Damage of the ureter during colorectal surgery is a known complication which fortunately happens in less than 1% of colectomies [124-126]. While in oncological patients, proximal injuries occur mainly on the left side during isolation and high ligation of the inferior mesenteric artery, in patients with IBD, these lesions are more frequent on the right side and are mainly related to ileocolic CD with extensive retroperitoneal inflammation or fibrosis [19,64].
Distal injuries can occur on both sites during proctectomy. The more risky areas are the lateral rectal ligaments and the plane between the rectum and seminal vesicles . The key to preventing injury is knowledge of the anatomy, early identification of the ureter and anterior rectal dissection preserving the Denonvillier's fascia . Prophylactic catheterisa-tion may be useful in selected cases, although it does not assure the prevention of transmural lesions and it has become associated with a risk of injury .
When damage is recognised at the time of surgery, repair over a catheter is indicated. Proximal injuries can be managed with direct end-to-end anastomosis, while distal injuries often require ureteroneocys-tostomy. Other options like creation of an anterior bladder flap (Boari flap), transureteroureterostomy and neocreation of the ureter with a segment of ileum are rarely necessary . However, up to 70% of injuries are not immediately recognised . Missed lesions should be suspected postoperatively in the presence of flank pain associated with fever and paralytic ileus. In this case, initial management is provided by endoscopic positioning of ureteral stent or nephrostomy. If the patient's conditions and renal function are impaired, reconstruction may not be indicated and nephrectomy may be the procedure of choice [129,130].
Male impotence and infertility is another possible side effect of medical therapy, especially during treatment with sulphasalazine [138-140]. This fact has also been noticed in a survey that compared the quality of life between patients with ulcerative colitis treated medically and patients who had received a restorative proctocolectomy; utilising specific questionnaires, it emerged that 26% of patients under medical therapy suffered from impotence and another 16% reported regular failure of ejaculation, while these problems were present in only 8% of those who underwent surgery . However, in most cases discontinuation or changing of the drug is sufficient to return to normality [138,139].
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