Iatrogenic ureteric injuries after abdominal surgery: a systematic review and meta-regression from the European Association of Urology Endourology Section.

Abstract

To systematically evaluate management strategies and associated outcomes of iatrogenic ureteric injuries, focusing on clinical success, renal unit loss, and the need for subsequent endoscopic or reconstructive procedures. A pre-registered protocol (CRD420251184018) guided a comprehensive search of PubMed and EMBASE databases. Observational studies reporting outcomes of ≥20 patients treated for iatrogenic ureteric injury with complete data on follow-up were included. Risk of bias was assessed using Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I). Random-effects meta-analysis with PLOGIT transformation was applied, stratifying results by treatment type and timing. Meta-regression examined the association of treatment modality with outcomes adjusting for the timing of reconstruction. A total of 30 studies were included (1517 patients), all retrospective and characterised by substantial heterogeneity in definitions and follow-up practices. ROBINS-I indicated serious risk of bias in most domains. The pooled clinical success rate was 87% (95% confidence interval [CI] 80-91%), with high heterogeneity I² = 76.0% due to different follow-up protocols, success outcomes, type and timing of management. Studies dominated by reconstructive procedures (15 studies) had higher success (91%, 95% CI 84-95%), than those primarily using endoscopic techniques (six studies; 66%, 95% CI 58-73%). Renal unit loss occurred in 2.3% (95% CI 1.5-3.6%). No differences in loss of renal unit were found. Additional endoscopic interventions were required in 3% (95% CI 2-4%) and further reconstructive surgery in 5% (95% CI 3-9%). Meta-regression showed endoscopic index management was associated with lower odds of success (odds ratio [OR] 0.14, 95% CI 0.05-0.40) and higher need for further reconstruction (OR 5.64, 95% CI 1.61-19.8). Across retrospective and heterogeneous studies, reconstructive-dominant management of iatrogenic ureteric injuries was associated with higher clinical success compared with endoscopic-dominant approaches, while renal unit loss remained uncommon. Endoscopic management was feasible in selected cases but was more frequently followed by additional endoscopic or reconstructive interventions.