Reducing the Risks Associated with Surgical Ureter Injuries

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Surgical ureter injuries account for 3% of medical malpractice claims among urologists insured by MagMutual. An unrecognized or mismanaged ureteral injury can lead to significant complications, including urinoma, abscess, ureteral stricture, and potential loss of ipsilateral kidney or even death, and represents a significant liability risk to surgeons.

To help urologists reduce the occurrence of claims related to surgical ureter injuries, MagMutual’s medical faculty and risk consultants have analyzed our claims data, determined the main causes of claims related to this injury and developed strategies to improve patient outcomes.

Top Risks

Top Strategies for Reduction

Based on these top risk drivers, implementing the following clinical and operational strategies can help you prevent unexpected outcomes and increase defensibility of a medical malpractice claim:

Clinical strategies

• If an intraoperative ureteral injury is directly observed, repair may be performed intra-abdominally. However, if the injury is not clear, further evaluation is needed with cystoscopy with retrograde pyelogram, and in rare instances, ureteroscopy may be necessary. The best course of action, whether the ureter should be repaired primarily, stented or reimplanted in the bladder, should be determined by urologic judgment. If a small laceration to the ureter is diagnosed intraoperatively, it can be sutured closed and a ureteral stent can be placed. Generally, repairing a ureteral injury falls under the scope of urologic practice and it is not typical for a gynecologist to perform this procedure. It is generally recommended that if a suspected injury without laceration exists, the patient should undergo ureteral stent placement and be reevaluated after 4-6 weeks to monitor for any persistent injury, strictures or fistula formation. A complete ureteral laceration should be reimplanted into the bladder, if possible, using techniques such as direct reimplantation, psoas hitch or Boari Flap. Primary ureteral re-anastomosis with stent may be attempted in rare circumstances, but it carries a high risk of ureteral stricture formation.
• Percutaneous nephrostomy should be selected in cases of obstruction with risk of sepsis, where either retrograde placement of a ureteral stent is unlikely to be successful or the patient is too hemodynamically unstable to undergo general anesthesia. Urologists should be aware that large or severely impacted stones within the ureter may not be able to be bypassed with a wire or ureteral stent, and in such cases, anterograde decompression of the collecting system is more appropriate.
• During ureteroscopy for the treatment of ureteral stones, it is important to proceed with care and attention to detail. Under no circumstances should a ureteroscope be forcefully inserted into the ureter. If the ureteroscope, whether flexible or semi-rigid, cannot be advanced, stent placement is recommended, and the ureteroscopy should be performed at a later time. Ureteral dilation should be used sparingly and only in rare cases. When performing laser lithotripsy, the stone should be clearly visible and appropriate settings should be chosen to minimize damage to the ureteral walls. Contact between the laser and the ureteral wall can easily lead to perforation. In cases of ureteral trauma, perforation, inflammation or luminal swelling, ureteral stenting is recommended to promote healing and prevent complications such as ureteral stricture. Stone fragments within the ureteral wall increase the likelihood of subsequent ureteral stricture. Urologists should be cautious and consider placing a ureteral stent after ureteroscopy. Stents are typically used after the use of a ureteral access sheath, treatment of a large ureteral stone or treatment of a proximal or mid-ureteral stone.

Operational strategies

• Establishing a strong working relationship with interventional radiology, including having on-call availability, is crucial for providing prompt anterograde access to the collecting system in urgent or emergent situations. Both urologists and interventional radiologists should have a clear understanding of which patients are suitable for urgent or emergent anterograde access.
• Ureteroscopy is a complex technique that requires consistent maintenance of skills. Urologists should avoid performing ureteroscopy if there are long intervals of time between cases, as this can negatively impact their proficiency. Flexible ureteroscopy, in particular, is challenging for urologists without experience in the technique and can lead to disorientation and poor visualization of stones. It is important for urologists to exercise extreme caution when using semi-rigid ureteroscopy in the upper ureter, where flexible ureteroscopy may be better suited. A lack of experience with flexible ureteroscopy may lead some urologists to improperly use semi-rigid ureteroscopy in the proximal ureter.

Other Top Risks

While surgical ureter injuries account for a significant amount of claims among urologists according to our data, we’ve identified several other drivers of loss based on claims frequency:

Risk Drivers by Top Cause

Risk Drivers by Frequency

Data Collection & Methodology

Data is based on MagMutual closed claims from 2011-2021 and corresponding exposure data. Clinical and non-clinical loss drivers are based on an in-depth review of each claim by a medical professional or clinical risk consultant. Risk reduction strategies are based on input from practicing physicians.