Editorial Comment for Pastore et al.

Pastore and colleagues ¹ presented the outcomes of 18 consecutive patients undergoing endoscopic rendezvous for iatrogenic ureteral detachment secondary to pelvic surgery. The authors should be congratulated for collecting and reporting a significant series of patients with this rare complication (0.4%–2.5% after pelvic surgery). Iatrogenic injury to the ureter is a potentially devastating complication of modern surgery. The ureters are most often injured in gynecologic surgery as reported by the authors, although colorectal and vascular pelvic surgery injuries have been reported. There is also potential for considerable ureteral injury during endoscopic procedures for ureteral pathology such as tumor or lithiasis.

As recently reported, distal ureteral injuries are best managed with ureteroneocystostomy with or without a vesicopsoas hitch; midureteral and proximal ureteral injuries can potentially be managed with ureteroureterostomy. Laparoscopic and minimally invasive techniques have been also used to manage iatrogenic ureteral injuries. ²

In this series, all patients were females, and the ureteral lesions were related to a previous hysterectomy and are located at 4 to 6 cm from the bladder. So far, the results obtained by the authors and their experience could be extended to patients with a different ureteral injury (i.e, male patients, distal or proximal ureteral damage, postendoscopic ureteral damage). Furthermore, although the 24 month success rate using this minimally invasive approach is acceptable, it is significantly lower when compared with patients treated with an ureterocystostomy.

The risk of ureteral stenosis from an intensive fibrosis still remains an important issue after endoscopic rendezvous. It often necessitated further endoscopic or surgical management, although recently it has been successfully managed using a new self-expanding ureteral stent. ³

The possibility to endoscopically treat patients with a complete ureteral detachment as reported by Pastore and coworkers remains a valid option, although pros and cons of this treatment should be discussed with the patients in particular considering the failure rate and the risk of subsequent treatment. With the lack of comparative large studies evaluating all the different options available for the management of this condition, it is important to manage the complications in tertiary referral centers, where all the different options are available, including the laparoscopic/robotic approach to define the best treatment for each patient. Although a ureteral injury is a rare condition in pelvic surgery, it still represents a dramatic complications for the patient and the surgeon; a rapid and dynamic approach is needed to identify the site lesion and consequently to identify the appropriate treatment. Finally, independent from the type or site of the lesion, the success rate and morbidity of the technique should guide our treatment.