Attention: Restrictions on use of AUA, AUAER, and UCF content in third party applications, including artificial intelligence technologies, such as large language models and generative AI.
You are prohibited from using or uploading content you accessed through this website into external applications, bots, software, or websites, including those using artificial intelligence technologies and infrastructure, including deep learning, machine learning and large language models and generative AI.
JOURNAL BRIEFS Urology Practice: Impact of Delayed Recognition of Iatrogenic Ureteral Injury in a Retrospective Population-Based Study
By: Jennifer A. Locke, MD, PhD; Rano Matta, MD, MSc; Refik Saskin, MSc; Francis Nguyen, MSc; Sarah Neu, MD, MSc; Sender Herschorn, MD | Posted on: 01 Nov 2021
Locke JA, Matta R, Saskin R et al: Impact of delayed recognition of iatrogenic ureteral injury in a retrospective population-based study. Urol Pract 2021; 8: 636.
Iatrogenic ureteral injuries (IUIs) are rare (incidence 0.5%-10%1) but can result in significant clinical consequence if unrecognized at the time of injury.2,3 In our own institutional series of 103 patients with IUI we observed significant patient morbidity with the delayed recognition of IUI.4 However, due to the limitations of our single institution review, we could not assess the overall impact of delayed recognition of IUI on larger numbers of patients and on the health care system.
We conducted a population-based, retrospective cohort study of patients ≥18 years old in Ontario, Canada using linked health administrative databases. In Ontario, all necessary health care services, physician services and prescription medication information are recorded and held at ICES (Institute for Clinical Evaluative Sciences, http://www.ices.on.ca). ICES is an independent, nonprofit research institute whose legal status under Ontario’s health information privacy law allows it to collect and analyze health care and demographic data, without consent, for health system evaluation and improvement. We linked validated ICES data sets to assess the primary independent variable, time of diagnosis of IUI, with the primary clinical outcomes, renal impairment and a composite outcome: hydronephrosis or stricture, as well as secondary outcomes, total direct health care costs and health care utilization. Multivariable logistic regression models, generalized linear models and exploratory analyses were used to analyze the data.
We identified 1,193 patients who experienced an IUI, 25.2% of whom had a delay in recognition.
- Delayed recognition of IUI was associated with hydronephrosis or stricture in 1 year following treatment of IUI (OR 2.27, 95% CI 1.69-3.04, p <0.0001) and renal impairment in 2 years following treatment of IUI (OR 2.69, 95% CI 1.84-3.94, p <0.0001) compared to immediate diagnosis after adjustment (tables 1 and 2).
- Total health care costs (IRR 2.06, 95% CI 1.89-2.24, p <0.0001), emergency department visits (IRR 2.07, 95% CI 1.77-2.43, p <0.0001), hospitalizations (IRR 1.62, 95% CI 1.48-1.78, p <0.0001) and outpatient urology visits (IRR 1.45, 95% CI 1.31-1.60, p <0.0001) were significantly higher in those with delayed vs immediate recognition after adjustment (tables 1 and 3).
- Previous radiation was significantly associated with delayed recognition of IUI after adjustment (OR 0.64, 95% CI 0.42-0.97, p=0.04).
Table 1. Outcomes of patients with IUI
| All Cases (1,193) |
Immediate (892) |
Delayed (301) |
|
|---|---|---|---|
| No. primary clinical outcome (%): | |||
| Hydronephrosis (within 1 yr) | 211 (17.1) | 134 (15.0) | 77 (25.6) |
| Stricture (within 1 yr) | 172 (14.4) | 114 (12.8) | 58 (19.3) |
| Hydronephrosis or stricture (within 1 yr) | 293 (24.6) | 183 (20.5) | 110 (36.5) |
| Renal impairment (within 2 yrs) | 152 (12.7) | 81 (9.1) | 71 (23.6) |
| No. secondary clinical outcome (%): | |||
| Cystitis (within 1 yr) | 16 (1.3) | 12 (1.3) | 1–5 |
| Pyelonephritis (within 1 yr) | 6 (0.5) | 1–5 | 1–5 |
| Bleeding (within 1 yr) | 43 (3.6) | 26 (2.9) | 12–16 |
| Sepsis (within 1 yr) | 17 (1.4) | 9 (1.0) | 12–16 |
| Incontinence (within 1 yr) | 33 (2.8) | 25 (2.8) | 3–7 |
| Nephrectomy (within 2 yrs) | 17 (1.4) | 11 (1.2) | 1–5 |
| Mean±SD total costs in 1 yr following index surgery* | 48,647.55±54,562.20 | 36,783.60±32,287.33 | 83,805.84±82,423.50 |
| Health care utilization in 1 yr following index surgery: | |||
| No. pts with ED visit (%) | 771 (64.6) | 535 (60.0) | 236 (78.4) |
| Mean±SD ED visits | 1.98±3.39 | 1.54±2.11 | 3.29±5.06 |
| No. with hospitalization (%) | 1,082 (90.7) | 799 (89.6) | 283 (94.0) |
| Mean±SD hospitalizations | 1.74±1.37 | 1.48±1.19 | 2.50±1.44 |
| No. with outpatient urology visit (%) | 1,154 (96.7) | 867 (97.2) | 287 (95.3) |
| Mean±SD outpatient urology visits | 7.49±6.94 | 6.66±5.69 | 9.94±8.63 |
| *IRR 2.06, 95% CI 1.89-2.24, p <0.0001. |
Table 2. Binary logistic regression analysis for primary outcomes of IUI
| Hydronephrosis or Stricture* | Renal Impairment† | |||||
|---|---|---|---|---|---|---|
| OR | 95% CI | p Value | OR | 95% CI | p Value | |
| Delayed vs immediate injury | 2.27 | 1.69–3.04 | <0.0001 | 2.69 | 1.84–3.94 | <0.0001 |
| Age | 0.99 | 0.98–1.00 | 0.02 | 1.02 | 1.01–1.04 | 0.00 |
| Gender (F vs M) | 1.03 | 0.75–1.40 | 0.87 | 0.65 | 0.44–0.95 | 0.03 |
| Obesity | 2.60 | 0.62–11.00 | 0.19 | 0.65 | 0.07–6.31 | 0.71 |
| Income quintile 1 | 1.15 | 0.74–1.78 | 0.55 | 1.09 | 0.59–2.02 | 0.79 |
| Income quintile 2 | 1.33 | 0.86–2.05 | 0.20 | 1.34 | 0.74–2.41 | 0.34 |
| Income quintile 3 | 1.30 | 0.83–2.03 | 0.25 | 1.50 | 0.82–2.75 | 0.19 |
| Income quintile 4 | 1.10 | 0.70–1.71 | 0.69 | 0.87 | 0.46–1.64 | 0.67 |
| Previous surgery | 1.14 | 0.86–1.51 | 0.36 | 1.53 | 1.04–2.25 | 0.03 |
| Previous radiation | 1.37 | 0.89–2.12 | 0.16 | 1.64 | 1.02–2.65 | 0.04 |
| Laparoscopic procedure | 0.53 | 0.27–1.04 | 0.07 | 1.01 | 0.49–2.10 | 0.97 |
| *2-Yr Charlson 1 | 1.38 | 0.77–2.49 | 0.29 | 1.14 | 0.39–3.33 | 0.80 |
| 2-Yr Charlson 2 | 0.95 | 0.57–1.58 | 0.83 | 1.71 | 0.81–3.58 | 0.16 |
| 2-Yr Charlson 3+ | 0.95 | 0.56–1.61 | 0.84 | 3.39 | 1.65–6.95 | 0.00 |
| Previous Ca | 0.98 | 0.61–1.57 | 0.94 | 1.53 | 0.84–2.81 | 0.16 |
| *In 1 year following treatment. †In 2 years following treatment. |
||||||
Table 3. Negative binomial logistic analysis for health care utilization outcomes
| ED Visits* | Hospitalizations† | Outpatient Urologist Visits‡ | |||||||
|---|---|---|---|---|---|---|---|---|---|
| IRR | 95% CI | p Value | IRR | 95% CI | p Value | IRR | 95% CI | p Value | |
| Delayed vs immediate injury | 2.07 | 1.77–2.43 | <0.0001 | 1.62 | 1.48–1.78 | <0.0001 | 1.45 | 1.31–1.60 | <0.0001 |
| Age | 0.99 | 0.99–1.00 | 0.71 | 1.00 | 1.00–1.00 | 0.99 | 1.00 | 1.00–1.01 | 0.09 |
| Gender (F vs M) | 1.02 | 0.87–1.19 | 0.82 | 0.98 | 0.89–1.08 | 0.70 | 0.80 | 0.72–0.88 | <0.0001 |
| Obesity | 1.08 | 0.47–2.45 | 0.86 | 0.70 | 0.39–1.23 | 0.21 | 1.28 | 0.76–2.14 | 0.35 |
| Income quintile 1 | 1.23 | 0.98–1.54 | 0.07 | 1.06 | 0.92–1.22 | 0.42 | 1.07 | 0.93–1.22 | 0.35 |
| Income quintile 2 | 1.20 | 0.95–1.50 | 0.12 | 1.11 | 0.96–1.27 | 0.15 | 1.09 | 0.96–1.25 | 0.19 |
| Income quintile 3 | 1.13 | 0.90–1.43 | 0.30 | 1.06 | 0.92–1.22 | 0.44 | 1.03 | 0.89–1.18 | 0.71 |
| Income quintile 4 | 0.90 | 0.72– 1.14 | 0.40 | 0.95 | 0.83–1.10 | 0.50 | 1.07 | 0.93–1.22 | 0.37 |
| Previous surgery | 1.23 | 1.07–1.43 | 0.00 | 1.06 | 0.97–1.16 | 0.20 | 1.02 | 0.93–1.11 | 0.66 |
| Previous radiation | 1.24 | 0.99–1.56 | 0.06 | 1.31 | 1.15–1.49 | <0.0001 | 1.13 | 0.98–1.30 | 0.10 |
| Laparoscopic procedure | 1.29 | 0.96–1.72 | 0.09 | 1.16 | 0.98–1.37 | 0.08 | 0.96 | 0.80–1.15 | 0.62 |
| 2-Yr Charlson 1 | 1.14 | 0.82–1.58 | 0.43 | 1.09 | 0.89–1.34 | 0.41 | 0.99 | 0.81–1.21 | 0.91 |
| 2-Yr Charlson 2 | 1.12 | 0.87–1.45 | 0.38 | 1.14 | 0.97–1.34 | 0.12 | 0.94 | 0.80–1.11 | 0.49 |
| 2-Yr Charlson 3+ | 1.56 | 1.21–2.01 | 0.00 | 1.27 | 1.08–1.50 | 0.00 | 0.90 | 0.76–1.07 | 0.22 |
| Previous Ca | 0.89 | 0.70–1.12 | 0.30 | 1.01 | 0.87–1.17 | 0.87 | 1.07 | 0.92–1.24 | 0.39 |
| *Number of ED visits within 1 year following index surgery. †Number of hospitalizations within 1 year following index surgery. ‡Number of outpatient urologist visits within 1 year following index surgery. |
|||||||||
Our results demonstrate that delayed recognition of IUI was associated with significant clinical, cost and health care utilization consequences, and underscore the need to find new techniques to identify IUIs at the time of injury.5 Although prophylactic stenting has been proposed, its use has not consistently been linked to increased detection of IUI or reduced complications.6,7 Furthermore, the utility of cystoscopy to identify IUI intraoperatively is unproved due to its low specificity for detecting IUI and the rarity of IUIs in general.8-10 Future studies should continue to explore new methods to facilitate intraoperative IUI recognition.
- Chung D, Briggs J, Turney BW et al: Management of iatrogenic ureteric injury with retrograde ureteric stenting: an analysis of factors affecting technical success and long-term outcome. Acta Radiol 2017; 58: 170.
- Blackwell RH, Kirshenbaum EJ, Shah AS et al: Complications of recognized and unrecognized iatrogenic ureteral injury at time of hysterectomy: a population based analysis. J Urol 2018; 199: 1540.
- Hove LD, Bock J, Christoffersen JK et al: Analysis of 136 ureteral injuries in gynecological and obstetrical surgery from completed insurance claims. Acta Obstet Gynecol Scand 2010; 89: 82.
- Locke J, Neu S, Navaratnam R et al: Morbidity and predictor for delayed recognition of iatrogenic ureteric injuries. Unpublished data 2020.
- Locke JA, Matta R, Saskin R et al: Impact of delayed recognition of iatrogenic ureteral injury in a retrospective population-based study. Urol Pract 2021; 8: 636.
- Croghan SM, Zaborowski A, Mohan HM et al: The sentinel stent? A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections. Int J Colorectal Dis 2019; 34: 1161.
- Dumont S, Chys B, Meuleman C et al: Prophylactic ureteral catheterization in the intraoperative diagnosis of iatrogenic ureteral injury. Acta Chir Belg 2021; 121: 261.
- Peacock LM, Young A and Rogers RG: Universal cystoscopy at the time of benign hysterectomy: a debate. Am J Obstet Gynecol 2018; 219: 75.
- Findley AD and Solnik MJ: Prevention and management of urologic injury during gynecologic laparoscopy. Curr Opin Obstet Gynecol 2016; 28: 323.
- Cadish LA, Ridgeway BM and Shepherd JP: Cystoscopy at the time of benign hysterectomy: a decision analysis. Am J Obstet Gynecol 2019; 220: 369.e1.
advertisement
advertisement