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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.

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