Management strategies and outcomes of iatrogenic ureteral injury according to the timing of diagnosis: a retrospective single-center study

Abstract

Iatrogenic ureteral injury is an uncommon but potentially serious complication of pelvic and abdominal surgery. Management may differ according to whether the injury is recognized intraoperatively or diagnosed after surgery. This study aimed to describe the clinical characteristics, management strategies, and urological outcomes of iatrogenic ureteral injuries according to the timing of diagnosis. We retrospectively reviewed patients with confirmed iatrogenic ureteral injury identified at a single institution between January 2000 and December 2025. Of 35 potentially eligible patients, 12 were excluded because the injury could not be adequately verified or clinically characterized, leaving 23 patients for analysis. Patients were classified according to whether the injury was diagnosed intraoperatively or postoperatively. Patient and injury characteristics, management strategies, and urological outcomes were compared descriptively between groups. Between-group comparisons were considered exploratory because of the small sample size. Sixteen patients were diagnosed intraoperatively and seven postoperatively. Among patients diagnosed postoperatively, the median time from index surgery to diagnosis was 7 days (interquartile range [IQR], 3–28; range, 1–53 days). Nephrostomy was used in 1 of 16 patients (6.3%) in the intraoperative group and 4 of 7 (57.1%) in the postoperative group, whereas ureteral stenting was used in 15 of 16 (93.8%) and 4 of 7 (57.1%), respectively. Definitive repair during the index surgery was performed in 15 of 16 patients (93.8%) diagnosed intraoperatively and in none of the patients diagnosed postoperatively. Three patients in the postoperative group subsequently underwent definitive reconstruction: one underwent ureteroureterostomy and two underwent ureteroneocystostomy with a Boari flap. Median follow-up was 7.7 months (IQR, 3.1–22.2) in the intraoperative group and 26.5 months (IQR, 7.1–41.8) in the postoperative group. An unfavorable final urological outcome was observed in 4 of 14 evaluable patients (28.6%) and 3 of 6 evaluable patients (50.0%), respectively. The management of iatrogenic ureteral injury differed according to the timing of diagnosis in this small retrospective cohort, with intraoperatively recognized injuries more often managed by immediate repair and postoperative injuries more often requiring urinary diversion. No clear difference in urological outcomes was detected between the groups during the available follow-up. Given the small sample size, heterogeneous clinical context, and long study period, these findings should be interpreted as descriptive and exploratory.