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05
Urological Iatrogenic Complications – from diagnosis to treatment

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Learning Objectives

  • To recognize the sites of iatrogenic urinary tract lesions – involving kidneys, ureters, bladder and urethra
  • To review the imaging findings of iatrogenic urinary tract lesions, with emphasis on  computed tomography (CT)
  • To recognize the importance of interventional radiology in the treatment of some of these injuries

 

Background

  • Iatrogenic lesions and complications of  medical procedures are frequent
  • The suspicion of iatrogenic injuries are  increasingly a reason to perform imaging studies
  • Imaging studies can be performed to characterize complications that are clinically apparent but also to exclude complications that are clinically silent 
  • Radiologists play a decisive role in the identification and sometimes in the initial management of these injuries 
  • The urinary tract is prone to injury from 
    • surgery (abdominal, obstetrical and gynaecological, urological)
    • minimally invasive procedures
    • radiation therapy
    • The iatrogenic complications will depend on the type of intervention, so the patient’s clinical history is paramount
  • It is mandatory for the radiologists to be aware, to recognise and to correctly diagnose these complications involving the urinary tract

Delays in the diagnosis of iatrogenic injuries lead to poor patient outcomes with the risk  of losing renal function

 

Imaging Findings or Procedure

  • We performed a review in our PACS to identify exemplifying cases of urinary tract lesions 
  • Following the identification of the cases a review of the patients clinical history was performed to establish it’s iatrogenic aetiology
  • We present our findings  as a case based series
  • We divide our findings by structure of origin of the lesion
    • Kidney
    • Ureter
    • Bladder
    • Urethra

 

KIDNEY

  • Though rare, iatrogenic renal lesions can be associated with significant morbidity
  • Frequent iatrogenic lesions – haemorrhage; hematoma; pseudoaneurysm; arteriovenous fistula; arteriocaliceal fistula; injury and disruption of the renal pelvicaliceal system; renal foreign bodies; renal infarcts
  • Iatrogenic procedures associated with these lesions - percutaneous renal biopsy; percutaneous nephrostomy; percutaneous nephrolithotomy; partial nephrectomy; anticoagulation-related hemorrhage; radiation therapy
  • The most common iatrogenic renal injuries are vascular
    • arteriovenous fistula and pseudoaneurysm are the most common iatrogenic biopsy-related or surgery-related vascular injuries in native kidneys 
  • CT first choice to detect iatrogenic kidney injuries
    • CT advantages - imaging the entire GU tract in addition to the kidneys; CT angiography highly sensitive in identifying renal vascular injuries
    • CT findings - haemorrhage / hematoma (hyperdense on nonenhanced scans, active extravasation of contrast media (active bleeding)); arteriovenous fistula (detected during the arterial phase, early or simultaneous opacification of one or several intrarenal arteries and veins); pseudoaneurysm (detected during the arterial phase, ovoid or round contrast-opacified abnormality that communicates with a ruptured vessel wall); infarction (nonenhancement of an area (usually wedge-shaped) or of the whole kidney, cortical rim sign may or may not be seen)
  • Renal angiography more limited diagnostic role, primarily used when planning percutaneous interventions
  • Superselective renal artery embolization is nowadays accepted as the most appropriate treatment of iatrogenic renal vascular pseudoaneurysm that arise peripherally in the kidney and do not respond to conservative manoeuvres
  • Covered stent grafts are used in pseudoaneurysms that arise from the main renal artery

 

URETER

  • retroperitoneal course
  • close proximity to vital abdominal and pelvic organs 
  • difficult to identify during surgical procedures (40-50 % detected during the procedure and repaired;50-60 % delayed diagnosis)
  • Distal third more susceptible to iatrogenic injury
  • Frequent iatrogenic lesions – ureteric ligation; ureteral kinking; ureteral obstruction by a suture;devascularization of the ureter by electrocoagulation; ureteric transection (partial or complete); ureteric perforation; crushed ureter;fistulous tract development
  • Iatrogenic procedures associated with these lesions – gynecologic and obstetric surgery; abdominal surgical procedures; urology procedures; radiotherapy
  • Ureterography most accurate diagnosis technique
  • CT urography has become the most common method for diagnosing ureteral injuries missed during the procedure
    • essential to perform evaluation on the excretory phase of contrast 
    • a more delayed phase (even hours) might be needed for complete opacification of the ureter
  • Signs associated with injured ureter at CT urography
    • transection or perforation of the ureter - extravasation of contrast media on excretory phase; urinary ascites (free fluid opacified on excretory phase); urinoma (collected fluid opacified on excretory phase)
    • ligation or kinking of the ureter – hydronephrosis; ureteric obstruction; non-opacification of the distal ureter
    • fistulous tracts - abnormal communication (usually between the ureter and the vagina) which opacifies on excretory phase

 

BLADDER

  • Iatrogenic bladder injuries not uncommon
  • Frequent iatrogenic lesions – bladder laceration / rupture ; fistulous tract development
  • Iatrogenic procedures associated with these lesions – endoscopic urological procedures; pelvic gynecological, general and urological surgery; radiation therapy
  • Hysterectomy and transurethral resection of bladder tumor are two procedures most frequently implicated in bladder injury 
  • CT cystography is the gold standard study for clinically suspected iatrogenic bladder injury
    • mandatory to perform retrograde bladder filling as excretory phase is not sufficient
  • Bladder Injury
    • extraperitoneal bladder injury – extravasation of contrast into the pelvis and along the retroperitoneum
    • intraperitoneal bladder injury – extravasated contrast outlining bowel loops and filling dependent intraabdominal spaces
    • fistulous tracts – excretion of intravenous contrast material into tract other than urinary (vagina, digestive tract or cutaneous) during delayed phase strongly suggests the diagnosis
 

URETHRA

  • High index of suspicion necessary
  • Iatrogenic lesions – urethral strictures; fistulous tract development
  • Iatrogenic procedures associated with these lesions – urological procedures; urinary catheterization; radiation therapy

  

Conclusion

  • Radiologists play a pivotal role in diagnosing delayed complications of medical procedures
  • It is crucial for radiologists to be familiar with the spectrum of iatrogenic injuries that affect the urinary tract
  • A high index of suspicion and awareness of patient medical and surgical history are vital 
  • Knowledge of the imaging findings associated with iatrogenic complications involving the urinary tract allows for faster diagnosis and treatment of these medically induced lesions, allowing for better patient management and outcome

 

 

 

 

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