title: Total ureteral avulsion leading to early nephrectomy as a rare complication of simple lumbar discectomy; a case report.
abstract: BACKGROUND
  Lumbar discectomy constitutes the most common and probably easiest spine surgery but it is not without complications. The aim of this work is to report a case with total ureteral avulsion during lumbar discectomy due to careless advancement of the pituitary rongeur.
  
  
  METHODS
  A 59-year-old male presented with refractory left L5-S1 lumbar disc herniation. During the surgery, left sided total ureteral avulsion occurred. Early postoperative progressive abdominal pain was the main clue for further investigation and diagnostic work-up.
  
  
  RESULTS
  Abdominal ultrasonography, intravenous pyelography, and abdominal contrast-enhanced computed tomography (CT) detected a left ureteral injury. Although the injury was detected early, ureteral repair or renal autotransplantation was not possible and nephrectomy was finally indicated, due to a significant ureteral loss.
  
  
  CONCLUSIONS
  Careful use of discectomy instruments, avoidance of excessive advancement of pituitary rongeurs (more than 3 cm), and thorough knowledge of the relevant anatomy are critical in preventing ureteral injury.
authors.affiliation: Associate Professor of Orthopedic, Fellowship of Spine Surgery, MD, Orthopedic Department, Orthopedic Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences Mashhad Iran.
authors.forename: Farzad
authors.initials: F
authors.lastname: Omidi-Kashani
authors.affiliation: Orthopedic Resident, Orthopedic Department, Orthopedic Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences Mashhad Iran.
authors.forename: Seyed Mahdi
authors.initials: SM
authors.lastname: Mousavi
keywords: Complication; Discectomy; Lumbar disc disease; Nephrectomy; Ureter