EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
Mamdouh
IATROGENIC INTRA-OPERATIVE URETERAL INJURIES DURING
URETEROSCOPIC STONE MANIPULATION IN ADULT PATIENTS
INCIDENCE, ETIOLOGY, AND MANAGEMENT
By
Mamdouh Mohamed Abol-Nasr
Department of Urology, El-Minia Faculty of Medicine
ABSTRACT:
Objective: To investigate the pattern, the incidence, and the etiology of ureteroscopic
injuries and the effects of early diagnosis and surgical treatment on the outcome of
such iatrogenic injuries in adult patients with ureteral stones over a period of two
years in a residency program teaching hospital.
Patents And Methods: Two hundred and seventy adult patients with ureteric stones
at different levels of the ureter who underwent ureteroscopy for the first time were
included in this study. The semi-rigid Wolf's ureteroscope (9.5F) was used in all
patients together with the usual ancillary products beside the Wolf's pneumatic
lithotripter for stone disintegration. The recorded data were collected and analyzed
using SPSS program.
Results: The patient's mean age was 43±11 years. Seventy percent were males (189)
while 30% were females (81). Two-hundreds and ten patients had distal ureteral
stones. Mid-ureteral and proximal ureteral stones were 42 and 18 patients
respectively. Twenty four patients developed ureteral injuries with an overall rate of
8.8%. Nine patients developed major ureteral injuries (3.3%) while fifteen patients
developed minor ureteral injury (5.5%). The most common ureteral injury
encountered was ureteral perforation (12 patients) being 4.4 % of all patient and 50%
of all injuries. Two patients developed intussusception of the distal ureter (0.7%).
Minor ureteral injuries constituted 62.5% of all ureteral injuries. Ureteral false
passage, ureteral abrasion, and significant bleeding developed in six, two and two
patients respectively. Site of injury was most common in the distal ureter (66%) of
injuries. Laparotomy with reconstructive ureteral procedure were done in 5 patients
(1.85%), while double-J stent placement with surgical drainage in 4 patients. Most of
minor injuries were discovered in the early part of the procedures and endoscopically
handled with termination of the procedure. Major injuries were discovered late during
the procedure on insisting to complete the procedure when the safety guidelines were
not followed.
Conclusion: Ureteral injuries on ureteroscopy for ureteral stones are more frequent
at the distal part of the ureter. Injury is more common at site of stone location.
Adherence to the safety guidelines and proper technique of ureteroscopy, proper
selection of cases, and following the diagnostic rules make ureteral injuries a rare
occurrence. Termination of ureteroscopy with insertion of a ureteral stent on finding a
difficult situation is a wise decision.
KEY WORDS:
Stone
Ureter
Endoscopoy
Injury
gained a place as a primary treatment
modality for many ureteral pathologic
lesions especially for ureteral stones.
Its modern clinical use was first
INTRODUCTION:
In a medical climate increasingly geared toward minimally
invasive procedures, ureteroscopy has
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
described in the late 1970s by Lyon et
al., as were the first complications1, 2.
Several large series have been
published on rates and types of
complications with an overall complication rates have ranged from 8% to
16%3-7. With the increased surgical
experience and improvements in endoscopic equipment, the overall intraoperative complication rates of uteroscopy have decreased greatly.
Mamdouh
All patients were adult age who
had single or multiple ureteral stones.
Patients with severe hydronephrosis,
those who had associated urinary tract
infections, and those who had large
ureteral stones were all excluded from
this study. Twelve patients who had
their procedure aborted because of
inaccessibility to the ureteral meatus
were also excluded .Three of them due
to failure of guidewire insertion, seven
due to technical difficulty during
procedure, and lastly two who
developed bladder neck injury at
beginning of the procedure. Six
patients who had proximal stone
migration into a renal calyx at the
beginning of the procedure with a
double-J stent insertion were also
excluded from this study.
Ureteral injuries are classified
based on their severity into minor and
major injuries. Minor complications
make up the majority of incidents
encountered during ureteroscopy.
These can be effectively managed by
non-operative means with minimal
sequelae. Major complications constitute injuries that necessitate operative
intervention or that are life-threatening. In two large series, open
surgery was performed in only 0.22%
of patients3,10. Although these injuries
are clearly rare, they can have
enduring effects that contribute to
long-term morbidity.
Pre-operative work-up included urine analysis and culture,
complete blood picture, and biochemical study in addition to plain film of
the urinary tract and intravenous
urography. Preoperative Plain film of
the urinary tracts was done before the
procedure. Pre-operative one gram
cefotaxime was given intra-venously
on call to operative theatre.
This study aimed to investigate
the pattern, the incidence, and the
etiology of the complications that
occur during uretral stone manipulation in adult patients using the
semi-rigid ureteroscope and pneumatic
lithotripsy. The study was done in a
teaching hospital with a residencyprogram over a period of two years
duration.
The semi-rigid Wolf's ureteroscope (9.5F) was used in all patients
together with the usual ancillary
products beside the Wolf's pneumatic
lithotripter for stone disintegration.
Ureter-vesical complex dilation was
done in 193 procedures (71.5%) while
direct introduction of ureteroscope was
performed without preliminary dilation
in 77 procedures (28.5%). All procedures had been planned to have in-situ
disintegration of the stone and extraction of large stone fragments using
dormia basket. At the end of the
procedure a double-J stent was
inserted and left for 4-8 weeks to
PATIENTS AND METHODS:
Retrospective study and review
of 270 files of adult patients who
underwent ureteroscopic manipulation
for their ureteral stones was done over
a period of two years in King Fahad
Hospital Hofuf, Saudi Arabia from
October, 2005 to December 2007.
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
ensure ureteral patency and avoid
complications in the post-operative
period.
Mamdouh
189 (70%) males and 81 (30%)
females. The location of the ureteral
stone was as follows: 210 (77.7%)
case had the stone in distal ureter, 42
(15.6%) case had their stone in midureter, while 18 (6.7%) of the patients
had their stone in the proximal ureter
respectively. The ureteral stones size
ranged from 0.9 mm to 1.6 mm. While
151 of the stones were present in the
left ureter (55.9%), 119 of the patients
had their stones on the right side
(44.1%). Patients' demographics and
ureteral stone criteria are shown in
table (1).
All recorded data related to
patient age, sex, previous surgery and
stone site, size and density in addition
to procedures time and any difficulties
and details of complications were collected and analyzed using SPSS
program.
RESULTS:
The patient age ranged from 19
to 61 years with a mean age of 43±11
years. Patients' sex distribution was
Table (1): Patients' demographics and ureteral stone criteria
Item
- Total number:
- Mean age:
- Sex distribution:
- Site of the stone:
- Proximal ureter:
- Mid-ureter:
- Distal ureter:
- Side of the stone
Number
(270) patients
43 ± 11 years (range:19 - 61 years)
189 males / 81 females
(210) patients
(42) patients
(18) patients
(151) left ureter – (119) right ureter
Out of all the 270 ureteroscopic
procedure, twenty four patients developed intra-operative ureteral injury
with an overall ureteral injury rate of
8.88%. Nine patients developed major
ureteral injuries (3.3%) while fifteen
patients developed minor ureteral
injury (5.5%). The most common
ureteral injury encountered was ureteral perforation; major and minor (12
patients) being 4.44 % of all patient
and 50% of all injuries. The second
most common but being a minor injury
was false passage of the distal ureter in
four cases and in the midureter in two
which were made during insertion of
the guide wire in all cases.
Percentage
(100 %)
70% / 30%
77.7 %
15.6 %
6.7 %
55.9% - 44.1%
The incomplete avulsion with
extensive extravasation occurred in
seven cases (2.59%). All patients
necessitated surgical intervention. Two
patients underwent uretero-vesical
reimplantation, one female patient
underwent resection and reanastomosis
of the proximal right ureter, while four
of them had just double-J stenting
during open surgical drainage of the
extravasated contents. Perforation was
insignificant with mild extravasation
in five patients (1.85%) who underwent double-J stent insertion just
diagnosed by retrograde fluoroscopic
study.
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
Two male patients developed
ureteral intussusception of the distal
ureter (0.74%). The two patients
underwent ureterovesical reimplantation. The first patient was an adult
male patient whose ureteral lumen was
narrow and the ureteroscope was
inserted directly without dilatation and
the injury followed on forceful dragging of the ureteroscope. The second
patient was 62-years old male patient
who underwent ureteroscopy also
without dilatation. He developed a
ureteral tumor bulging into the bladder
after ureteroneocystostomy.
Mamdouh
common minor injuries constituting
25% and about 21% of all injuries in
our study. Ureteral abrasion occurred
in two patients and significant
bleeding developed in also two
patients. The source of bleeding could
not be identified.
False passage constituted 25%
of all injuries in our series (2.2%)
more commonly in the distal part of
the ureter and 80% of them occurred at
site of stone location. All false
passages in our study were attributed
to forceful placement of the ureteroscopewithout dilatation in two cases
and by guidewire itself in three cases.
In all the cases of false passages
development, the injury occurred
during the early steps of the procedure
by means of retrograde imaging. A
double-J stent was inserted with
termination of the procedure in all
these patients. Two patients developed
bleeding, one before and one after
stone removal. A double-J stent was
inserted in these two patients and both
were given blood transfusion and
bleeding stopped with conservative
treatment.
The overall major ureteral
injuries constituted about 37% of all
injuries. Despite ureteral reconstruction and normal urographic features, the five patients still have intermittent loin pain. Major ureteral
injuries with its incidence and outcome
are shown in table (2).
Minor ureteral injuries constituted 62.5% of all ureteral injuries in
our study. This constitutes 5.55% of
all patient involved in this study.
Ureteral false passage and perforation
with mild extravasation were the most
Table (2): Types, incidence, and outcome of ureteral injuries
Type of injury
Total No. % injury % of patients
- Major injuries:
9
3.33%
- Partial avulsion:
7
29.1%
2.60%
- Intussusception:
2
8.3%
0.74%
- Minor injury:
15
5.55%
- False passage:
6
25.0%
2.22%
- Ureteral abrasion:
2
8.3%
0.74%
- Perforation:
5
20.8%
1.85%
- Significant bleeding:
2
8.3%
0.74%
Management
Surgery
D-J stenting
(3) repair (4) + Drainage
(2) repair
--
- Total
(5)
24
100%
Five patients developed minor
perforation with mild extravasation
(1.85%). They were treated by doubleJ stent insertion with termination of
the procedure in two cases. The other
8.88%
-----
(6) + 6 Termination
(2)
(5) + 2 Termination
(2) + 1 Termination
(19)
three patients were found to have
extravasation on doing retrograde
ascending uretero-pyelogam at the end
of the procedure. A double-J stent was
inserted and all of the patients had no
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
post-operative complications. Minor
ureteral injuries and their outcome are
shown in table (2).
Mamdouh
the distal part of the ureter, and two
developed perforation with mild
extravasation. The injury occurred at
any level of the ureter but the distal
part of the ureter has the most
predilections being injured in two
thirds of all injuries. The proximal and
the middle part of the ureter were
involved in one third of the injuries
and were equally affected. The sex
distribution and the anatomical
location of ureteral injuries, both are
demonstrated in table (3).
Eighteen out of the twenty-four
ureteral injuries (75%) occurred in
male patients while only six female
patients (25%) were involved.
Eighteen out of 189 males developed
ureteral injuries (9.5%) while six out
of 81 females had ureteral injury
(7.4%). Two female patients developed partial avulsion of the ureter,
two developed ureteral false passage in
Table (3): Sex distribution and anatomical location of ureteral injury
Type of injury
- Major injuries:
- Partial avulsion
- Intussusception:
- Minor injury:
- False passage:
- Ureteral abrasion:
- Perforation:
- Significant bleeding:
- Uretal injuries:
- Total patients:
Number
9
7
2
15
6
2
5
2
24
270
Sex
Distribution
Males Females*
5
2
2
-4
2
3
2
18
189
As regard the location of the
stone and its effect on ureteral injury,
we found that most of the major
ureteral injuries occurred at the site or
location of the stone (seven out of nine
patients). Seventy-nine percent of all
ureteral trauma occurred at the level of
stone location. The source of bleeding
was not identified whether from
2
-2
-6
81
Site of the injury
Proximal Middle
Distal
2*
1
4*
--2
(*) means a female patient.
-2
4**
1
-1
1*
1
3*
--2
4**
4
16****
Male rate: 9.5% Female rate: 7.4%
middle or distal ureter. False passage
of the ureter occurred in the distal part
of the ureter in most of the cases. This
type of ureteral minor injury definitely
occurred distal to the stone location.
The overall safe non-injurious ureteroscopic procedure was 91.2%. The
relation between the stone location and
the site of injury is shown in table (4).
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
Mamdouh
Table (4): Stone location and the site of ureteral njury
Type of injury
- Major injuries:
- Partial avulsion
- Intussusception:
- Minor injury:
- False passage:
- Ureteral abrasion:
- Perforation:
- significant bleeding:
- Uretal injuries:
- Total No. patients:
NO.
9
7
2
15
6
2
5
2
24
270
Stone site of affected
Pt.
Proximal Mid Distal
4
1
2
2
1
1
2
8
18
1
1
3
42
As regard the etiological
factors that lead to or predispose to the
ureteral injury, the neglect of insertion
of the safety guide-wire and forceful
aggressive insertion of the ureteroscope were the most common causes
of ureteral injuries that occurred in
eleven times and ten times respecttively. Inadvertent clumsy ureteroscopy was responsible for most of the
major ureteral injuries (all cases of
extensive perforation and distal ureteral intusssception in addition to the
two cases of significant bleeding)
especially if either inserted without a
guide-wire (4), on a guide wire in a
false passage (1), or without dilatation
of the uretero-vesical complex (2). The
etiology of injury and the time of its
diagnosis are shown in table (5).
Site of the injury
Proximal Middle
Distal
2 ++
1+
4 ++
2 ++
(+) means injury at site of the stone
5
2
4 +++
1
1+
1+
2
1+
1+
3 ++
1
2??
13
4
4
16
210 Safe complete procedure:
246 (91.2%)
Personnel who were insisting
to complete the procedure by any
means or tracing the migrating stones
in the upper ureter were involved in
performing the major injuries.
Dilatation of the ureter-vesical
junc-tion was not done in seven of the
cases while performing ascending
retrograde imaging on time was not
appreciated seven cases also. Placement or replacement of the safety
guide wire during work was not
appreciated in eleven cases and this
event was involved in most major
injuries. The dormia stone basket was
the causative factor in only two cases.
Injuries that were discovered at
early time of the procedure and
endoscopically handled with insertion
of a ureteral stent had an eventful postoperative course. The hospital stay
was two days. The patients who
developed major ureteral injuries had a
mean hospital stay of eleven days and
the operative time was prolonged at
least two hours more than patients who
underwent early ureteral stenting.
Surprisingly, seven of the nine
major ureteral injuries were done by
consultant well-experienced with
ureteroscopy. On the other hand, all
the minor injuries beside one case of
the significant bleeding were done
resident urologists under training.
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Table (5): Etiology and time at diagnosis of the ureteral injury
Injury Type
DILAT
- Partial avulsion:
++
- Intussusception:
++
- False passage:
**
- Ureteral abrasion:
- Extravasation:
++
- Significant bleeding: +
SGW
++++
++
+++
- Total
11/24
9/24
Etiology
RPG
+++++
++
--
++
7/24
URS
+++
++
-+
++
++
10/24
DORMIA
---+
+
2/24
Time at diagnosis
EARLY LATE
2
5
2
5
1
2
4
1
2
13/24
were made by means of the
ureteroscope and mostly at the site of
the stone. The first report of avulsion
was reported in 1967 by Hart16.
Luckily, its occurrence is relatively
rare with rates of 0% to 0.5% reported
in several large series3,8,10,18). This high
rate in our study was attributed to
prolonged procedure for upper ureteral
stones or inserting the semi-rigid
ureteroscope into the ureter without
preliminary dilatation depending on
experience. Both the indications and
the guidelines of a safe procedure were
not properly followed. Avulsion
generally occurs during forceful
removal of a stone through a segment
of ureter with a diameter smaller than
the stone itself. In our study, two cases
occurred in the proximal ureter at site
of stone location but the distal ureter
was the most commonly affected. The
proximal third of the ureter is at
particular risk as it has less muscle
support and contains a thinner layer of
mucosal cells than the distal ureter (17).
Additional risks for avulsion include
the presence of an impacted stone,
stone retrieval in a diseased portion of
the ureter, and the use of multiple wire
baskets19.
DISSCUSSION:
Any operative procedure either
surgical or endoscopic definitely has a
complication rate. As the ureter is a
slender tubal structure, ureteral injuries
do
occur
especially
during
ureteroscopic stone manipulation. The
ureteral injury in our study was
estimated in a special environment in a
teaching hospital for special patients
who have ureteric stones along the
whole ureter.
The intra-operative ureteral
injury rate was 8.9% in our study. The
most serious and frustrating injury was
ureteral intussusception; 0.74% of all
patients. A small number of iatrogenic
causes have been described including
retrograde intussusception as a result
of repeated ureteroscopy14. With the
use of larger ureteroscopes earlier,
there were also instances of the ureter
being dragged proximally as the
ureteroscope was advanced15. This
happened in our two cases where the
large ureteroscope was inserted
without dilatation of the intramural
ureter into a small ureter in one case
and a harder ureterin the other case
who developed tumor later. Intussusception should be suspected when
there is difficulty placing a stent at the
end of the procedure 14.
The early recognition of our
cases leaded to the high rate of
surgical repair and drainage of the
associated extravasaion with stenting
of the ureter. All our patients do well
Partial
ureteral
avulsion
occurred in 2.6% in our study and all
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Mamdouh
on long term follow-up. If the stone
does not travel easily with the basket
then basketing should be abandoned
and either lithotripsy should be
performed or stenting must be considered if significant trauma is present.
Vigilance should be employed with
proximal stones15. Open repair is the
mainstay of treatment of ureteral
avulsion that is dependent on factors
such as location of the avulsion and
length of devitalized ureterand patient
age and comorbidities, and renal
function15. Proximal and middle
ureteral short avulsions can be treated
with
ureteroureterostomy.
Distal
injuries are best addressed with ureteroneocystostomy. However, longer
ureteral defects as well as those in the
middle third may require the addition
of a psoas hitch, a Boari flap, or a
combination of both18
rate of perforation was attributed to
that our study involved only ureteral
stones which are most difficult to
manipulate. All instruments in the
ureteroscopic armamentarium have the
potential to perforate the ureter. The
vast majority of perfo-rations is small
and can be managed conservatively
with ureteral stent placement for 4-6
weeks15.
Ureteral perforation occurred
in 1.85% of our cases followed by
mild extravasataion and all developed
at the site of stone location. Both the
early diagnosis and ureteral stenting
made an excellent outcome. Although
the reported incidence of ureteral
perforation has decreased over the last
several decades, it remains one of the
most common complications15.
Excessive force and improper
placement of the ureteroscope, in
particular when entering the ureteral
orifice, can easily result in a false
passage necessitating termination of
the procedure15. Guidewires, stone
retrieval baskets, and lasers are all
capable of creating false passages
especially in the treatment of
urolithiasis15. If a false passage is not
appreciated, a truly disastrous conesquence can occur if the ureteroscope is
then passed over the misplaced
guidewire21. The ensuing dissection
can interfere with ureteral blood
supply resulting in necrosis and
stricture even loss of the entire ureter.
These injuries are benign and
treatment generally consists of ureteral
stenting for 2-4 weeks15.
False passage constituted 25%
of all injuries in our series (2.2%)
more commonly in the distal part of
the ureter. Often, false passages are
overlooked and many series fail to
comment or report on them5,6,10. In a
series of iatrogenic ureteric injuries,
Al-Awadi et al., described 15 false
passages (18.3%), making it one of the
most common complications in their
series20.
The first perforations were
reported by Lyon et al., in the late
1970s1, 2. Early series had perforation
rates exceeding 15%. In 1987, Kramolowsky reported perforations in 17%
of 142 ureteroscopic proce-dures19.
Development of smaller diameter
ureteroscopes had a dramatic impact
on reported perforation rates. In 1993,
Abdel-Razzak and Bagley had only
one minor perforation out of 65 cases
on using the semirigid ureteroscope
(6.9F)9. Recent large series reporting
on complications cite perforation rates
between 0.5% and 4.7% with the
majority at 1% or less 3–6,10. Our high
Like
most
complications,
adherence to proper technique and
safety will make this a rare occurrence.
Passing the ureteroscope over a
guidewire can help navigate difficult
passageways while balloon dilatation
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
can make narrow ureters easier to
traverse. If a guidewire cannot easily
pass a point of obstruction, an angledtip hydromer-coated guidewire should
be utilized to bypass the area gently. A
safety wire is imperative as cases
where the ureter is impassable will
require a stent22.
Mamdouh
In our study, 0.7% developed
bleeding that required transfusion.
Geavlete et al., reported a rate of 0.1%,
where visibility difficulties secondary
to bleeding forced them to halt the
procedure and place a ureteral stent3.
In their series of 290 cases, AbdelRazzak and Bagley reported on three
patients that had prolonged bleeding
lasting longer than two days24. None of
these
patients
required
blood
transfusion.
Small perforations with mild
extravasation occurred in 1.85% of our
cases. In their series of 290
procedures, Abdel-Razzak and Bagley
described three cases of extravasation
(1.0%) (25=29). Our high rate is
attributed to that we included only
patients with stones in our study and
our larger ureteroscope (9.5F) compared to that used in Bagley' study
(6.9F). In general, small perforations
result in minor amounts of extravasation that are of no clinical
significance.
When the safety guidelines of a
proper ureteroscopy were not taken
into consideration, complications and
definitely the injury rate will be
increased. The neglect of insertion of
the safety guidewire and forceful
aggressive insertion of the ureteroscope were the most common causes
of major ureteral injuries inour study.
Refusal of doing dilatation of the
intramural ureter and the neglect of
performing
ascending
retrograde
imaging on time were the second most
common etiological factors. Personnel
who were insisting to complete the
procedure by any means or tracing the
migrating stones in the upper ureter
were involved in performing the major
injuries.
Mucosal abrasion occurred in
less than 1% in our study. Any
instrument passed through the ureter
can cause mucosal abrasions. The
larger the instrument, the more is the
friction applied to the ureteral mucosa
(15)
. Identifiable mucosal abrasions
were reported in 0.3% of 2273 patients
by Butler et al.,10. They noted that the
seven mucosal tears were caused by
the ureteroscope itself but in our study
it occurred one by means of dormia
basket in one case having a lower
ureteral stone and the other by the
ureteroscope itself at the proximal
ureter at site of stone location.
Geavlete et al., likewise reported a low
incidence in their series with mucosal
abrasions being found in 1.5% of
patients3. These lesions generally have
no significant consequence. In most
cases, only observation is warranted. If
there is considerable bleeding or
edema, obstruction may ensue and a
ureteral stent should be placed for
drainage23.
CONCLUSION:
Ureteral injuries on ureteroscopy for ureteral stones are more
frequent at the distal part of the ureter.
Injury is more common at site of stone
location. Adherence to the safety
guidelines and proper technique of
ureteroscopy, proper selection of
cases, and following the diagnostic
rules make ureteral injuries a rare
occurrence. Termination of ureteroscopy with insertion of a ureteral stent
on finding a difficult situation is a wise
decision.
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
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119:35–36.
2. Lyon ES, Banno JJ, Schoenberg
HW. Transurethral ureteroscopy in
men using juvenile cystoscopy equipment. J Urol 1979; 122:152–153.
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G, et al., Complications of 2735
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‫إصابات الحالب أثناء إستخراج حصوات الحالب بإستخدام المنظـــار‬
‫ممدوح محمد أبوالنصر‬
‫قسم المسالك البولية – كلية طب المنيا‬
‫أحدث إستخدام منظار الحالب ثورة عظيمة فى مجال جراحات مناظير المسالك البولية‬
‫وخاصةً عمليات إستخراج وتفتيت حصوات الحالب‪ .‬وحيث أنه يستحيل وجود عملية جراحية‬
‫بال مضاعفات فإن لمنظار الحالب بالتأكيد نسبة مضاعفات له‪ ،‬منها إصابات الحالب المختلفة‬
‫والتى تم رصدها فى دراسات سابقة شملت كل أمراض الحالب‪.‬‬
‫وقد إستهدفت هذه الدراسة بالتفصيل إصابات الحالب المختلفة أثناء عملية إستخراج‬
‫حصوات الحالب فى الكبار‪ ،‬وتم تقسيم هذه اإلصابات إلى إصابات كبرى والتى تطلبت الشق‬
‫الجراحى للتعامل معها وإلى إصابات صغرى والتى قد تم التعامل معها من خالل المنظار‬
‫بوضع دعامة حالبية عكازية الطرفين بالحالب‪ .‬وقد أُجريت هذه الدراسة على مائتين وسبعين‬
‫مريضا ً لديهم حصوات بالحالب فى أجزاءه المختلفة‪.‬‬
‫وقد عانى أربعة وعشرون مريضا ً من إصابات مختلفة بالحالب بنسبة تسعــة بالمائة‬
‫تقريباً‪ .‬ومثـلت إصابات الحالب الكبرى نسبة ثمان وثالثين ونصف بالمائة منها‪ .‬وقد تم‬
‫تشخيص هذه اإلصابات فى وقت متأخر أثناء العمليةز وقد كان أخطر هذه المضاعفات هى‬
‫تهتك الحالب بينما كان أكثرها شيوعا ً هي إحداث ثقب فى الحالب بدرجا ٍ‬
‫ت مختلفة بنسبة خمسين‬
‫بالمائة من كل حاالت اإلصابات (عدد إثنى عشرة مريضا)‪ .‬وقد كان مكان إصابة الحالب أكثر‬
‫حدوثا ً فى الجزء األسفل منه فى ثلثى الحاالت‪ .‬وقد حدثت اإلصابات بالحالب نتيجة لعدم إتباع‬
‫أقرتها جمعية المسالك البولية األمريكيةأناء إجراء‬
‫إجراءات السالمة والخطوات اآلمنة والتى ّ‬
‫عملية منظار الحالب منها إستخدام ووضع السلك المرشد أثناء العملية وإستخدام اآلشعة‬
‫الصاعدة في الوقت المناسب والتعامل بمنتهى اللطف بالمنظار أثناء وجوده بالحالب‪.‬‬
‫وقد خلصت هذه الدراسة إلى ضرورة إتباع إحتياطات و إجراءات السالمة والخطوات‬
‫اآلمنة أثناء العملية لتفادى حدوث إصابات الحالب المختلفة‪ ،‬كما أنه من الحكمــة بمكان وضـع‬
‫دعامة حالبية عكازية الطرفين فى حال حدوث إضطراب أو حدوث مشاكل تقنية وإنهاء عملية‬
‫منظار الحالب وتأجيل التعامل مع الحصوات لمرحلة الحقة‪.‬‬
‫‪327‬‬