“There is a need for strategies to reduce the risk of ureteric injury, and to facilitate immediate recognition, during colorectal procedures. The preoperative placement of prophylactic ureteric stents or catheters has long been discussed as a technique that may assist colorectal surgeons in identifying and avoiding the ureters, and in recognising ureteric injury when it occurs.
Debate surrounds this topic, however, with no consensus on the precise benefit of prophylactic ureteric stents, and some concerns regarding potential stent-related complications. Whilst the European Association of Urology (EAU) guidelines state that ‘visual identification of the ureters and meticulous dissection in their vicinity are mandatory
to prevent ureteral trauma during abdominal and pelvic surgery’ (grade A recommendation), the use of ‘preoperative prophylactic stents’ are recommended only ‘in selected cases (based on risk factors and surgeon’s experience)’ (grade B). The American Society of Colon and Rectal Surgeons guidelines in surgery for diverticulitis state ‘ureteral stents are used at the discretion of the surgeon’ (grade 2C).
Table 4 Type of repair and outcomes of ureteric injuries
| Study | Injuries (n) | Stented and recognised intraoperatively | Stented and recognised postoperatively | Unstented and recognised intraoperatively | Unstented and recognised postoperatively |
|---|---|---|---|---|---|
| Bothwell [41](open) | 4/561 | 1/4—primary repair over stent | 1/4 (stent insertion had failed)—nephrostomy + stent | 1/4—stent inserted and repair performed | 1/4 re-exploration and ureteroureterostomy |
| Beraldo [32](laparoscopic) | 1/89 | 1/89—repair technique not specified | – | – | – |
| Boyan [34] (laparoscopic) | None | – | – | – | – |
| Chahin [35] | 1/66 | – | 1/66 recognised day 2, managed by retrograde stent reinsertion | – | – |
| Chiu [8] | 2503/811,071 | Not evaluated | – | – | – |
| Coakley [3] | 333/51,125 | Not evaluated | – | – | – |
| Chong [29] | None | – | – | – | – |
| Hassinger [38] | Not evaluated | – | – | – | – |
| Kutiyanawala [44] | 5/251 | No stented patients | No stented patients | 3/5—ureteric re-implant × 2 and ureteroureterostomy over stent in × 1 | 2/5Nephrostomy + JJ stent × 1 (prolonged recovery, fistula)Relaparotomy + removal of ligasure × 1 |
| Kyzer [33] | 1/118 | 1/1 repair technique not specified | – | – | – |
| Leff [19] | 4/194 | 3/4OPEN intraoperative repair | 1/4—delayed presentation as ureteral-cutaneous fistula | Not evaluated | Not evaluated |
| Luks [39] | 2/261 | 2/2 intraoperative repair, type unspecified | – | – | – |
| Merola [28] | 1/374 | None | 1 injury, recognised postoperatively—re-operation (repair not specified) | None | None |
| Nam [27] | None | – | – | – | – |
| Pathak [42] | None | – | – | – | – |
| Palaniappa [45] 2012(Open arm) | 7/4669 | 1/7Ureteroneocystostomy | 1/7Nephrostomy | 3/7Ureteroneocystostomy × 1, ureteroureterostomy × 2 | 2/7Bilateral nephrostomies × 1Ureteroureterostomy × 1 |
| Palaniappa [45]2012(Laparoscopic arm) | 7/1060 | 1/7 Ureteroureterostomy | 1/7 Ureteroneocystostomy | 2/7Ureteroneocystostomy × 1Ureteroureterostomy × 1 | 3/7Ureteroneocystostomy × 1Nephrostomy × 2 |
| Pokala [30] | 0 | – | – | – | – |
| Sahoo [40] | 0 | ||||
| Senagore [36] | 0 | – | – | – | – |
| Sheikh [43] | Not reported | – | – | – | – |
| Speicher [31] | Not reported | – | – | – | – |
| Tsujinaka [37] | 0 | – | – | – | – |
“The placement of prophylactic ureteric stents has a low complication rate, which may be further improved by the use of guidewires and fluoroscopy in stent/catheter insertion and sequential removal of stents, although further research is needed to confirm this. It should be noted that the IUI rate from attempted stent insertion is low but not negligible, and this
must be factored into the risk–benefit equation when determining if a stent is warranted. Prophylactic ureteric stents do not entirely prevent ureteric injuries, and in fact, higher rates
of IUI are reported in stented versus non-stented patients. In the absence of a randomised controlled trial, however, this is assumed due to a marked selection bias, with stents being
requested at surgeon discretion for anticipated high-risk resections. Prophylactic ureteric stents may improve intraoperative detection of ureteric injuries; however, current evidence is
inadequate to confirm this. The medico-legal climate may be a future driver for increased stent use, albeit with limited evidence. Small to moderate increases in cost and operative time are seen with the use of prophylactic stents. The authors feel that selected rather than routine stenting along with careful dissection and a high index of suspicion minimises re-
operation for inadvertent ureteric injury. Future developments may see greater use of novel technologies including lighted ureteric stents and fluorescent dye for ureteric identification,
particularly in minimally invasive cases.”
Croghan, Stefanie M et al. “The sentinel stent? A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections.” International journal of colorectal disease vol. 34,7 (2019): 1161-1178 Full Text for Emory Users
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