A Prospective Study Analyzing the Association Between High-grade Ureteral Access Sheath Injuries and the Formation of Ureteral Strictures - Beyond the Abstract

This study was developed as follow-up on previous work by Loftus et al. (J Endourol 2019) comparing ureteral wall injuries from two different ureteral access sheaths. In that study, the researchers found a rate of high-grade injury of 23.8%. When reviewing those findings, we began to wonder "what was the long-term outcomes of those patients with the high grade injuries?" While limited data exists on the long-term stricture rate after ureteroscopy, there is a paucity of data on the long-term stricture rate after ureteral access sheath use and no prior research looking specifically at high-grade injuries from sheaths. We then worked alongside our colleagues in France to follow-up on those patients with high-grade ureteral injuries.

One difficulty we encountered was actually tracking down imaging on the patients. Being tertiary care centers, many patients follow-up with their home Urologist so follow-up imaging is not available. We were able to track down imaging on 56 patients and found the risk of hydronephrosis without an obstructing stone to be only 5.5%. Just one patient developed a de novo stricture. We can take comfort in knowing that the risk of long-term stricture is rare after a high-grade injury from a ureteral access sheath, but missing one silent obstruction can have substantial impact so imaging should still be obtained to follow-up these patients.
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Ultimately, the take home messages is that even though high-grade injuries may look significant (and frightening!), their long-term outcomes are similar to patients without an injury when looking at ureteral stricture rate. It should be noted that pre-stented patients were excluded from our study, so injuries in ureters not passively dilated with a pre-placed stent still healed appropriately. Perhaps this will make Urologists feel more comfortable with using an access sheath and breathe a little easier if an injury like the one pictured is seen.

Written by: Karen Stern, MD, Fellow, Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH

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