title: Delayed-onset ureteral lesions due to thermal energy: an emerging condition.
abstract: OBJECTIVE
  To describe the risks of ureteral damage occurring during urological and gynecological procedures utilizing energybased surgical devices (ESD) during both laparoscopic and open procedures.
  
  
  METHODS
  During the last 20 months we observed five cases of iatrogenic ureteral lesions caused by ESD which required open surgery. There were 3 lesions of the lower ureter occurring during gynecological laparoscopic or robotic procedures, and 2 lesions of the upper ureter occurring during open enucleation of low-stage renal cell carcinomas.
  
  
  RESULTS
  In the laparoscopic gynecological lesions the cause was attributable to monopolar cutting and bipolar coagulation: they presented with urine extravasation after 20, 15 and 15 days respectively and required ureteral reimplantation in 2 out of 3 cases. In the upper ureteral lesions the causes were bipolar coagulation and LigaSure Impact TM used for perirenal fat dissection: they presented after 2 and 4 months respectively and required uretero-ureterostomy and inferior nephropexy in one case and nephrectomy in the other. In 3 out of 5 cases there was an unsuccessful attempt at placing an ureteral double J stent, and in the 2 cases where it was placed it did not prevent the formation of subsequent stricture in one.
  
  
  CONCLUSIONS
  The widespread diffusion of ESD has the potential drawback of inadvertent thermal energy transmission to the ureter. Delayed presentation of ureteral lesions and difficulties in ureteral stent placement were the common features of the cases observed. Inadvertent ureteral damage by different thermal energy sources is an emerging condition, requiring awareness, prompt recognition and adequate treatment with the reconstructive urology principles.
authors.affiliation: Department of Urology, University of Pisa. c.selli@med.unipi.it.
authors.forename: Cesare
authors.initials: C
authors.lastname: Selli
authors.forename: Filippo Maria
authors.initials: FM
authors.lastname: Turri
authors.forename: Cristina
authors.initials: C
authors.lastname: Gabellieri
authors.forename: Francesca
authors.initials: F
authors.lastname: Manassero
authors.forename: Maurizio
authors.initials: M
authors.lastname: De Maria
authors.forename: Andrea
authors.initials: A
authors.lastname: Mogorovich
mesh_terms: D002058:Burns, Electric / Q000209:etiology*; D004598:Electrosurgery / Q000009:adverse effects*; D006801:Humans; D013997:Time Factors; D014513:Ureter / Q000293:injuries*