Injuries to the ureter during gynaecological operations,


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Injuries to the ureter during gynaecological operations, their prevention and management.:

Dr. Aditi Kishore Shinde Final Year PGT Unit IIA Injuries to the ureter during gynaecological operations, their prevention and management.

Analogy :



MARK TWAIN Courage is the resistance to fear, mastery of fear , not the absence of fear


Outline Introduction. Applied Anatomy. Common sites of injuries. Types of injury Predisposition. Identification of a ureteric injury. Specific injury. Management. Prevention. Clinical Scenarios. Conclusion.

Learning Objective:

Learning Objective Outline functional anatomy. Issues surrounding ureteral injury. Basic principles of injury avoidance, recognition and management.


Incidence 75% ureteric injuries take place during gynaecological procedures .35- .4 % (most unilateral injuries unrecognised ) – 1.79% Simple abdominal Hysterectomy most common procedure. 30% chance of injury during gynaec-oncosurgery .5 – 1% - Abdominal Hysterectomy .1% - Vaginal hysterectomy

Anatomical considerations:

Anatomical considerations

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25 – 30 cm 12- 15 cm

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1.5 cm lateral to cervix at the level of internal os

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Common sites of ureteric injury :

Common sites of ureteric injury 1. Lateral pelvic wall above the uterosacral ligament. 2. Dorsal to the IP ligament at or near the brim. 3. Base of the broad ligament , ureter passes under the uterine artery. 4. Tunnel of W ertheim in the broad ligament. 5. Intramural portion near the insertion into the trigone .

Other sites of ureter injury:

Other sites of ureter injury

*Risk factors for ureteric injuries::

* Risk factors for ureteric injuries: I} Anatomical risk factors ? II} Pathological risk factors ? III} Technical risk factors ?

I} Anatomical risk factors::

I} Anatomical risk factors: The ureter : Has close attachment to the peritoneum. Closely related to FGT. Has variable course. Not easily seen or palpated.

II} Pathological risk factors::

II} Pathological risk factors: 1-Congenital anomalies of ureter or kidney. 2-Ureteric displacement by: -Uterine size ≥12 weeks -Prolapse. -Tumor{ ovarian neoplasms}. -Cervical or broad ligament swellings. 3-Adhesions: -Previous pelvic surgery. -Endometriosis. -PID 4-Distorted pelvic anatomy.

III} Technical risk factors::

III} Technical risk factors: 1- Massive intraoperative hemorrhage. 2-Coexistent bladder injury. 3- Technical difficulties. 4- Inexperienced surgeon.

*Types {Causes} of injury::

* Types {Causes} of injury: Intraoperative Postoperative 1} Crushing from misapplication of a clamp. 2} Ligation with a suture. 3} Transsection (partial or complete). 4} Angulation of the ureter with secondary obstruction. 5} Ischemia from ureteral stripping, LASER, or electrocoagulation. 6} Resection of a segment of ureter. N.B: Any combination of these injuries may occur. 1-Avascular necrosis. 2- kinking . 3-Subsequent obstruction over: - Haematoma ,or - Lymphocele

“ ½ of the the uretric injuries have no identifiable risk factor”:

“ ½ of the the uretric injuries have no identifiable risk factor”


ABDOMINAL Hysterectomy. Wertheim’s hysterectomy. Oophorectomy Uterine suspension Burch colposuspension Vesicovaginal fistula repair. VAGINAL Hysterectomy Anterior colporrhaphy Cervical biopsy Vesicovaginal fistula repair . Culdoplasty LAPROSCOPIC Division of adhesions Transection of uterosacral ligament Colposuspension Treatment of endometriosis Sterilisation (especially electrocoagulation) PROCEDURES ASSOCIATED WITH URETERIC INJURIES

Preventive strategies to reduce the risk of ureteric injuries::

Preventive strategies to reduce the risk of ureteric injuries: I} General Preventive strategies : Preoperative Intraoperative II} Specific Preventive strategies :

I} General Preventive strategies::

I} General Preventive strategies : A} Preoperative measures: 1) Intravenous urogram (IVU). 2) Ultrasound scan . 1,2 can identify ureteric dilatation and disclose anatomical variations. 3) Preoperative stenting in conditions of anatomical distortion. - EBM : No additional reduction in ureteric injuries.

Intraoperative Prevention:

Intraoperative Prevention DICTUM :Surgeon is to constantly and equivocally know where ureter is all times. Appropriate operative approach. Adequate exposure . Avoid blind clamping of blood vessels . Mobilise bladder away from operative site . Stay outside vascular sheath. Zone of thermal injury. Ureteric dissection and direct visualisation

Identification of the ureter.:

Identification of the ureter. The peritoneal reflection anterior to the uterus is incised and the bladder is reflected inferiorly with sharp dissection. The ureter is identified on the medial aspect of the broad ligament during the development of the perivesical and perirectal spaces, as is the superior vesical artery

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Ureteric stenting: No reduction in risk. May aid in intraoperative dectection of uretric injury .


Imaging No proof that pre-operative IVP or CECT reduces risk of injury. Endometriosis, PID and uterovaginal prolapse and previous intra-abdominal surgery not associated with increased prevalence of abnormal IVP findings.

II} Specific Preventive strategies::

II} Specific Preventive strategies : A} During abdominal hysterectomy: - Clamp {Cardinal , Uterosacral } ligaments close to the uterus. - Clamp , divide and ligate uterine vessels close to the uterus. - Clamp infundibulopelvic ligament near to the ovary after dissection and palpation. - Never to open vagina unless urinary bladder is dissected downward and laterally. - Use of intrafacial technique.

II} Specific Preventive strategies::

II} Specific Preventive strategies : B} During vaginal surgery: 1- Prevention of ureteric injuries can be achieved by adequate development of vesico-uterine space, by: -Downward traction on the cervix. -Counter traction upward by Sim’s speculum below the bladder. 2- All clamps: - Small bites. - Close to the uterus. 3- Avoid double clamping of uterosacral ligaments. 4- Vaginal oophorectomy should be avoided or done cautiously. 5-During anterior colporrhphy: -Avoid too lateral dissection. -Avoid deep sutures: as the distance between needle and ureter in upper vagina ≤0.9cm.

II} Specific Preventive strategies::

II} Specific Preventive strategies : C} During laparoscopy: can be achieved by: -Moving the fallopian tubes away from pelvic side walls before coagulation. -The bleeding points at uterosacral ligaments should be secured with sutures or clips instead of electrocoagulation. -In LAVH place stapler or suture across uterine vessels and cardinal ligaments instead of electrocoagulation.

Good Surgical Skills:

Good Surgical Skills

Laparascopic Injuries:

Laparascopic Injuries .3-.4% Thermal injury Delayed diagnosis reduces chances of sucessful repair. M/C : Laparascopic hysterectomy when uterine vessels are stapled and IP transection. Caution : Pelvic side wall and cul de sac.

Complex adenxectomy:

Complex adenxectomy Ureter lies in post leaf of BL medially If Adenexal mass is adherent to medial leaf of broad ligament, ureter is dissected laterally. I nflamed / scarred / fibrotic . Caution : Ligation of ovarian vessels.


A TUBO –OVARIAN ABSCESS FIRMLY ADHERENT TO THE BROAD LIGAMENT Removal of a pyosalpinx / chocolate cyst densely adherent to the peritoneum covering the lateral wall of the pelvis Ovarian cyst or paraovarian cyst burrows extraperitoneally and enfold the ureter Preventive measures: Ureter to be identified well above the cyst Dissected clear of it before any attempt is made to remove the cyst wall Complex adenexectomy - Retroperitoneal approach can be tried

Abdominal Hysterectomy:

Abdominal Hysterectomy High risk situations : Lower uterine or broad ligament fibroid. Bleeding from pedicles and cervico -vaginal angles. If doubt : Ureter is identified at common iliac A and methylene blue dye is instilled with a 21 gauge needle.

PowerPoint Presentation:

BROAD LIGAMENT FIBROID The lower portion of the broad ligament is filled with mass The right ureter usually lies below or to the outer side of the tumor mass To avoid injury to the ureter , the peritoneum on the superior surface of the tumour is incised The tumour is enucleated from within its pseudocapsule Stay close to the pathological tissue

PowerPoint Presentation:

Uretertic fistula may develop after simple TAH if when covering the raw surface of the peritoneum, a stitch is passed through the ureter as it lies immediately beneath the peritoneum on the lateral pelvic wall.

Caesarian Hysterectomy:

Caesarian Hysterectomy Supracervical Hysterectomy. Placement of forefinger into- endocervico -vaginal canal.

Vaginal Hysterectomy:

Vaginal Hysterectomy Concurrent vault fixation with VH increases the risk of ureter injury. Can be prevented by identification of the uterosacral ligaments by palpation in para-vesical space.

Bladder neck suspension:

Bladder neck suspension Injury during retro-pubic repair affects distal ureter. Condition: 1. Dissection of space of Retzius and Peri -urethral tissue. 2. High elevation of Burch colposuspension . 3. Lateral paravaginal defect repaired with Burch. 4.Excessive lateral traction on the bladder brings the ureter into field of operation.


POP Ureter is damaged by direct ligation or kinking from plication of redundant tissue. In Mc -Calls culdoplasty , identification of the US ligaments and traction by allis clamps reduces chance of injury. Cystoscopy with IV indigo-carmine used to check for ureter integrity.

Radical Pelvic Surgery:

Radical Pelvic Surgery Ureteric injury can be intentional or Accidental Intentional : MD Anderson’s type IV Radical Hysterectomy ( pelvic extentration ) : Resection and Re-construction of ureter. Radical Resection following therapeutic radiation , increase risk by 30% Increased rates during vaginal trachealectomy as fertility sparing treatment for FIGO IA and IB.


RADICAL HYSTERECTOMY Injury to the ureter in the tunnel of Wertheim can be minimised by Always free the ureter, leaving it inside its adventitious sheath and associated blood supply from the medial leaf of broad ligament Developing the space of Morrow – a potential space medial to the ureter, cephalad to the entrance to the tunnel Ureteric dissection always outside the sheath

Risk of ureteric injury during pelvic lymph node sampling:

Risk of ureteric injury during pelvic lymph node sampling

“ the venial sin is injury to the ureter, the moral sin is failure of recogntion “:

Higgins “ the venial sin is injury to the ureter, the moral sin is failure of recogntion “

Intraoperative :

Intraoperative Any suspicion should be clarified Promptly identify nature and severity of injury. Look for s/o : obstruction ans de-vascularization. Dye test : Intravenous phenazopyridine HCl , indigocarmine or methylene blue(5ml) , extravasates at the site of injury. ( 3-5 min) Intraoperative Cystoscopy. (non-obstructive, partially obstructive or late injuries due to ischemia and avascular necrosis can be missed) Peri -operative ultrasound using a larascopic probe.

Diagnosis of uretral injury :

Diagnosis of uretral injury INTRAOPERATIVE POSTOPERATIVE Almost half of the ureteric injuries can be prevented out of these half can be detected intraoperatively .

According to the Organ Injury Scaling System developed by the Committee of the American Association for the Surgery of Trauma, :

According to the Organ Injury Scaling System developed by the Committee of the American Association for the Surgery of Trauma, ureteric injuries are classified as follows : - Grade I laceration ; contusion or haematoma without devascularisation - Grade II laceration; < 50% transection - Grade III laceration; ≥50% transection - Grade IV laceration; complete transection with < 2 cm of devascularisation - Grade V laceration; avulsion with > 2 cm of devascularisation.


Sequelae 1. Spontaneous resolution and healing 2. Hydronephrosis and gradual loss of renal function 3. Urinoma / Urinary Ascites , infection in transection or nerosis with urinary extravasation. 4. Fistula formation: ureterovaginal / uretero -uterine or uretero -cutaneous. 5. Stenosis with insidious loss of renal function.


Postoperative Symptoms: Loin or flank pain 0-21 days Fever 0-21 Adynamic ileus/ peritonitis 0-7 Fistulas 0-30 Lower abdominal/Pelvic mass 20-40 Anuria(if bilateral) <24 Asymptomatic Incidental Frank discharge of urine from drain, vagina or abdominal wound.


Investigation WBC count. Urea and electrolytes. Intravenous pyelogram (IVP). Retrograde / antegrade ureterogram . Ultrasound of abdomen and pelvis. CT Scanning. Fistulogram /double dye test. Cystoscopy. Fluid analysis from drains, ascitic collection.


Findings Leukocytosis Transient rise in serum creatinine (-.8mg/dl) Transabdominal ultrasound or CT shows hydroneprosis , urinoma ascites. Cystoscopy: Affected ureter, no spurting of urine from ureteric orifice. Fistula identification

Intravenous urography:

Intravenous urography Gold standard of post-operative diagnosis. Non- visualisation Dilatation. Delayed dye spillage. Peritoneal Extravasation Urinoma


General guidelines Management

Aim of MAnagement:

Aim of MAnagement Preservation of renal function. Anatomical Continuity. Decision Depends on : Time of detection. Extent of injury. Site of injury. General condition of the patient.


Conservative? In small fistulae , no obstruction: monitoring of patient status with serial creatinine values. Patients waiting for definative repair- >5days. If feasible a stent can be placed : via PCN, and fluoroscopic guidance for 6-8 weeks.

When to operate?:

When to operate? If detection of the injuries is within 5 days operate immediately. After 5 days tissue odema , inflammation makes repair difficult and definative surgery is to be planned after 6 weeks. Interim measures to preserve renal funtion , PCN to carried out.


OPERATIVE MANAGEMENT MAJOR INJURY MINOR INJURY Ureteric stent Balloon dilation Open repair Upper Middle Distal Short defect End to end anastomosis Long defects Ureteroileocystostomy Ureteroileal transposition Transureteroureterostomy Auto transplantation Nephrectomy Short defect End to end anastomosis Long defects Re implantation psoas hitch / Boari Flap Uretero Neocystostomy/ Ureteral Reimplantation


PRINCIPLE OF URETERIC REPAIR Meticulous ureteric dissection preserving ureteric sheath with its blood supply Tension –free anastomosis by ureteric mobilisation Use minimum amount of fine absorbable suture to attain a watertight closure Use peritoneum or omentum to surround the anastomosis especially if the peri -ureteric tissue is rigid and fibrotic as better healing of the repair site is achieved Drain the anastomotic site with a closed suction drain to prevent urine accumulation Stent the anastomotic site with ureteric catheter Consider a proximal diversion – diversion of the urinary stream with percutaneous nephrostomy is usually necessary if the defect is large, the ureter has been completely transected or the ureter lies in a bed of inflammation


GENERAL GUIDELINES FOR MANAGEMENT OF URETERAL INJURIES identified at the time of surgery M ucosa sparing wall injury: Oversewing with absorbable suture. Ureteral ligation : Deligation , assessment of viability, stent placement Partial transection : Primary repair over ureteral stent Total transection Uncomplicated upper and middle thirds : Uretero-ureterostomy over ureteral stent Complicated upper and middle thirds : Uretero-ileal interposition Lower third : Uretero-neocystotomy with psoas hitch over ureteral stent Thermal injury : Resection and then management as per a transection

Best repair options:

Best repair options

Operative techniques:

Operative techniques Ureteral ligation : Deligate – Check viability. Partial Urethral transection : Repair with small absorbable interrupted sutures with or without stent. Complete Transection : Mode of repair depends on the level of injury. Upper Middle Lower Complicated or not ?

Uncomplicated Upper and Middle 1/3:

Uncomplicated Upper and Middle 1/3 End to end anastomosis over stent Spatulated Anastomosis

Complicated Upper and Middle 1/3:

Complicated Upper and Middle 1/3 Transuretero-ureterostomy Uretero-ileal interposition e

Lower 1/3rd of the ureter:

Lower 1/3 rd of the ureter Psoas Hitch Boari’s flap : Uretero-neocystostomy

Conditions of carrying out a PCN :

Conditions of carrying out a PCN Upper renal compromise Stent Placement Rapid renal dysfunction Irreversible damage with Pyonephrosis

Clinical Scenario’s :

Clinical Scenario’s

Extensive Bladder injury:

Extensive Bladder injury

Interaoperative ureteral Stenting :

Interaoperative ureteral Stenting

Cervical fibroid:

Cervical fibroid R-P Disssection .

Take home messages:

Take home messages Most ureteric injuries can be prevented by mastering the knowledge of ureteric anatomy. Suspicion and intraoperative detection improves prognosis. Early involvement of urologist in decision making during ureteric repair. Skilled postoperative monitoring helps detect ureteric injury before renal compromise. Lawsuits can be prevented by taking the party into confidance . Ureter-phobia can be overcome only by revisions and re-revisions of your anatomy text book and it’s subsequent application intraop . There is no substitute for a experienced surgical mentor.

Dedicated to unit II A:

Dedicated to unit II A Experience is a hard teacher, she gives the gives the test first and the lesson later - Veronica Law

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