplate, anulus fibrosis) from the spinal canal to decompress the neural structures. Overall complications of microsurgical discectomy range between 1.5% and 15.8% in the literature with an average of 7.8%.[4],[5] Ureteric injury after microdiscectomy has been reported rarely.[6] The mechanisms that may lead to ureteric injury after posterior approaches to lumbar spine involve injury by pituitary rongeurs or sucking in of ureter into the field while removing the disc material.[7] Most of these injuries are not recognized intraoperatively.[8] A high index of suspicion and awareness of this complication as likely event are required for timely diagnosis and treatment. In our case, the ureteric injury was recognized in the early postoperative period. Thus, an astute neurosurgeon and timely intervention by urologist can help in early diagnosis and appropriate treatment of this potentially devastating complication.


   Case Report Top


A 44-year-old male patient, known case of symptomatic left paracentral prolapsed intervertebral disc (PIVD) presented to our outpatient department with a history of microdiscectomy via interlaminar window at L5-S1 done in a private hospital 5 months ago. The surgery was uneventful according to the details available from concerned neurosurgeon and operative records. Two days after surgery, the patient developed left flank pain with high-grade fever. Clinical examination revealed left flank tenderness. Contrast-enhanced computed tomography (CT) abdomen revealed a large collection in left retroperitoneal area anterior to left psoas muscle overlying sacral ala region [Figure 1]. Urology consultation was taken, and immediate CT-guided pigtail drainage of collection was done, which drained clear fluid [Figure 2]a. The creatinine level of fluid was 40 mg/dl. A provisional diagnosis of left ureteric injury was made and a left retrograde pyelography (RGP) was done, which revealed complete cut-off with extravasation of contrast at mid sacroiliac joint, and a left percutaneous nephrostomy (PCN) was placed [Figure 2]b. The patient was discharged in good condition on left PCN, with a daily output of about 1.5 L. Antegrade pyelography done after 4 weeks showed complete cut-off at the upper border of left sacral ala [Figure 3]. The patient was subsequently referred to our institute for further management. With a provisional diagnosis of iatrogenic left ureteric stricture secondary to injury during microdiscectomy, we planned him for definitive surgery. A lower midline incision was made, and a transperitoneal approach was used. Intraoperatively, the left ureter was normal up to the pelvic brim. The ureter below the pelvic brim was fibrosed and strictured [Figure 4]a and [Figure 4]b. The defect length was around 6 cm, thus a decision to make Boari flap was made. The repair was completed using Boari flap, and a tension-free nonrefluxing tunneled anastomosis was fashioned between the healthy segment of the left ureter and Boari flap [Figure 5]a,[Figure 5]b,[Figure 5]c. The postoperative course was unremarkable. The patient was discharged in stable condition and is doing well in his two follow-up visits.
Figure 1: Contrast-enhanced computed tomography abdomen showing large collection anterior to left psoas muscle (arrow head)

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Figure 2: Computed tomography abdomen showing (a) pigtail catheter in collection, (b) left nephrostomy in situ

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Figure 3: Left antegrade pyelogram showing complete cut-off at upper border of left sacral ala (arrow)

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Figure 4: Intraoperative photos showing (a) complete cut-off at mid ureteric level (arrow) with long segment loss of ureter, (b) length of defect as measured using ureteric catheter

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Figure 5: Intraoperative photos showing (a) Boari flap being harvested (arrowhead), (b) closure of flap over double-J stent (arrow), and (c) final picture after completion of anastomosis

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   Literature Review Top


Using words like microdiskectomy/microdiskectomy, ureteric/ureteral injury in MEDLINE and literature citations, a total of 3 relevant case reports of ureteric injury after lumbar microdiscectomy were identified from 1977 to 2015. All three earlier reported cases involved surgery at the L4-L5 vertebral level in contrast to our case where the L5-S1 vertebral level was involved. [Table 1] and [Table 2] highlight the salient points of previous case reports.
Table 1: Analysis of available literature

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Table 2: Analysis of available literature

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   Discussion Top


The term “microsurgical discectomy” describes the removal of herniated parts of lumbar intervertebral discs through a posterior approach with the help of a surgical microscope and microsurgical instruments. It implies the application of the general principles of microsurgery as well as the approach to the anatomical target area through a limited skin incision. Using MEDLINE and literature citations, we identified total 3 case reports of ureteric injury after lumbar microdiscectomy. All three earlier reported cases involved surgery at the L4-L5 vertebral level, in contrast to our case where the L5-S1 vertebral level was involved [Table 1] and [Table 2]. Overall complications of microsurgical discectomy range between 1.5% and 15.8% in the literature with an average of 7.8%.[4],[5] There are significantly less severe intraoperative complications as compared to nonmicrosurgical discectomies.[10] The most important as well as the most frequent complications are: urinary retention (5%), perineural fibrosis (3%), superficial wound infection (2%), dural tears (1%), deep venous thrombosis (1%), postoperative segmental instability (1%), disc space infection (<1%), root injury (<1%), lesions due to positioning (<1%), cauda equina syndrome (<0.1%), retroperitoneal blood vessel injury (<0.1%), and epidural hemorrhage (<1%).[10] Ureteral injury is a rare complication of lumbar spinal surgery.[3] Posterior as compared to anterior or anterolateral approaches to the lumbar spine are more commonly associated with ureteric injuries.[4],[5] Commonly cited factors responsible for ureteral injury during posterior lumbar discectomy include lean and thin patient, defects in or absence of the anterior annulus, and retroperitoneal scars or adhesions from previous surgery or inflammation.[4] None of these risk factors was present in our case. The use of a rongeur-type instrument while removing herniated material, or clearing the disk space may also cause ureteral injury.[7] The ureter is anatomically related close to vertebral bodies, especially, near L5 and S1. It crosses the common iliac artery and vein ventrally and appears medial to these vessels at the lumbosacral junction.[11] Diagnosis of ureteric injury after lumbar spine surgery is likely to get delayed in view of nonspecific symptoms and no intraoperative pointers to such an event.[8] Urgent ultrasonography or CT abdomen can reveal retroperitoneal collection or proximal hydroureteronephrosis.[12] Once the ureteric injury is diagnosed, it is essential to know the extent of the damage. RGP may reveal contrast extravasation or complete cut-off at the level of injury. If the injury is partial, a double-J stent may be placed and later on definitive therapy can be done.[12] If the injury is complete PCN should be done initially, and the level of injury may be evaluated afterward using antegrade pyelography or nephrostogram.[13] In our case, since the injury was complete, left PCN was done initially. Definitive repair can then be done according to the level of ureteric injury. In our case, since there was long segment mid and lower ureteric stricture, Boari flap repair was done.[14] Using this repair, a defect of up to 10–15 cm can be bridged. Thus, a neurosurgeon's awareness for causing possible ureteral injury even during microdiscectomy, and timely intervention by a urologist, if such an event occurs, is essential for early detection and appropriate management.


   Conclusion Top


Ureteric injury following microdiscectomy for PIVD can occur rarely. A high index of suspicion, prompt diagnosis, and early intervention by a urosurgeon are essential for decreasing the morbidity and salvaging the renal function.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Elliott SP, McAninch JW. Ureteral injuries: External and iatrogenic. Urol Clin North Am 2006;33:55-66, vi.  Back to cited text no. 1
    
2.
Delacroix SE Jr, Winters JC. Urinary tract injures: Recognition and management. Clin Colon Rectal Surg 2010;23:104-12.  Back to cited text no. 2
    
3.
Altebarmakian VK, Davis RS, Khuri FJ. Ureteral injury associated with lumbar disk surgery. Urology 1981;17:462-4.  Back to cited text no. 3
    
4.
de Divitiis E, Spaziante R, Stella L, Cappabianca P, Genovese L. Surgery of the lumbar intervertebral disc. Results of a personal minimal technique. Neurochirurgia (Stuttg) 1984;27:16-9.  Back to cited text no. 4
    
5.
Nystrüm B. Experience of microsurgical compared with conventional technique in lumbar disc operations. Acta Neurol Scand 1987;76:129-41.  Back to cited text no. 5
    
6.
Tainio H, Kylmala T. Rupture of the ureter: An unexpected complication of microdiskectomy. BJU Int 1999;84:369-70.  Back to cited text no. 6
    
7.
Cho KT, Im SH, Hong SK. Ureteral injury after inadvertent violation of the intertransverse space during posterior lumbar diskectomy: A case report. Surg Neurol 2008;69:135-7.  Back to cited text no. 7
    
8.
Trinchieri A, Montanari E, Salvini P, Berardinelli L, Pisani E. Renal autotransplantation for complete ureteral avulsion following lumbar disk surgery. J Urol 2001;165:1210-1.  Back to cited text no. 8
    
9.
de Quintana-Schmidt C, Clavel-Laria P, Bartumeus-Jené F. Ureteral injury after posterior lumbar surgery. Case report. Neurocirugia (Astur) 2011;22:162-6.  Back to cited text no. 9
    
10.
Stolke D, Sollmann WP, Seifert V. Intra- and postoperative complications in lumbar disc surgery. Spine (Phila Pa 1976) 1989;14:56-9.  Back to cited text no. 10
    
11.
Krone A, Heller V, Osterhage HR. Ureteral injury in lumbar disc surgery. Acta Neurochir (Wien) 1985;78:108-12.  Back to cited text no. 11
    
12.
Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: An evidence-based analysis. BJU Int 2004;94:277-89.  Back to cited text no. 12
    
13.
Smith TG 3rd, Coburn M. Damage control maneuvers for urologic trauma. Urol Clin North Am 2013;40:343-50.  Back to cited text no. 13
    
14.
Selzman AA, Spirnak JP. Iatrogenic ureteral injuries: A 20-year experience in treating 165 injuries. J Urol 1996;155:878-81.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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  In this article
    Abstract
   Introduction
   Case Report
   Literature Review
   Discussion
   Conclusion
    References
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