How to treat jatrogenic ureteral injury after posterior spinal surgery? Case report and review of literature

Introduction Entry into the retroperitoneal space during open posterior spinal surgery introduces the rare possibility of iatrogenic ureteral injury. Case presentation We describe a case of ureteral injury after spinal surgery in a 49‐year‐old female with persistent lumbar pain and high fever 2 weeks after spinal surgery. After admission to the urology department, a computer tomography scan was performed and revealed right‐side hydronephrosis grade III and large retroperitoneal fluid collection. After radiological confirmation of right ureteral injury, a ureteral stent was placed, but 4 weeks later, ureteral stricture was confirmed on antegrade pyelography. Therefore, surgical ureteroplasty was indicated 2 months after initial admission to the urology department. Six weeks later, the stent was removed, and intravenous pyelography revealed a normal ureteral passage. Conclusion There should be a low threshold for ureteral injuries after spinal cord surgery in patients with high fever and elevated blood creatinine levels.


Introduction
Although traditional spinal fusion surgery is associated with more complication reports than a minimally invasive approach, ureteral injuries are still very rare. [1][2][3][4] However, in these rare circumstances, medicolegal implications may be involved in addition to devastating consequences. 4 Here, we present a case of a 49-year-old female with CT urography and retrograde pyelography confirmed ureteral injury after TLDF. In this case report, we aim to elucidate the vulnerability of the ureter during posterior lumbar surgery.

Case report
A 49-year-old female presented to our department complaining of severe lumbar pain and a high fever. Her past medical history revealed a neurosurgical procedure for discus hernia performed 2 weeks prior (TLDF). There was no report about other medical histories, previous traumatic incidents, or radiation exposure. After admission to the urology department, a CT scan was performed and revealed grade III right-side hydronephrosis and large retroperitoneal fluid collection starting from the right renal pelvis and propagating caudally and laterally, with a diameter of 11 9 6 cm. CT urography showed evidence of urinary extravasation from the right ureter (Fig. 1). The nephrostomy was placed subsequently, and right antegrade pyelography confirmed proximal ureteral injury (Fig. 2a). Furthermore, a cystoscopy was performed, and a ureteral stent was placed on the right side (Fig. 2b).
Four weeks later, the ureteral stent was removed, and control antegrade pyelography was performed (Fig. 3). Since complete ureteral stricture persisted during follow-up, open surgical ureteroplasty was indicated 2 months after initial admission to the urology department. We resected approximately 15 mm of the stenotic part of the lumbar ureteral segment and performed a primary end-to-end ureteral anastomosis over the ureteral stent. Six weeks later, the stent was removed, and intravenous pyelography revealed a normal ureteral passage (Fig. 4). The patient continued to do well 6 months postoperatively, with no further complications.

Discussion
Ureteral injury is a rare but serious potential complication of spinal procedures. It is often clinically unsuspected, as   symptoms are nonspecific, and the patient may present weeks and even months after the injury. 5 It should be considered in the differential diagnosis of any patient who presents with symptoms of acute abdominal pain after lumbar spine surgery.
In this case, we reported a right ureteral injury sustained in a female patient after TDLF. We suspected that the patient had delayed abdominal and lumbar pain associated with a fever due to a ureteral injury. When planning the treatment of ureteral injury, it is recommended to have a highly sensitive diagnostic tool to determine the exact location and diameter of the ureteral injury. 6 Therefore, we ordered and diagnosed ureteral injury using contrast-enhanced CT since the symptoms were nonspecific and occurred several weeks after the surgery. 1 Although several treatment options are possible, upon injury detection, surgical treatment is often inevitable and sometimes requires a complex reconstruction technique. 6 If possible, a one-stage ureteral injury repair operation should be performed to prevent ureteral stricture. 7 A minimally invasive approach is favorable but sometimes highly challenging, especially in neglected cases. 2 In this case, we were able to perform open end-to-end ureteral alignment (ureteroureterostomy), which was successful due to the short stricture length and favorable stricture location.

Conclusion
There should be a low threshold for ureteral injuries after spinal cord surgery in patients with symptoms of delayed lumbar or abdominal pain associated with a high fever and elevated blood creatinine levels. Contrast-enhanced CT and retrograde urography are recommended in the diagnosis of ureteral injury, and open surgery with stricture resection and possible primary anastomosis is preferable after a previous unsuccessful trial with ureteral stent placement.