Urological Involvement in the Multidisciplinary Management of Placenta Accreta Spectrum in a Centralised, High-Volume Centre: A Retrospective Analysis

Objectives Placenta accreta spectrum (PAS) significantly increases the complexity of childbirth and frequently involves urologic organs. Multidisciplinary team (MDT) care is paramount to ensure optimal outcomes. We aimed to evaluate urologic interventions in patients with PAS at a centralised, tertiary referral centre. Methods An analysis of a prospectively collected data set, consisting of all women presenting with PAS at our institution between November 2013 and June 2019. Patients who required urological intervention were identified, and perioperative details were retrieved. Results Forty-two cases of PAS were identified. The mean maternal age was 35 years, and mean gestational age at delivery was 34 weeks. Thirty-seven cases were managed electively, with 5 cases managed conservatively (no hysterectomy) and 5 requiring emergency management. Fifteen patients (36%) had suspected bladder invasion on MRI. A total of 36 patients (86%) had ureteric catheters inserted, 14 (33%) required bladder repair, and 2 had ureteric injuries (5%). Conclusions PAS frequently requires urological intervention to prevent and repair injury to the urinary bladder and ureter. PAS is a rare condition that is best managed in an MDT setting in a centralised, tertiary, high-volume centre with access to a variety of medical and surgical sub-specialities.

Salvage Robot-assisted Radical Prostatectomy Following Focal Ablation With Irreversible Electroporation: Feasibility, Oncological and Functional Outcomes

BackgroundTo report the feasibility, oncological and functional outcomes of salvage robot-assisted radical prostatectomy (sRARP) for recurrent prostate cancer (PCa) after irreversible electroporation (IRE).MethodsThis was a retrospective analysis of patients who underwent sRARP after IRE treatment in our institution. Surgical complications, oncological and functional outcomes were assessed.Results15 patients with at least 12 months follow up were identified out of the 234 men who underwent primary IRE between 2013 and 2019. The median [IQR] age was 68 (62 – 70) years. The median [IQR] time from focal IRE to sRARP was 42 (21 – 57) months. There were no rectal, bladder or ureteric injuries. The T-stage was pT2 in 9 (60%) patients and pT3a in 6 (40%) patients. Only one (7%) patient had a positive surgical margin. At a median [IQR] follow up of 22 (16 – 32) months no patient had a biochemical recurrence (PSA >0.2). All 15 patients were continent (pad-free) by 6 months and 9 (60%) patients had erections sufficient for intercourse with or without PDE5 inhibitors. No predisposing factors were identified for predicting erectile dysfunction after sRARP. ConclusionsIn patients with recurrent or residual significant PCa after focal IRE ablation it is feasible to obtain good functional and oncological outcomes with sRARP. Our results demonstrate that good outcomes can be achieved with sRARP, when respecting close monitoring post-IRE, good patient selection and surgical experience.

Morbidity and predictors of delayed recognition of iatrogenic ureteric injuries

Introduction: Although intraoperative iatrogenic ureteric injuries (IUI) are rare, significant consequences can occur if they are unrecognized at the time. The focus of our study is to characterize the associated morbidity and identify predictors of delayed recognition of IUI. Methods: Sunnybrook Health Sciences Centre Research Ethics Board approved the study. Patients with a diagnosis of IUI between 2002 and 2020 were identified through an institutional electronic medical record system. Data pertaining to the demographic characteristics, diagnosis, and management of IUI and overall outcomes were collected retrospectively. Results: Of the 103 patients identified, 83% were female, 52% had previous abdominal surgery, and 18% had previous radiation. The median age was 67 (21–88) years. Twenty percent were not recognized at the time of surgery. Although delayed recognition was not a significant predictor for poor outcome after subsequent repair (i.e., hydronephrosis, ureteric stricture/obstruction), it was associated with substantial morbidity to the patient (i.e., additional procedures) and increased cost to the healthcare system (i.e., longer hospital stay, readmission to hospital). Patients who underwent laparoscopic surgery had an 11 times more likely chance of having an unrecognized IUI as compared to those who underwent open surgery (odds ratio 11.515, p=0.0001). Conclusions: Delayed recognition of IUI may be associated with considerable adverse effects. In this retrospective case series, we identified laparoscopic surgery as a significant predictor for delayed recognition of IUI. This information underscores the need for future studies to facilitate intraoperative identification of ureteric injuries, particularly during laparoscopic procedures.

Ureteric Injuries after Hysterectomy in a Tertiary Care Center of Nepal: A Descriptive Cross-sectional Study

Introduction: Pelvic surgery is the most common cause of iatrogenic ureteral injury. The incidence of ureteric injuries varies between skilled and inexperienced surgeons. The study aims to determine the prevalence of ureteric injuries sustained during hysterectomy in a tertiary care center of Nepal. Methods: A descriptive cross-sectional study involving the women attending the gynecological outpatient department of a tertiary care center of Nepal, for various benign and malignant conditions and later on underwent hysterectomy from June 2019 to June 2020 was done after obtaining ethical clearence from the Institutional Review Committee (Reference No. 245). Convenient sampling method was used. The data were entered in Excel and analyzed using Statistical Package for Social Sciences version 17. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Results: Altogether, 1 (0.63%) (0.55-0.71 at 95% Confidence Interval) out of 159 patients sustained the ureteric injury during hysterectomy in a tertiary care center of Nepal. The injury was seen during the exploratory laparotomy for adnexal mass. The injury was recognized intraoperatively and was repaired with double J stenting. A total of 159 patients were enrolled in the study that had undergone hysterectomy over one year for various benign and malignant conditions. Out of which 21 (13.2%) had undergone surgeries for malignant conditions and 138 (86.79%) for benign conditions. Conclusions: Iatrogenic ureteric is still a major cause of harm and concern in hysterectomy. Patients with ureteric injury should be evaluated and intervened at the earliest.

Etiology and Ureteral Reconstruction Strategy for Iatrogenic Ureteral Injuries: A Retrospective Single-Center Experience

Objective: To analyze the etiology, characteristics, and ureteral reconstruction strategies of iatrogenic ureteric injuries in a high-volume center. Methods: Between September 2010 and August 2019, we retrospectively collected patients who underwent ureteral reconstruction due to iatrogenic ureteric injuries. Patient profiles, laboratory data, imaging studies, perioperative data, and complications were recorded. Results: Sixty-eight patients were enrolled in this study. The upper, middle, and lower thirds of the ureter were affected in 30, 2, and 36 cases, respectively. Of the 68 ureteric injuries, 69.1% occurred during urological procedures, followed by gynecological procedures, general surgery, radiotherapy, and orthopedic surgery. The majority of urological injuries (41, 87.2%) occurred due to stone removal. There was a significant difference in the age, sex, and location of ureteric injuries between the urological and nonurological groups. The median follow-up time was 17.9 months. The overall symptom remission rate was 91.2% and ranged from 87.5 to 100% for different reconstructive surgeries. Conclusions: Urological procedures were the most common cause of iatrogenic ureteric injury; thus, extra care should be taken. Timely detection and appropriate treatment of the ureteric injuries are necessary. Treatment strategies should be depended on the location and length of injury.

Iatrogenic ureteric injuries in urological surgeries- a tertiary hospital experience.

Objectives: To review our experience in the management of iatrogenic ureter injuries caused by different urological procedures. Study Design: Descriptive Case series. Setting: Department of Urology, Jinnah Postgraduate Medical Centre Karachi. Period: January 2011 to December 2018. Material & Methods: We included all cases of iatrogenic ureteric injuries induced by urology department only. Gynecological and general surgical iatrogenic injuries were excluded in this study. All pertinent details like indication for surgery, type of surgery, location of injury, laterality, type of injury, time of recognition of injury (i-e intra-operative, early and late), treatment modality and their surgical outcomes were recorded. Results: We managed 56 iatrogenic ureteric injuries in 47 patients during study period. Mean age was 43.14+ 8.86 years. There were 31 males (66%) and 16 females (34%). Right sided injury was observed in 29 patients (61.7%), left sided injury in 16 patients (34.0%) while bilateral injuries were seen in 2 patients (4.3%). Regarding site of injury proximal ureteric injuries were the most common accounting for 32 patients (68.1%). Intraoperative diagnosis was the most common time for diagnosis seen in 30 patients (63.8%). The endoscopic urological surgeries were the most common cause of urological iatrogenic ureteric injury accounts for 71.4% of cases. Open upper tract surgeries were responsible for 8 cases (14.2%). One patient sustained proximal ureteric injury during retro-peritoneal lymph node dissection (RPLND). Laparoscopic urological surgeries were responsible for four cases of injury. One patient developed ureteric avulsion. 13 patients presented with late Ureteric stricture. We have five nephrectomies while three patients needed permanent nephrostomies. Our success rate was 83%. Conclusions: Endo-urological procedures are the commonest causes of ureteric injuries in our study. Prompt diagnosis and early corrective intervention can result in satisfactory outcome in about 83% of cases.