Ureteral Avulsion During Contemporary Ureteroscopic Stone Management: “The Scabbard Avulsion”

Ureteral avulsion during ureteroscopic stone management is extremely rare. To date, many publications reporting avulsion have been associated with "blind basket extraction" under fluoroscopy and the use of the Dormia stone basket. Fortunately, despite the significant rise in the numbers of ureteroscopic cases being performed, the rate of ureteral avulsion remains low. This is likely in part because of improvements in ureteroscope technology and stone manipulation devices. We present three recent cases of ureteral avulsion referred to our center for further management. To our knowledge, these cases represent the first published description of avulsion where the ureteroscope became wedged in the intramural ureter, resulting in full-length avulsion of the ureter. The avulsion occurs both proximally and distally with a resultant length of ureter left attached to the ureteroscope. We dub this mechanism the "scabbard" avulsion. We describe the most likely mechanism of this injury, with suggestions on how to prevent it and how to release the ureteroscope should it become wedged in the intramural ureter.