E-ISSN : 2757-7163
Materials and Methods: In this retrospective analysis, 23 patients who experienced iatrogenic distal ureteral injuries underwent repair using the modified Lich–Gregoir technique from January 2021 to January 2025. The preoperative evaluation included tests such as serum creatinine, urinalysis, renal ultrasound, and cross-sectional imaging, with selective use of retrograde pyelography or renal scintigraphy. Surgical outcomes were measured by examining ureteral patency, renal function, operative details, and complications, which were categorized using the Clavien–Dindo classification. Patient-reported outcomes were assessed through the Patient Global Impression of Change (PGI-C) scale.
Results: The study included 11 men and 12 women, with a median age of 44 years. Gynecological surgery was the leading cause of injury, accounting for 52.2%, followed by urological surgery at 39.1%, and colorectal surgery at 8.7%. The median duration of surgery was 150 minutes, and patients typically stayed in the hospital for 4 days. A psoas hitch procedure was conducted in 3 patients, representing 13.0% of the group. The median follow-up period was 22 months. All patients (100%) experienced successful surgical outcomes. Complications were noted in two patients, with each experiencing a urinary tract infection and a wound infection, both at a rate of 4.3%. Based on PGI-C scores, 95.7% of patients felt "very much improved," while 4.3% reported being "much improved."
Conclusion: The Lich–Gregoir ureteroneocystostomy, when modified, offers a reliable, safe, and effective surgical solution for treating injuries to the distal ureter caused by medical procedures.
Definitive management of distal ureteral injuries typically requires surgical reconstruction to restore urinary continuity and preserve renal function. Ureteroneocystostomy is the most widely accepted approach, with several techniques described, including the Politano–Leadbetter and the extravesical Lich– Gregoir methods [4]. The Lich–Gregoir technique, originally developed for anti-reflux ureteral reimplantation, has become popular due to its relative technical simplicity, shorter operative time, and low complication profile [5].
Over time, several modifications of the Lich–Gregoir technique have been introduced to optimize outcomes, especially in complex or reoperative settings. The extravesical approach minimizes bladder dissection and avoids extensive intravesical manipulation, which can be advantageous in patients with iatrogenic injuries after major pelvic surgery. However, the evidence specifically addressing the role of the modified Lich–Gregoir technique in adult iatrogenic distal ureteral injuries remains scarce. Most previous reports have either pooled various etiologies or focused primarily on pediatric or reflux populations [6,7].
The objective of this study was to assess the surgical and functional outcomes of repairing iatrogenic injuries to the distal ureter using the modified Lich–Gregoir ureteroneocystostomy technique, with a focus on perioperative factors, complication rates, and long-term functional outcomes.
Inclusion criteria were: a confirmed iatrogenic injury involving the distal third of the ureter, repair performed using the modified Lich–Gregoir technique. Exclusion criteria included malignant ureteral injuries, bilateral involvement, prior ureteral reconstruction on the affected side, and concomitant bladder pathology requiring alternative reconstruction.
All patients underwent standardized assessment, including physical examination, serum creatinine measurement, and urinalysis. The diagnosis of ureteral injury was established based on clinical suspicion (such as persistent flank pain or fever) and confirmed via CT urography or retrograde pyelography. Imaging studies consisted of renal ultrasonography and either computed tomography urography or magnetic resonance urography to define the extent of injury. Retrograde pyelography was performed in selected cases, while renal scintigraphy was used when functional assessment was clinically indicated. In cases of infection or obstruction, appropriate antibiotics and urinary diversion (ureteral stenting or percutaneous nephrostomy) were applied before definitive surgery.
All procedures were performed via an open surgical approach under general anesthesia by experienced reconstructive urologists. After identification and proximal mobilization of the injured ureter, devitalized tissue was excised and a 4.8 Fr double-J stent was inserted. All patients underwent direct ureteroneocystostomy without the need for additional ureteroureterostomy. The bladder was mobilized toward the ipsilateral psoas tendon when required to reduce tension. The modified Lich–Gregoir ureteroneocystostomy consisted of creating a 2–3 cm submucosal tunnel on the bladder dome or lateral wall. The distal ureter was spatulated for 1–1.5 cm, and a mucosa-to-mucosa anastomosis was fashioned with interrupted 5-0 vicryle sutures. A psoas hitch was applied when necessary to achieve a tension-free anastomosis. A perivesical drain and urethral Foley catheter were placed in all patients, with drains removed once minimal output was achieved. The Foley catheter was removed on postoperative day 14. Double-J stent was removed on postoperative week 6.
The primary outcomes were anastomotic patency and preservation of renal function, assessed by ultrasonography or CT urography at 3, 6, and 12 months postoperatively, and annually thereafter. Secondary outcomes included perioperative parameters (operative time, hospital stay), complications (graded by the Clavien–Dindo system), need for secondary intervention, and patient-reported outcomes. Patient satisfaction was assessed using the Patient Global Impression of Change (PGI-C) scale at the latest follow-up. Postoperative evaluation was based on clinical symptoms and imaging. Routine voiding cystourethrography (VCUG) was not performed; however, it was reserved for patients presenting with symptoms suggestive of vesicoureteral reflux, such as recurrent urinary tract infections or flank pain during voiding. Ureteral patency was confirmed by the absence of hydronephrosis or obstructive uropathy on follow-up imaging.
Statistical Analysis
Data analysis was conducted using IBM SPSS Statistics
for Windows, Version 24.0 (IBM Corp., Armonk, NY, USA).
To summarize the data, descriptive statistics were applied:
continuous variables were presented as median and interquartile
range (IQR), while categorical variables were described using
frequencies and percentages. The Wilcoxon signed-rank test
was employed to assess differences in renal function parameters
before and after surgery. A p-value of less than 0.05 was deemed
statistically significant.
Table 1. Demographic and preoperative characteristics of patients
In our study group, every injury (100%) was detected after surgery, with a median diagnosis time of 4 days (IQR: 2–7) following the initial operation. The median duration of surgery was 150 minutes (IQR: 110–205), and patients stayed in the hospital for a median of 4 days (IQR: 4–7). A psoas hitch procedure was necessary for 3 patients (13.0%). The median follow-up period was 22 months (IQR: 8–30). All patients (100%) experienced surgical success, which was defined as maintaining renal function and ureteral openness without needing further surgery. Renal function was preserved in all cases. The median serum creatinine level before surgery was 0.92 mg/dL (IQR: 0.78–1.10), and at the last follow-up, it was 0.88 mg/dL (IQR: 0.75–1.05). There was no statistically significant difference between preoperative and postoperative renal function metrics (p> 0.05) (Table 2).
Table 2. Peroperative and postoperative characteristics of patients
Postoperative morbidity was low. Two patients experienced Clavien–Dindo grade II complications: one urinary tract infection (4.3%) and one wound infection (4.3%), both managed conservatively. The patient with a urinary tract infection was managed with culture-specific antibiotics and remained infection-free during the subsequent follow-up. No major complications or reoperations occurred during follow-up.
Patient-reported outcomes were highly favorable. According to the PGI-C scale, 22 patients (95.7%) reported being "very much improved," while one patient (4.3%) reported being "much improved."
In our series, gynecological surgery was the primary etiology (52.2%), which is consistent with the distribution reported by Gild et al. [2] and Selzman et al. [3]. Our findings reinforce that despite advances in surgical techniques, the distal ureter remains highly vulnerable during major pelvic procedures, particularly in cases recognized postoperatively. Such injuries often remain unrecognized intraoperatively, underscoring the importance of early diagnosis and prompt surgical repair to prevent long-term sequelae such as stricture formation, hydronephrosis, and renal function loss.
A variety of surgical techniques have been described for the reconstruction of distal ureteral injuries, including the Politano– Leadbetter and Lich–Gregoir methods. The technical simplicity of the modified Lich–Gregoir technique, as previously noted by Ahn et al. [4] and Atar et al. [5], was reflected in our median operative time of 150 minutes. Furthermore, the complete preservation of renal function—confirmed by stable median creatinine levels (0.92 vs 0.88 mg/dL) supports the safety of this extravesical approach even in the potentially inflammatory environment of an iatrogenic injury. In our series, the use of a modified Lich–Gregoir technique yielded excellent surgical and functional outcomes. Only two minor postoperative complications; urinary tract infection and superficial wound infection were observed, both of which resolved with conservative management. Notably, no patient required reoperation during the follow-up period, and all reconstructions remained patent and functional.
Our results are comparable to those reported in previous studies. Demirdag et al. demonstrated favorable outcomes with the modified Lich–Gregoir ureteroneocystostomy in iatrogenic distal ureteral injuries, with a high success rate and low complication profile [1]. Similarly, laparoscopic adaptations of this technique, sometimes combined with psoas hitch or Boari flap, have been shown to yield excellent results in benign distal ureteral pathologies [5]. The 100% success rate observed in our study may be attributed to careful patient selection, standardized preoperative evaluation, and performance of surgery by experienced reconstructive urologists.
The present study has several limitations. First, its retrospective design may introduce selection bias. Second, the relatively small sample size limits the generalizability of our findings. While the modified Lich–Gregoir technique is inherently an anti-reflux procedure, a limitation of our study is the lack of routine objective reflux assessment via VCUG. Nevertheless, none of our patients demonstrated clinical symptoms or radiological findings necessitating such invasive testing during the median 22-month follow-up. Third, although our median follow-up duration was 22 months, longer-term outcomes beyond five years are lacking. Finally, the absence of a comparison group prevents direct evaluation of the superiority of this technique over alternative reconstructive methods.
Although there are some limitations, our findings contribute to the increasing evidence that supports the modified Lich– Gregoir ureteroneocystostomy as a reliable, effective, and long-lasting solution for treating iatrogenic distal ureteral injuries. Future prospective research involving larger participant groups and extended follow-up periods is necessary to confirm these results and to compare them with outcomes from other reconstructive methods.
Ethics Committee Approval: This study was approved by the Ethics Committee of Basaksehir Cam and Sakura City Hospital. (Date: 06.08.2025; No: 264).
Informed Consent: Written informed consent was obtained from all patients.
Publication: The results of the study were not published in full or in part in form of abstracts.
Peer-review: Externally peer-reviewed.
Authorship Contributions: Any contribution was not made by any individual not listed as an author. Concept – S.Ş., M.S., Ç.Ş.; Design – S.Ş., M.S., Ç.Ş.; Supervision – S.Ş., R.U., H.L.C.; Resources – M.S., Y.Ç.; Materials – M.S., Y.Ç.; Data Collection and/or Processing – M.S., Ç.Ş., Y.Ç.; Analysis and/ or Interpretation – S.Ş., Ç.Ş., R.U.; Literature Search – Ç.Ş.; Writing Manuscript – Ç.Ş.; Critical Review – S.Ş., M.S., Y.Ç., H.L.C.
Conflict of Interest: The authors declare that they have no conflicts of interest.
Financial Disclosure: The authors declare that this study received no financial support.
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