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168
K. Attalla and J. P. Sfakianos
Prevention andEvaluation
Early recognition of a ureteral injury is critical to
abate associated long-term sequelae. Thus, the
earliest recognition of an iatrogenic ureteral
injury is intraoperatively. Preventive measures
include the use of intraoperatively placed ureteral
stents to aid in identication of the ureters.
Ureteral stents are often requested or placed by
gynecological, colorectal, and vascular surgeons,
given the relevant anatomy in close proximity to
the ureters. Although prophylactic placement of
ureteral stents may assist with identication of
ureteral injuries, the ability to decrease the incidence of injury is unclear [3, 4]. Nevertheless, a
recent review of the National Surgical Quality
Improvement Program (NSQIP) demonstrated a
lower rate of ureteral injury after colectomy with
the use of ureteral stents [5]. In many situations
there is anatomical distortion of the ureter secondary to mass effect, i.e. from gyn or colorectal
tumors or brosis, i.e. from aortic aneurysms,
that lead to difculties in recognition or dissection of the ureter leading to increased risk of
injury.
Postoperatively, a high index of suspicion is
required to diagnose and localize a ureteral
injury, which harbors several signs and symptoms. An even higher index of suspicion is
required following laparoscopic or robotic cases;
whereas one-third of ureteral injuries are recognized intraoperatively during open surgery, fewer
injuries are recognized with minimally invasive
approaches [6, 7]. Conditional upon the patient’s
clinical status, the recognition of ureteral injuries
ranges from immediate to delayed. Fever, ileus,
hematuria, leukocytosis, abdominal tenderness
and/or distention, or a rise in serum creatinine
secondary to peritoneal reabsorption of urine or
secondary to an obstructed renal unit may be suggestive of ureteral injury with resultant peritoneal
irritation, urinoma, or abscess formation. If a surgical drain was placed at the time of surgery, uid
may be sent for spot creatinine; it is positive for
urine leakage if spot creatinine is greater than
serum creatinine. If renal function permits the
administration of intravenous (IV) contrast, computed tomography (CT) of the abdomen and pel-
vis with IV contrast medium and delayed
urographic phase is an effective diagnostic tool
in localizing ureteral injury. Retrograde pyelogram represents the most sensitive diagnostic
tool to assess the location of injury and may also
permit the simultaneous cystoscopic placement
of a ureteral stent, depending on the extent of
injury.
Management
Management of endoscopically induced ureteral
injuries vary based on the extent of the injury.
Perforation of the distal ureter is best managed
with placement of a ureteral stent, typically
removed approximately 4–6weeks later. A urethral Foley catheter may or may not be placed
temporarily to avoid reux of urine from the
bladder into the ureter to allow for maximal and
optimal healing. Complete ureteral avulsions
require surgical exploration and repair.
The evaluation of a suspected ureteral injury
often occurs intraoperatively; as such, visualization of the pelvic ureter is limited by initial exposure achieved for the primary operation. The
urological surgeon evaluating a possible pelvic
ureteral injury may do so cystoscopically with a
retrograde pyelogram if surgical exposure precludes direct access to the pelvic ureter.
Intravenous administration of methylene blue
may be a useful aid inlocalizing subtle injuries.
Similarly, injection of methylene blue can be
achieved cystoscopically in a retrograde fashion
by ureteral catheterization. If on-table imaging is
suggestive of injury, or if uoroscopy is not readily available, the initial incision is extended or a
counter-incision is created for adequate mobilization and direct visualization of the ureter.
Inspection of the segment of ureter in question
should note tissue viability, as evidenced by the
appearance of the ureteral tissue, extravasation of
urine, and size of the disruption or injury. Inquiry
as to the mechanism of injury should be made, as
thermal injuries requiring debridement beyond
the readily apparent area of injury is required.
Other common mechanisms of injury include
sharp injury or transection, crush injuries, suture
17 Injury Repair ofPelvic Ureter
169
ligation, and the application of stapling or clip
devices to the ureter. Prior to surgery proper
inspection of patient imaging is important to
understand anomalies of anatomy such as solitary kidneys or duplicated ureters.
Should the injury appear to be limited to a
contusion with tissue viability, a ureteral stent
may be cystoscopically placed as detailed previously. On the other hand the mechanism of injury
such as thermal or high-powered projectile are
important to recognize as the viability of the surrounding tissue maybe compromised requiring a
larger resection area prior to reconstruction.
Injuries recognized intraoperatively or within
1 week of surgery should be repaired immediately. In unstable trauma cases with concomitant
ureteral injury, primary repair or reconstruction is
delayed and the ureter is ligated proximal to the
area of injury; a percutaneous nephrostomy tube
is subsequently placed for drainage of the renal
unit. Delayed recognition of a ureteral injury is
managed with a ureteral stent, and/or percutaneous nephrostomy tube, or a percutaneous nephroureteral stent with a Foley catheter for complete
drainage and maximal decompression of the urinary tract. Denitive repair is deferred until
6weeks following the injury. Associated sequelae
are additionally addressed; urinomas are optimally managed with the placement of a percutaneous drain, and abscesses are managed with
percutaneous drain placement and culturespecic antibiotics.
The management and reconstruction of ureteral injuries are conditional upon the length of
the defect and location of the injury. Primarily,
short (3–4 cm) mid-ureteral defects can be
repaired. Depending on the mechanism of injury,
both ends of the ureter are debrided of all devascularized tissue accordingly. The proximal and
distal ureter are both widely spatulated and an
end-to-end anastomosis is completed using a 4-0
Vicryl suture in an interrupted fashion (Fig.17.1).
Careful handling of ureteral tissue with noncrushing forceps and the preservation of ureteral
adventitia are critical to avoid disruption of the
ureteral blood supply. A double-J ureteral stent is
placed over a guidewire prior to completing the
anastomosis (Fig.17.1).
The preferred strategy for distal ureteral
reconstruction is ureteral reimplant with or without a psoas hitch (Figs.17.2 and 17.3). (insert the
gure in this location; you have the gures at the
end of the chapeter, please place them in the
appropriate spot throughout the article:BB).The
peritoneum overlying the ureter is incised proximally and distally to expose the injury and mobilize the ureter for a tension-free anastomosis.
Dissection should be carried distally until the
level of injury. The ovarian ligaments in females,
may be retracted anteriorly to facilitate exposure.
The ureter is transected just proximal to the
injured segment of ureter; if already transected
inadvertently, the ureteral tissue is carefully
examined and debrided. If a reuxing extravesical reimplant is desired, an approximately 2-cm
incision is made on the ipsilateral aspect of the
bladder dome. The ureter is spatulated at the posterior, 6o’clock aspect of the ureter and an anastomosis is performed in an interrupted fashion.
Ureteral to bladder mucosal apposition is critical
in maintaining optimal anastomotic principle.
Prior to completing the anastomosis, a double-J
ureteral stent is passed over a guidewire, with the
proximal curl of the stent in the renal pelvis and
the distal curl of the stent placed in the bladder. A
second-layer closure of the bladder serosa to the
ureteral adventitia may be performed. A leak test
to assess the integrity of the anastomosis is completed by instilling 200–300cc of normal saline
into the bladder. In a similar fashion, a nonreuxing anastomosis can be performed. To do this, a
submucosal incision is made extravesically and a
tunnel is formed. An incision is then made
through into the bladder and the ureter is tunneled into the bladder. Similar to a reuxing procedure, the ureter is then spatulated and either in
an interrupted or a running fashion anastomosed
mucosa to mucosa.
A psoas hitch in addition to ureteroneocystomy is a highly effective approach to reconstructing the lower third of the ureter (Fig.17.4).
The ureteral gap is bridged by “hitching” the
bladder to the ipsilateral psoas minor tendon
using 2-0 Vicryl suture in a vertical manner to
avoid entrapment of the genitofemoral nerve. For
larger mid- to distal ureteral defects (Fig.17.5), a
170
Fig. 17.1 (a–c)
Double-spatulated
ureteroureterostomy
K. Attalla and J. P. Sfakianos
ab c
Fig. 17.2 Transvesical ureteroneocystostomy
Boari ap may be employed to create a tensionfree anastomosis between the bladder and the
ureter for larger areas requiring bridging
(10–15 cm in length). Following assessment of
the length of the defect and debridement of devitalized or injured ureteral tissue, the colon is
mobilized medially by an incision along the
white line of Toldt. An incision is made in the
posterior peritoneum to dissect the proximal ureter; mobilizing the ureter at or above the level of
the common iliac artery ensures adequate proximal mobilization. The contralateral aspect of the
bladder is mobilized by dividing the superior
vesicle pedicle. Division of the inferior vesicle
pedicle is typically unnecessary, but may be performed if needed. Normal saline may be instilled
through an indwelling urethral catheter to inate
the bladder and assist with dissecting the peritoneal lining off the bladder. Division of the ipsilateral medial umbilical ligament may help to
further mobilize the bladder. A ne 4-0 or 5-0
stay suture is placed on the distal end of the proximal ureter.
Epithelium
ab
cd
17 Injury Repair ofPelvic Ureter
Bladder
Ureter
Detrusor
muscle
Stent
171
Fig. 17.3 (a–d) Direct ureteroneocystostomy
The bladder ap is prepared by instilling normal saline into the bladder, if not already performed. A surgical marking pen is used to outline
the ap; the bladder ap should be no shorter
than 4cm at the base and 3cm at the tip in order
to avert distal ureteral constriction after tubularization. To ensure adequate blood supply to the
ap, the ideal ratio of ap length to base width
should be no greater than 3:1. The length of the
ap should be equivalent to the length of the
defect, plus an additional 3–4cm to allow for a
submucosal tunnel if a nonreuxing anastomosis
is desired. After the appropriate dimensions of
the ap are outlined, four stay sutures are placed
along the four corners of the ap.
An incision is made along the distal aspect of
the ap. The posterior bladder wall is elevated
toward the psoas muscle with insertion of an
index nger into the bladder (if repair is being
performed in an open fashion) and hitched to the
psoas tendon. If concerns regarding tension on
the anastomosis exist, the ipsilateral kidney may
likewise be mobilized for an additional length of
5–8 cm. Likewise, a nonreuxing anastomosis
may be performed between a spatulated distal
ureteral stump and the edge of the bladder ap.
If a nonreuxing anastomosis is desired, an
approximately 3-cm submucosal tunnel is created by hydrodistension beneath the mucosal
layer with normal saline. The overlying mucosa
is incised. The tagged end of the spatulated ureter
is carefully brought through the tunnel and an
anastomosis is performed using 4-0 Vicryl in an
interrupted fashion. An initial stay stitch approximating the ureter to the bladder, incorporating the
muscular layer of the bladder, may aid in stabilizing the anastomosis. A double-J ureteral stent is
placed over a guidewire and the bladder is closed
in a two-layer fashion, rst by reapproximating
the mucosal layer using a 4-0 Vicryl suture, followed by the muscularis and adventitial layers
with a 3-0 Vicryl suture. The peritoneal lining of
the bladder initially incised may be used as a
third layer of reinforcement. An 18-French or
172
Psoas
K. Attalla and J. P. Sfakianos
muscle
Fig. 17.4 Ureteroneocystostomy with bladder remodeling and psoas hitch
larger urethral catheter is left in place, and a
closed-suction drain
may be placed at the discretion of the sur-
geon. A cystogram may be performed prior to
catheter removal to conrm the integrity of the
reconstruction and bladder closure.
References
1. Medina D, Lavery R, Ross SE, etal. Ureteral trauma:
preoperative studies neither predict injury nor prevent
missed injuries. J Am Coll Surg. 1998;186(6):641–4.
https://doi.org/10.1016/s1072- 7515(98)00108- 2.
2. Pereira BM, Ogilvie MP, Gomez-Rodriguez JC, etal.
A review of ureteral injuries after external trauma.
Scand J Trauma Resusc Emerg Med. 2010;18(6)
https://doi.org/10.1186/1757- 7241- 18- 6.
3. Morrow J, Curry D, Dooher M, etal. Minimally inva-
sive management of delayed recognition iatrogenic
ureteric injury. Ulster Med J. 2017;86(3):181–4.
4. Norris BL, Everaerts W, Posma E, et al. The urolo-
gist’s role in multidisciplinary management of pla-
centa percreta. BJU Int. 2016;117(6):961–5. https://
doi.org/10.1111/bju.13332.
5. Coakley KM, Kasten KR, Sims SM, etal. Prophylactic
ureteral catheters for colectomy: a national surgi-
cal quality improvement program-based analysis.
Dis Colon Rectum. 2018;61(1):84–8. https://doi.
org/10.1097/DCR.0000000000000976.
6. Grainger DA, Soderstrom RM, Schiff SF, et al.
Ureteral injuries at laparoscopy: insights into diag-
nosis, management, and prevention. Obstet Gynecol.
1990;75(5):839–43.
7. Parpala-Spårman T, Paananen I, Santala M, et al.
Increasing numbers of ureteric injuries after the
introduction of laparoscopic surgery. Scand J
Urol Nephrol. 2008;42(5):422–7. https://doi.
org/10.1080/00365590802025857.
absorbab
end of ureter
cystotomy
ab
17 Injury Repair ofPelvic Ureter
Normal location
of kidney
Mobilized kidney
Delayed
le suture
Iliopsoas muscle
Delayed
absorbable
suture
173
Peritoneal
flap
Tied distal
Closed
Fig. 17.5 (a, b) Loss of pelvic ureter. Ureteroneocystostomy to remodeled bladder with psoas hitch. Kidney mobilized
caudad and secured in place with psoas hitch
Ureteroscopy
JonathanModai andMatthewD.Dunn
18
Introduction
Over the last several decades, technological
advances in the elds of optics and camera design
have led to the miniaturization of scopes, thus
creating ureteroscopes, which allow access to all
parts of the upper urinary tract. This has revolutionized the way urologists access, survey, and
treat afictions in the upper urinary tract, with
renal stone disease being the most common.
What used to require open surgery, which carried
risks of relatively high morbidity and possible
mortality, was suddenly possible through natural
orice surgery with a minimal risk of
complications.
This is not to say that ureteroscopy is free of
complications. Since it was rst described in
1977 [1], reports of both minor and major complications have begun to surface, with modern
data reporting an overall complication rate of
3.5% [2]. While most complications are minor
and can be managed conservatively, some rare
complications can have far-reaching consequences and, at times, can even be lifethreatening. With modern reports showing a rise
in the number of women suffering from upper
urinary tract afictions [3–5], their exposure to
such complications has also increased. In this
J. Modai · M. D. Dunn (*)
Department of Urology, University of California Los
Angeles, Los Angeles, CA, USA
e-mail: mddunn@mednet.ucla.edu
chapter, we will cover the known complications
of ureteroscopy, dividing them into intraoperative, early postoperative, and late postoperative.
Intraoperative Complications
Ureteral Wall Injury
Background
Ureteroscopy involves many steps, including
guidewire insertion to assist in the passage up to
the ureter or access sheath placement if repeated
entry to the upper tract is required. Wire and
access sheath insertion, ureteral dilatation, ureteroscopic manipulation, stone extraction, and
lithotripsy can all cause varying degrees of ureteral wall injury, ranging from supercial mucosal erosions to complete avulsion [6, 7]. Such
complications are underreported, and their rates
uctuate wildly between different studies, ranging from 1.8% to 46.5% with severe injury
reported in as high as 13.3% of patients [6, 8–25].
In rare cases, submucosal or extra-ureteral stone
migration can further complicate the situation,
making complete stone removal difcult and, at
times, impossible [8, 10, 12].
Prevention
Prevention of injury requires using the smallest
available instruments possible [21, 24, 26, 27]
and respecting the ureteral anatomy by not
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_18
175
176
J. Modai and M. D. Dunn
forcing the tissues to accommodate instrumentation. Patience and using a gentle technique can
assist in lowering the risk of ureteral damage.
This is especially important in males, elderly
patients, and patients who have not been prestented, as they were found to be at risk of access
sheath insertion-related injury. If retrieval of a
basketed stone fragment is difcult, force should
not be applied, and the stone should be released
and fragmented further before retrieval is
attempted again. If the stone does not disengage
from the basket, a laser ber can be passed
through the scope alongside the basket to fragment the stone within, or, if this is not possible,
the basket can be disassembled and a ureteroscope with a laser ber passed alongside it.
Recognition
An injury is usually recognized visually during
the procedure or upon its conclusion when the
ureter is surveyed along its length. In severe
cases, extravasation of contrast can be seen on
retrograde pyelography.
Management
When a minor ureteral injury is recognized during surgery, most clinicians recommend completing the procedure and leaving a ureteral stent in
place. The stent is usually removed after
1–6 weeks, depending on the severity of the
injury observed. If a major injury occurs, the procedure should be terminated and a stent, if possible, or a nephrostomy tube left in place.
unduly force was applied during surgery.
Fortunately, it is a rare complication, with a
reported occurrence ranging from 0.04% to 1.3%
[2, 8–14, 28]. Several mechanisms for avulsion
have been described, the most common of which
is a forceful attempt to retrieve a stone larger than
the ureteral lumen [8–13]. Other less common
scenarios include removal of an instrument from
a tight ureter after ureteral injury has occurred
[29, 30] or a trial to straighten and retrieve an ureteroscope with a broken deection mechanism or
a fractured distal section by forcefully withdrawing it [31, 32]. A variation on ureteral avulsion,
ureteral intussusception, describes a partialthickness circumferential mucosal sleeve that is
withdrawn with the ureteroscope under the same
circumstances that cause avulsion [33].
Prevention
Prevention of ureteral avulsion and intussusception follows the same principles as those for other
ureteral injuries. Small instruments, a gentle
technique, and patience are key. Surgeons should
keep an eye out for ureteral injury during surgery
and limit applying forces once an injury is recognized. If the injury is severe, surgery should be
aborted and a ureteral stent left in place for several weeks. In case of a retained ureteroscope
with a broken distal section or deection mechanism, one can try to straighten the ureteroscope
manually by passing a coaxial dilator alongside
the ureteroscope, and, if that fails, one should cut
the handle of the ureteroscope or its distal end
using a percutaneous antegrade approach [31].
Ureteral Avulsion
andIntussusception
Background
Ureteral avulsion is one of the most feared complications of ureteroscopy, resulting in devastating damage to the ureter, requiring open or
laparoscopic surgical repair, and, on some occasions, causing long-term patient morbidity. It is
feared not only for its signicant consequences
but also for its preventable nature, as it is usually
the result of a faulty surgical technique, where
Recognition
Diagnosis of ureteral avulsion is straightforward,
with the avulsed ureter seen within the bladder in
men, outside the urethra in women, or over the
ureteroscope itself. Diagnosis is conrmed by a
retrograde pyelogram where extravasation of
contrast to the retroperitoneum can be seen without any contrast reaching the renal cavities.
Diagnosis of ureteral intussusception is less obvious and requires a high index of suspicion, as a
retrograde pyelogram does not show contrast
extravasation.
18 Ureteroscopy
177
Management
Treatment of ureteral avulsion requires surgical
repair ranging from a variety of ureteral reimplantation techniques, bowel transposition, kidney autotransplantation, and, at times, even
nephrectomy. Even though ureteral intussusception preserves ureteral continuity and is thus theoretically less severe than ureteral avulsion, it
requires the same treatment approach, for the
intussuscepted segment is usually devascularized
and destined to form a narrow stenotic and dysfunctional segment.
Bleeding
Background
Hematuria is a common occurrence after ureteroscopy, but signicant bleeding is reported in
0.1–19% of cases [2, 8–11, 13–18, 25, 28,
34–36]. Most cases are classied as transient,
meaning they resolve within 48 h [16, 34].
Bleeding occurs usually as the result of trauma to
the urinary collecting system from instrumentation, excessive intrarenal pressures, or reckless
application of energy, mostly laser, to the mucosa.
In as many as 2.1% of cases, bleeding can result
in poor visibility, requiring termination of the
procedure [8–10, 18], and, in up to 1.6% of cases,
it can be complicated by postoperative clot retention [34, 37]. The majority of intraoperative
bleeding occurs mostly during endoscopic treatment of ureteropelvic junction stenosis by means
of an endopyelotomy and is usually the result of
injury to the nearby crossing vessels [29, 38].
Prevention
Because bleeding is a direct result of tissue injury,
prevention mainly revolves around gentle instrumentation and careful application of energy
modalities within the urinary system. Using
smaller instruments [27] and gentle manipulation
of instruments and wires can lower the risk of
bleeding of an ureteral and renal origin. Using a
ureteral access sheath and keeping the irrigation
pressure low help keep the intrarenal pressures
below 50mmHg and prevents forniceal rupture
and bleeding [39, 40]. When treating upper tract
urothelial carcinoma, bleeding can be prevented
by avoiding contact between the scope and laser
ber and the tumor and ablating it using a
Tm:YAG laser or a Ho:YAG laser with a long
pulse width and low energy and frequency settings [41]. To avoid major bleeding during endopyelotomy, ureteral incisions should be made in
the posterolateral aspect of the proximal ureter, in
the anterior aspect of the mid-ureter, and in the
anteromedial aspect of the distal ureter.
Preoperative CT angiography (CTA) is highly
recommended as it allows for the localization of
the vessels crossing the ureter near its narrowed
section and for presurgical planning of the surgical incisions.
Management
Treatment of minor bleeding is mostly conservative, with cessation of bleeding without any
intervention in the vast majority of cases and
transfusion needed in only up to 0.7% of cases
[2, 28, 34]. The majority of bleeding can be lifethreatening [42], requiring immediate resuscitation maneuvers, insertion of a ureteral dilating
balloon to tamponade the bleeding and embolization, and endovascular or open repair as
needed.
Dicult Access
Access to the upper urinary tract without prior
dilatation is unsuccessful in up to 37% of cases
due to either a narrow ureteral orice or an ureteral segment [43]. This narrowing can be due to
a stricture or a ureteral wall spasm. In these cases,
termination of the procedure, leaving a ureteral
stent in place, allows for gradual dilatation of the
ureter with subsequent ureteroscopy a week or
more later. This is the preferred option, as
attempts to dilate the ureter carry a 5% risk of
ureteral perforation [44] and attempts to forcefully insert the ureteroscope can result in serious
injury and future stricture formation [45].
178
J. Modai and M. D. Dunn
Early Postoperative Complications
Vascular Anomalies
Background
Accidental or intentional application of energy to
the renal parenchyma during ureteroscopy can, in
rare occasions, result in the creation of either an
arteriovenous stula or a pseudoaneurysm
[46–55]. These unstable vascular anomalies can
rupture when subjected to high blood pressures
and bleed into either the surrounding tissues or
the urinary collecting system.
Recognition
Because these malformations take a few weeks to
form, symptoms usually appear within weeks
from the procedure and can include unexplained
anemia, abdominal or ank pain, fever, and even
life-threatening hemorrhage or hematuria. Once
suspicion of a vascular anomaly arises, diagnosis
is easily made with CTA or angiography.
Management
Treatment usually requires either embolization or
surgical removal of the vascular anomaly, with
unstable or feverish patients also requiring supportive treatment with uid resuscitation, blood
transfusions, or antibiotics if infection is present.
Urinoma, Perirenal Abscess,
andHematomas
High intrarenal pressures and instrument manipulation can cause damage to the pelvicalyceal
system, resulting in urinoma, perirenal abscess,
or subcapsular, perirenal, or retroperitoneal
hematoma. These are uncommon, with a reported
incidence of up to 2.2% [14, 18, 34, 46, 56–65].
Presenting symptoms include ank pain, hematuria, fever, sepsis, and even shock in the postoperative period, prompting CT scan or CTA where
the lesion is identied. Depending on presentation and clinical course, treatment can be conservative or require antibiotic treatment, drain or
stent placement, embolization, surgical repair
and rarely nephrectomy.
Urinary Infection andSepsis
Background
Urinary tract infection (UTI) after ureteroscopy
is not uncommon, with up to 15% of patients
developing a UTI after the procedure [2, 9,
14–19, 25, 28, 34–36, 58, 66, 67] and as many as
5% progressing to full-blown urosepsis [2, 8, 11,
14, 16, 18, 19, 28, 34, 35, 68–73]. Reported risk
factors for postoperative UTI include preoperative UTI, history of recurrent UTIs, positive
presurgical urine culture, high Charlson comorbidity or ASA scores, older age, female gender,
smoking, diabetes, bowel surgery, coronary heart
disease, anticoagulant therapy, chronic kidney
disease, dyslipidemia, immunosuppression, presence and duration of indwelling ureteric stents,
stone burden, presence of infectious stones, duration of surgery, presence of residual fragments,
history of previous surgery for renal stones, long
pre and post-operative hospital stay, decient
nutritional status, neurogenic bladder, and low
and high body mass index [74].
Prevention
Prevention of postureteroscopy UTI relies on
several factors. The procedure should be done in
a sterile urinary system, and so preoperative urine
cultures should be obtained, and if positive,
appropriate antibiotic treatment given several
days before the procedure. While single-dose
preoperative antibiotic treatment failed to reduce
the risk of postoperative UTI in multiple trials
[75, 76], both the European and American urological associations recommend this practice.
The addition of postoperative antibiotic treatment does not appear to decrease the risk of postoperative UTI any further [66]. Ureteral access
sheath use might also reduce the risk of infectious complications due to the reduced intrapelvic pressures during the procedure [77]. Avoiding
prolonged ureteroscopic procedures can also help
lower the risk of infectious complications [73].
Recognition
A urinary tract infection can be difcult to diagnose in patients who have undergone ureteroscopy as most will report dysuria, urgency, and