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18 Ureteroscopy
179
frequency in the postoperative period, especially
if a ureteral stent was left in place. This difculty
is compounded by the fact that postoperative
fever is nonspecic, with many possible alternative diagnoses, including atelectasis, phlebitis,
and drug reactions. When a patient reports severe
or prolonged lower urinary symptoms, especially
when accompanied by fever, a UTI should be
suspected and urine culture obtained before
appropriate treatment is initiated, until the urine
culture results come back. Physicians should
keep an eye out for signs of sepsis, including
severe malaise, pallor, perspiration, leukocytosis
or leukopenia, and cardiovascular instability,
and, if these occur, they should acquire blood culture and perform upper tract imaging before
beginning aggressive treatment.
Management
If infection develops, most cases resolve with
appropriate antibiotic treatment. If a ureteral stent
was left in place, one should consider urethral
catheter placement to prevent vesicoureteral
reux of infected urine and lower the risk of
severe systemic infection. Nevertheless, physicians should stay alert for the development of urosepsis, as in these cases, immediate aggressive
treatment can reduce mortality [46, 78]. Patients
found to be at risk to develop post- surgical urosepsis are those with positive preoperative urine
cultures, pre-stented patients, older patients, diabetic patients, those with ischemic heart disease,
and those with longer procedural duration [73].
Common pathogens cultured in uroseptic patients
include Escherichia coli, Enterococcus, Proteus,
Pseudomonas, Serratia, group B Streptococci,
Staphylococcus aureus, and Candida [79–81],
with stone cultures more accurately identifying
the culprit than preoperative urinary cultures [82].
Treatment includes broad spectrum antibiotic
treatment, monitoring and supportive care, and
urinary drainage as needed.
Pain andUreteral Obstruction
Postoperative pain can plague 0.9–10.2% of
patients undergoing ureteroscopy, affecting
mostly the ank and lower abdominal regions [9,
17, 19, 28, 36, 83]. Most cases can be managed
with analgesics, but, in up to 3.4% of patients,
pain will be the result of ureteral obstruction
caused by edema, blood clots, or residual fragments [2, 15, 18, 19, 28, 34, 58, 70]. These cases
might require renal drainage by either a ureteral
stent or nephrostomy tube placement or a repeat
ureteroscopy.
Ureteral Stent Discomfort
Fear of postoperative pain and upper urinary tract
obstruction is the foundation for the practice of
ureteral stent placement at the end of ureteroscopy. However, studies have found that the presence of a ureteral stent is accompanied by
complaints of dysuria, frequency, urgency, nocturia, ank discomfort, and hematuria in as many
as 88% of patients, with more than 70% of them
requiring analgesic support [84–86]. For this reason, both the European and American urological
association guidelines recommend avoiding routine ureteral stent placement after an uncomplicated ureteroscopy, proposing that it should be
considered only in patients with larger stone burden, requiring prolonged surgery, with obvious
upper urinary tract damage or with a single functioning kidney.
Premature Labor
Possibly the only female-specic complication of
ureteroscopy, premature labor, can occur in
4.3–8.7% of pregnant patients undergoing ureteroscopy [87, 88]. The most common indication
is managing obstructing ureteral stones. The risk
is higher during the third trimester, in patients
with urinary tract infection at presentation, and
when ureteroscopy is performed for stone
removal and not for diagnostic purposes.
Although conservative care in managing ureteral
stones might seem prudent in light of these statistics, delayed intervention was also found to carry
the risk of premature labor [87, 89]. No prospective studies have compared the obstetric compli-
180
J. Modai and M. D. Dunn
cation prole of ureteroscopy to stent or
nephrostomy placement, but, because of the
higher encrustation rate seen during pregnancy
[90] and the need for repeated exchanges, many
believe that ureteroscopy is the better choice. In
any case, a multidisciplinary approach to these
patients is advised.
Ureteral Stent Migration
Background
Although designed to remain in a stable position,
stent migration, either upward to the kidney or
downward to the bladder, can occur in 0.7–3.6%
of patients, caused by incorrect placement, incorrect stent size selection, or ureteral peristalsis [8,
14, 16, 18, 34, 35, 83, 70]. In some patients, the
ureteral stent is left with a string attached to facilitate future removal, and, in these cases, unintentional tension can also cause the stent to dislodge
from its position.
Prevention
Choosing the correct stent size and rmness to t
the patient’s anatomy and using the correct technique are key to preventing ureteral stent migration after surgery. In patients for whom the
ureteral stent was left with a string attached, positioning the string in a safe location, leaving it
with some slack to accommodate movement, and
informing the patient about the string and the
importance of avoiding any tension on it can help
prevent unintentional stent displacement.
Recognition
While some patients can be asymptomatic, others
will present with ank pain, nausea, urine leakage, fever, and even full-blown sepsis. In some
cases, mainly in women with complaints of urine
leakage, especially if a string was left in place,
the stent can be seen outside the urethral meatus
on physical exam. In other cases, diagnosis can
be easily made with either a ultrasound (US),
abdominal X-ray, or CT showing the mispositioned ureteral stent.
Management
Treatment requires stent removal or repositioning, depending on the clinical scenario. In
patients presenting with fever or sepsis, stent
repositioning to ensure renal drainage, urethral
catheter placement, urine and blood cultures,
antibiotic treatment, and supportive care are
suggested.
Intravascular Stent Misplacement
Unfortunately, the literature contains several
accounts of stents being malpositioned into either
the iliac veins or vena cava, resulting in postoperative hematuria, thromboembolic event, or
obstruction of the upper urinary tract [91–100].
Most cases can be treated by endovascular extraction of the stent, with some requiring surgical
removal.
Post-Obstructive Diuresis
In patients with a single functioning kidney or
bilateral obstruction, ureteroscopy to relieve
upper urinary tract obstruction can result in postobstructive diuresis, putting the patient at risk of
dehydration, serum electrolyte imbalances,
arrhythmias, and death [16]. This complication is
rarely reported on, and so its incidence is
unknown. Patients developing post-obstructive
diuresis will present with dramatically increased
urine production with possible symptoms including malaise, fatigue, nausea, vomiting, confusion, and even stupor and coma. When a clinical
suspicion arises, assessing hourly urine production and lab work showing hypernatremia and
increased blood urea nitrogen and creatinine can
establish the diagnosis. Careful monitoring, free
access to water, and, at times, intravenous uid
support are required to avoid and treat this complication. If hyponatremia is present, careful uid
management is needed to avoid overzealous
correction of serum sodium levels that can lead to
cerebral edema.
18 Ureteroscopy
181
Late Postoperative Complications
Ureteral Strictures
Background
According to the modern literature, 0.1–3% of
patients will develop ureteral strictures after ureteroscopy [2, 8, 9, 12, 14, 18, 25, 28, 83, 101].
This is a signicant complication, as it can result
in prolonged discomfort, recurrent and complicated UTI, and loss of renal function, if not
addressed in a timely manner. Moreover, treatment will frequently require surgical correction,
with some amenable to endoscopic correction,
while other more complicated cases may require
laparoscopic, robotic, or open surgery [9, 12, 83,
102, 103].
Prevention
While the exact pathophysiology of ureteral
stricture formation after ureteroscopy remains
unknown, many believe it is the result of ureteral
wall inammation and brosis, caused by the
presence of a stone or by insults suffered during
the procedure itself [104, 105]. Because of that,
suggested preventive measures include using a
gentle surgical technique, using the smallest
instruments possible, utilizing general and not
regional or local anesthesia, complete removal of
impacted stones to avoid formation of stone granulomas, and avoiding simultaneous performance
of endopyelotomy and stone fragmentation and
removal in the same session [9, 106–110].
Recognition
Ureteral strictures usually develop within weeks
to months of the procedure. While some patients
can be asymptomatic, others will present with
ank or abdominal pain, fever, recurrent UTIs, or
hematuria. Because some cases can be asymptomatic, and these silent cases can result in permanent renal damage, many suggest performing
an imaging study a few weeks after ureteroscopy
to rule out hydronephrosis as a sign of a possible
stricture. The nal diagnosis can be made with a
CT urogram showing hydroureteronephrosis
above the strictured area and a MAG3 (mercaptoacetyltriglycine) renal scan showing functional
obstruction of the affected kidney. However, a
more invasive, diagnostic ureteroscopy can also
establish the diagnosis with the added benet of
enabling treatment of the stricture at the time of
diagnosis.
Management
Possible treatments for ureteral stricture disease
include endoscopic and open, laparoscopic, or
robotic procedures. Endoscopic treatment is the
least invasive and includes balloon dilatation and/
or laser incision of the strictured section. These
are mainly effective in the treatment of relatively
short, non-obliterative strictures in wellvascularized tissue [111, 112]. If endoscopic
treatment fails, the stricture is too long or tight, or
the tissue is ischemic, then open, laparoscopic, or
robotic surgical correction is required. This
includes resection of the strictured section and
re-anastomosis, buccal ureteroplasty, interposition of the interstitial graft, autotransplantation,
and even nephrectomy [9, 12, 83, 102, 103].
Neglected Stents
Background
Ureteral stents placed at the end of ureteroscopy
need to be removed in a timely manner. Failure to
do so can result in stent encrustation, fragmentation, and obstruction [113, 114], subjecting the
patient to prolonged stent-related discomfort,
upper urinary tract obstruction, infectious complication risk [114, 115], and, in extreme scenarios, perinephric abscess formation, renocolic
stula formation, and death [116, 117].
Prevention
Stent neglection is mainly an issue of patient
compliance. Physicians should make sure to educate patients with ureteral stents on the importance of removing the stents on time and staying
under surveillance until their urological issues
are resolved. Other key prevention measures
include minimizing ureteral stent use and keeping close tabs on patients in whom a ureteral stent
was placed. A patient registry is useful to keep
track of patients who were stented in an emergent
182
J. Modai and M. D. Dunn
setting or for those who require long-standing
ureteral stents for chronic ureteral obstruction,
such as those with a pelvic malignancy, and a
complicated stricture disease.
Recognition
Patients with a neglected stent will present with
either a stent-related complication, such as UTI,
hematuria, or ank pain, or will incidentally be
found when an imaging study performed for
other reasons reveals the stent in the urinary
system.
Management
Most neglected stents cannot be simply removed
cystoscopically if they are heavily encrusted.
Such stents require complex endoscopic, percutaneous, and even open surgical intervention to
be removed [114, 115].
Conclusions
Although considered minimally invasive and
generally safe, ureteroscopy is tied to a wide variety of complications, most of which are minor
and self-limited, but some are serious with potential morbid and even fatal results. While an experienced, attentive clinician can lower the rate of
these complications, all should keep alert, for
delayed diagnosis of the complications can lead
to devastating consequences.
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Transanal Local Excisions
andEndoluminal Approaches
KamilErozkan andEmreGorgun
19
Introduction
As explained by the adenoma–carcinoma
sequence, sporadic colorectal cancer begins with
adenoma formation and progresses to cancer
with recurrent driver mutations [1]. Screening
colonoscopies aim to detect and destroy precancerous lesions before invasive carcinoma develops [2]. Early identication and removal of
precancerous lesions during screening colonoscopies have led to a signicant decrease in
colorectal cancer incidence and mortality [3].
There are different methods to remove polyps of
different sizes. Polyps smaller than 10mm are
typically excised with a cold snare, while larger
polyps require historically segmental resections
or, more recently, local excisions. Surgical organ
resections can lead to a signicant increase in
mortality and morbidity, alongside increased
postoperative pain, blood loss, and prolonged
length of hospital stay. Histopathological analysis after major surgeries for premalignant lesions
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 66772- 5_19.
K. Erozkan · E. Gorgun (*)
Department of Colorectal Surgery, Digestive Disease
and Surgery Institute, Cleveland Clinic,
Cleveland, OH, USA
e-mail: gorgune@ccf.org
often reveals a high percentage of benign results
[4], thus putting patients at an unnecessary risk.
Surgeons have been adopting less invasive methods, such as transanal local excisions (TAEs) and
endoluminal procedures, to remove premalignant
lesions in order to reduce postoperative pain, permit shorter hospital stays, and enable a faster
recovery process. These techniques can be
applied to various benign diseases, but their
growing appeal lies in their ability to serve as
minimally invasive methods to remove earlystage malignant and premalignant lesions.
Transanal local excision (TAE) is a commonly
used surgical technique to remove certain types
of benign or early-stage malignant lesions in the
rectum using conventional retractors and sutures
(Fig. 19.1). Another technique, transanal minimally invasive surgery (TAMIS), is the most popular transanal endoluminal approach among
surgeons. TAMIS enables excision using conventional laparoscopic instruments or robotic surgical systems via transanal access platforms (e.g.,
the SILS™ Port (Medtronic, Minneapolis, MN,
USA), the GelPOINT® Path transanal access
platform (Applied Medical, Rancho Santa
Margarita, CA, USA), the KeyPort Flex (Richard
Wolf, Knittlingen, Germany), the SSL (Single
Site Laparoscopy access system, Ethicon
Endo- Surgery, Cincinnati, OH), and the Endorec®
(Aspide Médical, La Talaudière, France)) placed
in the anal canal. Full-thickness excision is possible through TAE and TAMIS procedures.
© 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_19
189
190
Fig. 19.1 Transanal local excision with conventional instruments
K. Erozkan and E. Gorgun
Nevertheless, dissection in the submucosal plane
is sufcient for benign, premalignant, and supercial invasive cancers; however, intramuscular or
full-thickness resection is recommended for the
local management of rectal cancers >T1.
Although access to proximal lesions is more efcient with TAMIS compared to TAE, the useability of both techniques is limited for distal
colorectal lesions. For upper rectum and rectosigmoid lesions, advanced polypectomy techniques
are preferred.
Endoscopic mucosal resection (EMR) and
endoscopic submucosal dissection (ESD) are
currently two of the most popular transanal endoscopic procedures for excising large premalignant lesions. EMR is a method that lifts, snares,
and then excises lesions. The polyp is lifted using
various solutions and snared by slowly closing a
loop wire while simultaneously cauterizing it.
Even though piecemeal excision is acceptable in
the case of totally benign large lesions, the goal is
to remove high-risk lesions in an en bloc manner.
An increased number of snared pieces decreases
the adequacy of the histopathological examination and can also lead to full-thickness defect as a
result of entrapment of the muscle layer in the
bite. On the other hand, ESD is a procedure in
which the lesion is excised by dissecting within
the submucosal plane. The ESD procedure begins
by lifting the lesion using an injectate similar to
the one used in the EMR technique. After the
mucosal incision, dissection is carried out in the
submucosal plane using an endoscopic cutting
knife.
Although all the techniques mentioned above
are minimally invasive, complications can be
observed. The most common complications
include perforation, bleeding, abscess, stricture,
urinary retention, and fecal incontinence. This
chapter provides an in-depth review of the common complications of transanal local excisions
and endoluminal procedures, including their
indications, background, and techniques for their
prevention, recognition, and management..
Perforation
Background
The thickness of the colorectal wall, colonic
folds, exures, and peristalsis can lead to perforation during transanal local excisions and endoluminal approaches. Perforations are generally
classied as either intraprocedural or delayed.
Intraprocedural perforations should be examined
separately as minor and major perforations
(Fig.19.2). Minor perforations are partial perforations generally characterized by defects in the
muscularis propria, while major perforations
describe full-thickness injuries in the colon and
rectum wall. Intraprocedural perforations are
commonly detected during the procedure, and
appropriate treatments are performed. Major
surgery is only required for a small number of
patients. Delayed perforations occur after the
procedure with a more severe clinical presentation and can lead to abscess formation or sepsis.