534 Central European Journal of

O R I G I N A L P A P E R TRAUMA AND RECONSTRUCTIVE UROLOGY A multidisciplinary approach to urinary system iatrogenic injuries Vladimir Beloborodov1, Vladimir Vorobev1, Igor Golub1, Aleksandr Frolov1, Elena Kelchevskaya1, Darizhab Tsoktoev1, Tatyana Maksikova2

1Department of General and , Irkutsk State Medical University, Irkutsk, Russian Federation 2Department of Propedeutics of Internal Diseases, Irkutsk State Medical University, Irkutsk, Russian Federation

Citation: Beloborodov V, Vorobev V, Golub I, et al. A multidisciplinary approach to urinary system iatrogenic injuries. Cent European J Urol. 2020; 73: 534-543.

Article history Introduction Urinary system iatrogenic injuries appear because of urological, obstetric-gynecological, Submitted: June 3, 2020 and surgical manipulations in the retroperitoneal space, pelvis, or perineum. The purpose of this research Accepted: Nov. 24, 2020 was to analyze and obtain knowledge about the issue of iatrogenic injuries, to apply injury prevention Published online: Dec. 14, 2020 algorithms, and to assess multidisciplinary perspectives in modern surgery. Material and methods The research was interdisciplinary and consisted of several modules: a prospec- tive, single-centre study of urinary system iatrogenic injuries (476 patients) along with four interregional and international procedural types of research. Results The analysis results indicate an extremely high significance of urinary system injuries evoking nu- merous negative consequences that are hard to eliminate. A comparative assessment of interdisciplinary interaction demonstrates the more effective interpretation of examination results, more comprehensive and credible clinical diagnosis, more qualitative evaluation of a patient’s condition, more effective choice Corresponding author of initial treatment policy, and more satisfactory treatment in patients’ opinion. The research allowed Vladimir Vorobev for the identification of a typical procedural mistake in the urethral catheter setting causing a high risk 1 Krasnogo Vosstaniya of urethra injuries followed by urethra strictures or consecutive infections of the urinary tract. Street Conclusions More complicated treatment procedures cause a higher probability of urinary system iatro- 664003 Irkutsk, Russian Federation genic injuries. The absence of unified algorithms and typical procedural mistakes cause such incidents. phone: +7 950 054 3210 A partial solution to this issue could be found in a more profound interdisciplinary interaction in all treat- [email protected] ment phases as well as in identifying and eliminating procedural mistakes.

Key Words: kidney iatrogenic injury ‹› ureter iatrogenic injury ‹› urethra iatrogenic injury ‹› urinary bladder iatrogenic injury ‹› urinary system iatrogenic injury

INTRODUCTION implies a broad discussion of medical cases or joint treatment, including surgical manipulations. It is Urinary system iatrogenic injuries include ureter, not new for urologists to interact with oncologists, urinary bladder, urinary tract, and kidneys injuries. radiologists, gynecologists, proctologists, and other It is widely thought that the main reasons for such specialists [4, 5]. In some cases, multidisciplinarity injuries are urological, obstetric-gynecologic, and reflects a lack of general knowledge when interact- surgical manipulations involving the retroperitoneal ing specialties in isolation do not study the stated space, pelvis, or perineum [1, 2]. issue (, pelvic surgery) [6]. Analysis of literature data on urinary system iat- In the era of rapid progress, approaches to multidis- rogenic injuries allows for the making of some con- ciplinary medical help are changing [7]. A modern clusions. Firstly, the issue is properly studied and clinician is hardly able to make a complicated math- analyzed [2, 3]. A classic multidisciplinary approach ematical and statistical analysis of research results

Cent European J Urol. 2020; 73: 534-543 doi: 10.5173/ceju.2020.0153 535 Central European Journal of Urology on his or her own – it is more efficient to use the ser- ria was carried out prospectively by the continuous vice of statisticians, special software, and/or artificial sampling method. intelligence [7, 8]. During the research, 615 patients had iatrogenic One of the outstanding branches of interdisciplin- injuries of the urinary system. The research inclu- ary science is tissue-engineered surgery [9], when sion criteria fit 476 patients. All included patients a team of interacting biologists, urologists, chemists, received conservative or surgical treatment. morphologists, biotechnologists work for a collective Out of 476 patients initially included in the research, goal. 247 were subsequently excluded: 211 patients Modern multi-layer spiral computed tomography dropped out due to deviations from the study proto- (MSCT) equipment allows doctors to get highly de- col, and 36 due to personal reasons. tailed 3D models of internal organs and pathological The inclusion criteria were: processes. Nowadays it is hard to imagine planning – Confirmed acute iatrogenic injury of one of these a kidney resection concerning the malignant tumor organs (kidney, ureter, bladder, urethra); without a 3D model showing vessels, the kidney col- – The patient had complications after the previous lecting system, and surrounding organs [10, 11]. injury to one of these organs (kidney, ureter, blad- Making a high-quality model requires concerted ef- der, urethra); forts from a urologist, radiologist, IT specialist, and – The patient is over 18 years old; the use of special software. A model can be printed – The patient signed a voluntary informed agree- with a 3D printing station and used for rehearsing ment to participate in the study. operation steps and team interaction [11, 12]. A more The exclusion criteria were: extensive, though the not less important, applica- – Absence of convincing data for the iatrogenic na- tion of 3D printing is caused by making consumables ture of the injury; (stents, catheters, etc.) considering an individual pa- – The patient did not sign a voluntary informed tient’s anatomic features [13, 14]. agreement to participate in the study; The basis of multidisciplinary interaction is an edu- – The patient refused to participate at any stage cational program which should consist of modules of the research; delivered by different departments helping a student – Due to any reason, the patient did not complete during one semester get mutually supportive infor- the planned examination and treatment. mation letting to make an overall pattern of a normal The research has the following endpoints: or pathological process, a disease function, and prog- – The primary ‘solid’ endpoint is the examination ress, and to develop true critical thinking [6, 8, 15]. not earlier than three months after treatment The current review of urinary tract iatrogenic inju- and detected relapse at any stage of the postop- ries and multidisciplinary interaction issues has re- erative observation. sulted in setting the following goal: to analyze and – The secondary ‘soft’ endpoints are signs of a com- gain knowledge about the current condition of the plication as a result of iatrogenic injury and com- issue of iatrogenic injuries, to apply preventive mea- plication relapse after treatment. sures algorithms and to assess multidisciplinarity The research incorporated anamnestic, clinical, bio- perspectives in modern surgery. chemical, radiological, ultrasound, magnetic reso- nance, and endoscopic methods. An anamnestic MATERIAL AND METHODS method allows for establishing the possible cause and duration of the disease. The research was comprehensive and consists of sev- Laboratory tests included clinical analysis of blood eral modules. and urine, determination of total protein, blood A prospective, single-centre study of urinary system sugar, creatinine, urea, bilirubin, amylase and trans- iatrogenic injuries (partially presented) was per- aminase activity, and water-electrolyte balance formed in the urological hospital Irkutsk city clini- in the blood. All patients underwent bacteriologi- cal hospital Nº1. The clinical part of the research cal urine test, electrocardiography, and ultrasound includes an analysis of the examination and treat- of the urinary tract with an assessment of the re- ment results of patients who underwent therapeutic sidual urine volume. Patients estimated the quality measures for urinary system injuries and their com- of life (QoL) by using the self-test standard question- plications from September 2016 to November 2019. naires. Patients recorded complaints, satisfaction The research includes male and female patients, with the state of health, and prescribed treatment. over 18 years old, with an established diagnosis To clarify the nature and degree of pathological of urinary system iatrogenic injuries. The selection changes, examination included uroflowmetry, ure- of patients for the study who fit the inclusion crite- throcystography, urethrocystoscopy, ureterorenos- 536 Central European Journal of Urology copy, MSCT, or magnetic resonance imaging (MRI) Federation participated in the examination study of the urinary system with or without contrast (due on knowledge of the urinary system's topographic to any contraindications) with 3D image reconstruc- anatomy and signs of injuries. From October to No- tion for the final verification of the diagnosis. vember 2019, doctors of various specialties took part Three months after the treatment all patients were in distant survey-testing (in the Russian Federation, recommended follow-up examinations at one-year Germany, Israel, United Arab Emirates, France) intervals according to the established research pro- to identify typical procedural mistakes in bladder tocol: consultation with a urologist, clinical blood catheterization. From September 2016 to November and urine tests, MSCT, or MRI of the urinary sys- 2019, (if it needed, so – 3 team, 20 nurses, 20 doc’s) tem. Also, patients used the QoL scale to assess the analyzed the effectiveness of profound interdisci- subjective quality of life status. plinary interaction in the process of conservative Treatment was prescribed according to clinical and surgical treatment and patients' and doctors’ guidelines. In the case of acute urethral injury, ure- satisfaction with that. throcystoscopy was performed with a urethral cath- The employees of various surgical, therapeutic, neu- eter (recanalization) and prolonged drainage (for rological, and intensive care units voluntarily and a period of 2 weeks to 3 months). In case of com- anonymously participated in an examination study plications (pelvic and perineal urohematoma, para- on the survey and control of the equipment setting urethral abscess, or phlegmon), patients underwent and maintenance of a urethral catheter. The exam cystostomy, revision of the lesion area, and recanali- consisted of an ‘I know / I don't know’ assessment. zation. In cases of the urethral stricture, there were A confidential survey concerning the topographic two treatment methods: for short strictures up to anatomy and signs of damage of the urinary system 10 mm – internal optical urethrotomy (DIVU), for was distributed among doctors of different special- strictures of greater length – anastomotic, magnify- ties involved in of the retroperitoneal space ing, or replacement urethroplasty. and pelvis (general and , purulent In the case of acute bladder injury, depending on its surgery (its special surgical department), gynecol- nature and size, treatment included extended urethral ogy, urology, coloproctology, ). The survey drainage (less than 5 mm) or revision and suturing assessed the knowledge of topographic anatomy nu- of the defect (more than 5 mm). To eliminate urinary ances and understanding of the anatomical orienta- fistulas, reconstructive operations were performed. tion principles of the urinary system. By using the In the case of acute ureter injury (urohematoma, ‘I know / I don't know’ assessment, surgeons de- complete separation of the ureter, partial or complete scribed the anatomical landmarks and topography damage of external intersection, ligation, or ureter of the kidneys (1st question), ureters in the middle necrosis), depending on the nature, length and size and upper thirds (2nd question), ureters in the lower of the injured area, the treatment included ureteral third (3rd question), and the topography of the blad- stenting, revision, and reconstructive surgery. In the der (4th question). An incomplete or inaccurate an- case of complications, one of the methods of recon- swer to any of the four questions referred to a gen- structive surgery was performed. No cases required eral level of ‘I don’t know’. intestinal of the ureter. Also, an online virtual survey (using the Google ap- In the case of acute kidney injury, depending on its plication) concerning the identification of typical nature, the treatment included ureteral stenting, procedural mistakes in catheterization of the urinary nephrostomy, vascular embolization or kidney re- bladder was voluntarily and anonymously completed vision, hemostasis, ligation or restoration of vessel by doctors of various specialties (from the Russian integrity, resection, or nephrectomy. In case of dam- Federation, Germany, Israel, United Arab Emirates, age to the pyelocaliceal system with the development France). The survey consisted of 20 questions, with of infectious complications, paranephritis, and uri- a single or multiple-choice answer, hidden control nary leakage, inspection, and reconstruction of the questions, distracting questions, and without speci- kidney or nephrectomy were performed. fying the primary purpose of the survey to increase The study also included four interregional and in- the reliability of the results. ternational procedural types of research: from Sep- This article presents the most significant parts of the tember 2016 to November 2019, the medical staff studies to highlight the problem of interdisciplinary of several medical institutions in Irkutsk participat- interaction for urinary system iatrogenic injuries. ed in the examination study on the rules for placing The initial data and the results were analyzed using and maintenance of a urethral catheter. From Sep- the STATISTIKA software for Windows 10.0 (Stat- tember 2019 to November 2019, surgeons of vari- soft, Inc, USA), SPSS Statistics 23.0 (IBM, USA), ous specialties from different regions of the Russian and Stata 14.2 (StataCorp, USA). 537 Central European Journal of Urology

RESULTS tients dropped out: 211 due to deviations from the study protocol, and 36 due to personal reasons. Ac- A prospective, single-center study of the urinary cording to the protocol (per-protocol group, PP), system iatrogenic injuries problem continued from 229 patients completed the study. Table 1 presents September 2016 to November 2019. There were the general characteristics of patients in these groups. 615 patients with confirmed urinary system iatro- Presented data analysis showed that the ITT and PP genic injuries. The research inclusion criteria ap- groups are statistically equal in terms of age, gender, plied to 476 patients. All included patients received and the duration of the disease. Patients included in conservative or surgical treatment. the study (ITT) and completed the study (PP) dem- From the group of 476 patients initially included onstrate statistical equality of the ratio for a group in the study (intention-to-treat group, ITT), 247 pa- of kidney and urinary bladder injuries. There was a discrepancy between the number of patients en- rolled in the study (ITT) and completed the study Table 1. The initial parameters in ITT and PP groups of patients (PP) for the ureter injuries group (greater adher- ence) and urethra injuries group (less adherence). ITT PP Parameter P (n = 476) (n = 229) A significant discrepancy appeared between the number of patients included into the study and Average age, years 59.93 ±15.5 58.01 ±15.9 0.900 Gender, male / female ratio, % 74/26 65/35 0.557 The acute injury duration, days 2 (1; 3) 2 (1; 4) 0.694 Table 3. Initial parameters of ITT and PP groups for ureters The ‘overlooked’ iatrogenic 224 (53; 365) 365 (38; 365) 0.826 iatrogenic injury injury duration, days ITT PP QoL, points 4.76 ±0.9 4.84 ±0.8 0.785 Parameter P (n = 68) (n = 60) The acute/overlooked injury 78/22 54/46 0.104 Average age, years 52.4 ±17.5 54.4 ±17.3 0.590 ratio, % Gender, male/female ratio, % 15/85 13/87 0.723 Cases of acute injury, N 371 124 0.005 The acute injury duration, days 3.0 (1; 5) 3.0 (1; 4) 0.671 Cases of overlooked injury, N 105 105 < 0.0001 The ‘overlooked’ iatrogenic Kidney injury, N 54 34 0.247 365 (39; 365) 365 (34.5; 365) 0.668 injury duration, days Ureter injury, N 68 60 0.001 QoL, points 4.7 ±1.0 4.7 ±1.0 0.923 Bladder injury, N 40 23 0.514 Internal ureter injury without 12 7 0.412 Urethral injury, N 314 112 0.027 urohematoma, N Internal ureter injury with ITT – intention-to-treat; PP – per-protocol; QoL – quality of life; N – number 6 4 0.674 urohematoma, periarteritis, N External ureter injury, N 5 5 0.848 Table 2. The initial parameters of ITT and PP groups for iatro- Ureteric strictures, N 45 44 0.973 genic kidney injuries ITT – intention-to-treat; PP – per-protocol; QoL – quality of life; N – number ITT PP Parameter P (n = 54) (n = 34) Average age, years 55.5 ±17.1 59.7 ±17.3 0.304 Table 4. The initial parameters of ITT and PP groups for iatro- genic bladder injuries Gender, male / female ratio, % 62/38 58/42 0.772 ITT PP The acute injury duration, days 1.5 (1; 4) 1.5 (1; 4) 0.907 Parameter P (n = 40) (n = 23) The ‘overlooked’ iatrogenic 62.5 (30; 124) 34 (17; 147) 0.862 Average age, years 64 (54; 72) 50 (34; 77) 0.080 injury duration, days Gender, male/female ratio, % 87/13 76/24 0.522 QoL, points 4.9 ±0.9 5.1 ± 0.7 0.630 The acute injury duration, days 1 (1; 4) 1 (1; 1) 0.135 Acute kidney parenchyma injury, N 21 15 0.754 The ‘overlooked’ iatrogenic Acute renal artery/vein injury, N 3 3 0.581 55 (32; 98) 55 (32; 98) 1.0 injury duration, days Acute pyelocaliceal system injury, N 9 4 0.584 QoL, points 4.6 ± 0.9 4.5 ± 1.1 0.826 Arteriovenous fistulas, 5 3 0.949 Internal bladder injury, N 7 2 0.399 pseudo-aneurysms, N External bladder injury, N 23 12 0.825 Acute pyelonephritis, 16 9 0.810 paranephritis, urinary leakage, N Urinary fistulas, N 10 9 0.395

ITT – intention-to-treat; PP – per-protocol; QoL – quality of life; N –number ITT – intention-to-treat; PP – per-protocol; QoL – quality of life; N – number 538 Central European Journal of Urology patients who completed the study in the group Table 6. The treatment effectiveness of patients with iatrogenic of acute injury (a large percentage of exclusion from kidney injuries the study occurredmdue to various reasons, mainly Complication due to failure to attend the follow-up appointment Type of injury / Treatment Recovery, PP, n / relapse, complications method n (%) within the prescribed period) and full compliance n (%) with participation in the study for patients with Conservative Hematuria 15 12 (80%) 3 (20%) overlooked injuries. All cases of urinary system iatrogenic injuries had Conservative 6 2 (33%) 4 (67%) a significant impact on the quality of life. therapy Subcapsular / Tables 2 to 5 present the characteristics of the pa- Vessel perinephral 1 1 (100%) 0 embolization tients in these subgroups (kidney, ureter, bladder, hematoma urethra injuries) (Table 2). Revision, 3 3 (100%) 0 The cases of acute kidney parenchyma injury or re- hemostasis Conservative nal vessel injury appeared as a result of percutaneous 5 2 (40%) 3 (60%) therapy nephrostomy (PCN) or percutaneous nephrolitho- Pyelonephritis / tripsy (PCNL). Acute kidney collective system injury paranephritis Kidney revision 2 2 (100%) 0 in 3 of 9 (33%) cases were caused by PCN or PCNL, Nephrectomy 1 1 (100%) 0 and in 6 cases (67%) – by kidney stenting (Table 3). Stenting 4 2 (50%) 2 (50%) All cases of internal ureter injury were a result Urinary flow Revision, suturing 2 2 (100%) 0 of ureteroscopy and intraoperative detection allowed of a defect for the timely insertion of a drainage stent in order Conservative 3 0 3 (100%) to avoid the development of urogematom (Table 4). therapy Three cases (42.8%) of internal bladder injury were Arteriovenous fistulas, Embolization 3 1 (33%) 1 (33%) the result of impaired placement of a urethral cath- pseudoaneurysms Kidney resection 1 1 (100%) 0 eter and 4 cases (57.2%) developed due to transure- thral resection of bladder tumors (Table 5). Nephrectomy 1 1 (100%) 0 The development of urethrorrhagia was caused by PP – per-protocol; n – number; y – years incorrect urethral catheter implantation technique in all cases. Table 7. The treatment effectiveness of patients with iatrogenic ureters injuries Table 5. The initial parameters of ITT and PP groups for urethra Complication Type of injury / Recovery, iatrogenic injuries Treatment method PP, n / relapse, complications n (%) n (%) ITT PP Parameter P Conservative therapy (n = 314) (n = 112) Hematuria 7 7 (100%) 0 + stenting Average age, years 60.8 ±14.3 61.1 ±14.7 0.907 Pyelonephritis \ Conservative therapy 6 6 (100%) 0 Gender, male/female ratio, % 99/1 99/1 1.0 ureteritis + stenting The acute injury duration, days 1.0 (1; 1) 1.0 (1; 1) 1.0 Stenting 4 2 (50%) 2 (50%) The ‘overlooked’ iatrogenic Urohematoma Revision, suturing of 2 (1; 9) 2 (1; 8) 0.657 2 2 (100%) 0 injury duration, days a defect QoL, points 4.6 ±0.9 4.5 ±0.8 0.494 External ureter Defect stenting and 5 5 (100%) 0 IPSS before injury, points 28.2 ±4.5 28.8 ±4.3 0.391 injury suturing IIEF5 before injury, points 12 (5; 14) 11.5 (5; 14) 0.736 Direct anastomosis 2 2 (100%) 0 Renal pelvis grafting 2 2 (100%) 0 Traumatic catheterization, 168 12 <0.0001 Upper ureter urethrorrhagia, N Ureterocalycostomy 4 4 (100%) 0 stricture Injury after transurethral 18 3 0.219 Nephrectomy 2 2 (100%) 0 operations, N Nephrostomy 2 2 (100%) 0 External urethral injury during 14 12 0.027 pelvic organs operations, N Direct anastomosis 2 1 (50%) 1 (50%) Ureteral Reimplantation 12 10 (83%) 2 (17%) Urethral fistula, N 7 7 0.049 stricture of the middle Boari operation 14 12 (85.7%) 2 (14.3%) Urethral strictures, N 107 78 0.786 and lower third Nephrostomy 4 2 (50%) 2 (50%) ITT – intention-to-treat; PP – per-protocol; P – p-value ; n/N – number QoL – quality of life PP – per-protocol; n – number 539 Central European Journal of Urology

All of the per-protocol patients were included Table 8. The treatment effectiveness of patients with iatrogenic in the examination and treatment results analysis. bladder injuries The study contains an indicative analysis of treat- Complication Type of damage Recovery, ment effectiveness depending on the method of pri- Treatment method PP, n / relapse, / complications n (%) mary treatment with an indication of the frequency n (%) of any significant complications occurrence of disease Perforation less Prolonged urethral 2 2 (100%) 0 relapses. Tables 6 to 9 present the results (Table 6). than 5 mm drainage The results of the analysis indicate significance Perforation Revision, suturing of the complications of iatrogenic kidney injury, which more than 12 12 (100%) 0 of a defect resulted in a large number of cases requiring surgical 5 mm treatment with possible loss of an organ (Table 7). Reconstructive Bladder fistula 9 6 (67%) 3 (33%) The results of the analysis indicate the high efficien- surgery cy of conservative treatment tactics and reconstruc- tive operations of the ureters, which allow for the PP – per-protocol; n – number achievement of recovery in most cases (Table 8). The results of the analysis indicate the high efficien- Table 9. The treatment effectiveness of patients with iatrogenic cy of the treatment tactics recommended for blad- urethra injuries der perforations, however, the issue of bladder fistula Complication Type of damage Recovery, is still not completely resolved (Table 9). Treatment method PP, n / relapse, / complications n (%) The results of the analysis indicate the extremely n (%) high impact of urethral injuries, leading to many Urethral inter- Prolonged urethral 15 4 (27%) 11 (73%) negative consequences, the elimination of which nal trauma drainage seems to be a difficult task. External Revision, suturing 12 4 (33%) 8 (67%) To evaluate the effectiveness of multidisciplinary in- urethra trauma of a defect teraction, some patients participated in a procedural Reconstructive Urethral fistula 7 4 (57%) 3 (43%) experiment (double-blind, randomized participation) surgery of interdisciplinary interaction. The treatment re- Urethral sults are presented by comparing two groups – the strictures, DIVU 32 14 (43.7%) 18 (56.3%) standard treatment group (ST) and the interdisci- less than 5 mm plinary interaction group (MD). Table 10 presents in length these comparative results. Evaluation of satisfaction Urethral strictures, Urethroplasty 46 40 (86.9%) 6 (13.1%) with the treatment was performed by the method more than 5 mm of subjective assessment (1 point – poor, 5 points in length – excellent) (Table 10). The comparative assessment of interdisciplinary in- PP – per-protocol; DIVU – direct vision internal urethrotomy; n – number teraction demonstrated a significantly more effective interpretation of the examination results, a more Table 10. Examination and treatment results of ST and MD complete and accurate clinical diagnosis, a better as- groups sessment of the patient's condition, a more effective ST MD Parameter P selection of primary treatment tactics, and greater (n = 190) (n = 39) satisfaction with the treatment by the patients. Erroneous, incomplete 32 (16.8%) 1 (2.5%) 0.036 The survey of knowledge of the urinary system topo- or inaccurate diagnosis, % graphic anatomy and signs of damage using ‘I know / Incorrect assessment 45 (23.6%) 2 (5%) 0.024 I don't know’ format was passed by 49 doctors of vari- of the disease severity, % ous specialties. An incomplete aswer to any of the four Incorrect or incomplete questions was interpreted as ‘I don’t know’. Figure 1 interpretation of the survey 76 (40%) 3 (7.6%) 0.003 reflects the results. results, % This study demonstrated a high level of understanding Successful primary treatment 72 (37.8%) 2 (5%) 0.001 of the topographic anatomy nuances among doctors of tactics, % all specialties, which means that iatrogenic injuries are Satisfaction with treatment, 3.2± 1.0 4.5 ±0.5 0.021 not the consequences of lack of knowledge, but come patient, score from procedural irregularities in clinical situations. Satisfaction with treatment, 3.9 ±0.7 4.5 ±0.5 0.087 The online-survey testing on common procedural doctor, score mistakes during bladder catheterization taken by ST – standard treatment group; MD – interdisciplinary interaction group; of various specialties (from the Russian n – number; P – value 540 Central European Journal of Urology

Figure 3. The bladder catheterization algorithms and urethral Figure 1. The urinary system topographic anatomy knowledge catheter maintenance study among doctors. examination.

Figure 2. The study results on typical procedural mistakes Figure 4. The bladder catheterization algorithms and urethral of bladder catheterization. catheter maintenance study among nurses.

Federation, Germany, Israel, UAE, and Korea) dem- [16, 17]. Indirect damage, for example, can lead to onstrated a contradictory result (Figure 2). interventions and incidents in the vascular system The survey study among medical staff concerning the (stenting, prosthetics, occlusion, and embolism) and technique of catheter placement and maintenance the central and peripheral nervous systems (spinal also showed conflicting results. Figures 3 and 4 pres- surgery, installation of neurostimulators, etc.). Uri- ent the results of knowledge and adherence to the al- nary tract infection associated with medical care plays gorithm's assessment from 20 nurses and 20 doctors. an important role [18]. Thus, the above results (Figures 2 to 4) identified the The increasing number of iatrogenic injuries has typical procedural mistake in the urethral catheter brought special attention to their prevention and sub- placement algorithm, which leads to a high risk of ure- sequent treatment [19]. Preventive procedures include thra injuries with the subsequent development of ure- identifying errors in the execution of typical proce- thral strictures or urinary tract secondary infection. dures, explicit and hidden, which can cause iatrogenic injuries [16, 17]. For example, excessive performing of DISCUSSION transurethral surgery, lack of periodic lubrication, and exceeding the recommended duration of a procedure The purpose of this research was to analyze obtain contributes to damage due to leakage and mechanical knowledge about the problem of urinary system friction of the instrument in the urethra [20]. iatrogenic injuries, to apply injury prevention algo- Specialists should train to focus not only on the rithms and to evaluate the prospects of interdiscipli- treatment but also on the diagnosis of complications narity in modern surgical practice. in the treatment of non-urological diseases. Obstetri- Damage to the urinary system can be direct or indi- cians, gynecologists, proctologists, surgeons, radiolo- rect, which leads to a complete or partial loss of func- gists, and other specialists should learn the nuances tion (due to denervation, devascularization, forma- of anatomy, the peculiarities of the unintentional tion of scar contractures or pathological bends, etc.) trauma mechanisms, and diagnostic techniques for 541 Central European Journal of Urology screening them. Such training will reduce the num- The contribution of operations from related disci- ber of ‘overlooked’ iatrogenic injuries [21]. All relat- plines is minimal. On the opposite side, most of the ed specialties should know measures and techniques strictures (96%) and damage to the ureter arose be- to reduce the risk of injury [19]. For example, the use cause of bowel surgery, obstetric-gynecological op- of light indication (luminous catheters and stents erations, vascular interventions, or external beam [22]), tissue-organ mock-ups for working out the [27]. A similar situation was with course of the operation, or complex assistance of ar- damage to the bladder and the urethra. However, tificial intelligence, augmented reality [23]. these occur due to typical procedural er- Assessment of iatrogenic injuries is consistent with rors (medical: during endourological surgery – the global trends – traumatic medical procedures lead bladder resections, adenoidectomies or prostatec- to the patient’s decline in quality of life, there is tomies; medical surgeries: traumatic catheteriza- a risk of incomplete recovery of the urinary system tion of the bladder), which indicates a defect in the functioning even with the correct treatment tactics, algorithms of work (typical procedural errors) and as well as the risk of irreversible organ loss or the non-compliance with safety regulations. External development of chronic disease [1]. The increasing injuries in all cases were the results of the work complexity of medical procedures does not reduce of coloproctologists, gynecologists, and surgeons. the risk of iatrogenic injuries [24]. The more medical These results highlight the critical importance knowledge is accumulated and the academic inter- of multidisciplinary interaction in all operations. action develops, the clearer becomes the importance Any large surgical center should have a competent of even minor incidents. An incorrect interpretation urologist who can promptly identify and eliminate of simple bladder catheterization complications can iatrogenic lesions, or prevent them in the preopera- lead to serious consequences for the patient’s health tive period (participating in the diagnosis [28], and [25]. In terms of long-term effects, the most signif- performing prophylaxis, for example, catheterizing icant injuries concern the urethra, and to a lesser the kidneys with luminous stents-catheters [22]) extent, kidneys, and bladder. Ureter injuries mostly or intraoperative period (participating in the opera- can be successfully treated [2, 26]. tion) [29]. The problem of a multidisciplinary ap- This study has shown several important results. proach becomes especially urgent in terms of treat- First, adherence to treat patients with iatrogenic in- ment, which often requires multiple interventions juries of the kidney, ureter, and bladder (P >0.05) and long-term rehabilitation. We consider it expedi- was significantly higher than adherence in patients ent to introduce the principles of a multidisciplinary with urethral injuries. Probably, this ratio is due to approach and principles of teamwork of related spe- more significant and early manifesting consequences cialists at the training stage [30]. Therefore, a multi- of iatrogenic injury of the kidney, ureters, and blad- disciplinary team should perform the training, which der than with damage to the urethra. For example, correlates with other researchers [31]. the formation of a urethral stricture is possible The present study also evaluated the effectiveness weeks or months after the patient left the hospital, of multidisciplinary interaction in individual groups and urinary leaks and hematomas are a significant (standard treatment, 190 patients; multidisciplinary consequence, detected during the period of hospital- approach, 39 patients; with P kidney in all aspects ization. Also, a possible reason is a typical diagnos- of the assessment not more than 0.036), which dem- tic collision, when it is not always possible to timely onstrated excellent results of such teamwork. identify a urethral stricture at the outpatient stage An attempt to identify the causes of iatrogenic injuries (obstructive symptoms are misinterpreted by spe- using the example of bladder catheterization showed cialists, leading to suspicions of BPH), in contrast no significant contribution from the medical person- to ureteral strictures (since hydronephrosis is an ob- nel education; however, the correct execution of pro- vious problem that is easily detected by ultrasound). cedures demonstrated a great influence, which also At the same time, patients with neglected injuries correlates with the other researchers' results [30]. were more adherent to treatment, probably due The assessment of the understanding of the uri- to their greater importance for the patient's health. nary system organs topographic anatomy features Many previously described studies [16, 17] named and the risks of their injury, the typical procedural urological percutaneous interventions as the main mistakes, as well as the observance of medical in- source of kidney damage in modern clinical practice tervention algorithms established the main sources (nephrostomy, nephrolapaxia (percutaneous neph- of iatrogenic injuries: typical procedural mistakes rolithotomy), or endourological manipulations and [32], the violation of injuries prevention algo- operations (stenting, ureteroscopy), open or lapa- rithms [24] as well as complex clinical situations roscopic operations (kidney resection and others). with problematic anatomical orientation and a risk 542 Central European Journal of Urology of accidental damage to the urinary system organs genic injuries showed the highest significance and [33]. The wide geography of the study participants effectiveness of this approach. The study highlighted demonstrates the universal nature of the problem. such parameters as inaccurate or incorrect diagnosis There are no strict standardized clinical algorithms (p = 0.036), incorrect assessment of the disease se- and recommendations for typical procedures. Thus, verity (p = 0.024), incomplete or incorrect interpre- it is important to study the procedural complications tation of examination results (p = 0.003), successful problems, and to develop, and implement common primary treatment tactics in eliminating iatrogenic algorithms for typical procedures. complications (p = 0.001), patient’s satisfaction with treatment (p = 0.021). We consider it expedient CONCLUSIONS to widely implement this approach in medical care.

Interdisciplinary interaction in the prevention and Conflicts of interest treatment of patients with urinary system iatro- The authors declare no conflicts of interest.

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