Current Strategies to Prevent Iatrogenic Ureteral Injury During Colorectal Surgery

Iatrogenic ureteral injuries are a source of major concern among surgeons performing colorectal procedures. Although they are uncommon, these lesions lead to severe morbidity and long-term functional disabilities, as well as an increase in mortality, hospital stay, and cost. The laparoscopic approach has gained popularity in the field of colorectal surgery and is associated with improved global postoperative outcomes. However, it is also considered to increase the risk of ureteral injury when compared to open surgery, especially during left colonic and rectal resections. To overcome these difficulties, surgical techniques have been improved over time through standardization of both open and laparoscopic procedures. However, these techniques are not infallible, and, in difficult cases, instrumental aids such as preoperative ureteral stenting may be used. To substitute the reduced haptic feedback in laparoscopic surgery, lighted stents have been developed. Unfortunately, prophylactic stenting, whether standard or lighted, is also associated with its own morbidity and its benefit-risk ratio remains highly controversial. To enhance the surgeon's visualization capabilities, augmented reality technologies have been developed. Near-infrared fluorescence and hyperspectral imaging are two promising techniques, which have been tested both in the preclinical and clinical settings. Early results show that these technologies could improve our ability to identify and protect the ureters, although technical limitations remain to be solved. Reviewing the current literature, this article aims to evaluate pre- and intraoperative techniques to identify the ureters and potentially to avoid iatrogenic injury. In addition, future trends are explored.