URETERIC INJURYIn

OBGY

Dr Mohit SatodiaGMCH-32

Chandigarh

incidence• 75 % of the ureteric injuries occur during

gynaecological surgeries• Incidence is .3 to .4 %• Most common procedure :total abdominal

hysterectomy(.5 to 1%)• Vaginal hysterectomy(.1%)• Gynae-oncosurgery(30%)

Interesting facts……

• Most common site:-pelvic brim near the infundibulopelvic ligament

• Most common type of injury:-obstruction• Most common activity leading to injury:-

attempts to obtain haemostasis• Most common time of diagonosis:-none• Most common long term sequele:-none

Course of ureter

Blood supply of ureter

Common sites of injury• Lateral pelvic sidewall above the uterosacral

ligament• Dorsal to infundibulopelvic ligament near or at

the pelvic brim• Cardinal ligament• Tunnel of Wertheim• Intramural portion of the ureter

Anatomical risk factors

• Ureter……..1.Has close attachment to peritoneum2.Has variable course3.Not easily seen or palpated.

Pathological risk factors

• Congenital anomalies of ureter or kidney• Ureteric displacement by:

1.Uterine size >/=12 weeks2.Prolapse3.Tumour4.Cervical or broad ligament swellings

• Adhesions1.Previous pelvic surgeries2.Endometriosis3.PID

• Distorted pelvic anatomy

Technical factors

• Massive intraoperative haemorrhage• Coexistant bladder injury• Technical difficulties• Inexperienced surgeon

Types of injuries

• Intraoperative1. Crushing(misapplication of a clamp)2.Ligation(with a suture)3.Angulation(with secondary obstruction)4.Ischaemia(stripping,laser,electrocoagulation)5.Transection(partial or complete)6.Resection

• Post operative1. Avascular necrosis2. Kinking3. Subsequent obstruction over:• Haematoma• Lymphocele

Procedures asso. with ureteric injuries

• Abdominal1. Hysterectomy2. Werthiem’s hysterectomy3. Oopherectomy4. Uterine suspension5. Burch colposuspension6. Vesicovaginal fistula repair

• Vaginal1.Hysterectomy2.Anterior colporrhaphy3.Vesicovaginal fistula repair4.Culdoplasty

• Laparoscopic1. Division of adhesions2. Transection of uteroscral ligaments3. Colposuspension4. Treatment of endometriosis5. Sterilisation(especially with

electrocoagulation)

Preventive strategies

• General preventive strategies1.Preoperative2.Intraoperative

• Specific preventive strategies

General preventive strategies

• Preoperative measures1.Intravenous urogram2.Ultrasound scanIdentify ureteric dilatation and disclose anatomic

variations3.Preop stenting in case of anatomic distortion

• Intraoperative measures1.Appropriate operative approach2.Adequate exposure3.Avoid blind clamping of blood vessals4.Mobilise bladder away from the operative site5.Stay outside the vascular sheath6.Zone of thermal injury7.Dissection should preferably be done under direct

visualisation

• surgeon is to constantly and equivocally know where the ureter is all times

Specific preventive measures

• Laparoscopy associated injuries .3 to .4 % of all the cases More likely result of thermal injury More likely to be diagonosed 2 to 5 days after the

surgery Most commonly during laparoscopic hysterectomy ---when uterine vessals are stapled or electrocoagulated---infundibulopelvic ligament is transected Extreme caution when using cautery or laser near or

over the ureter

• Complex adnexectomy Between pelvic brim to tunnel of werthiem Ureter is commonly injured Injuries can be avoided using retroperitoneum

approach…..advantages:1.Access the pelvic vessals for haemostasis2.Adhesion and pathology free space to operate If an adnexal mass is adherant to the medial half of the broad

ligament or pelvic peritoneum overlying the ureter ,the ureter can be safely dissected laterally from the peritoneum

• Abdominal hysterectomy From where ureter enters tunnel under uterine artery ,lateral to the

uterosacral ligaments,until ureter terminates in the bladder High risk of injury-LUS fibroid or cervical fibroid,protruding into broad ligament-bleeding from pedicals ,esp at the vaginal corners Myomectomy of a broad ligament fibroid should be preferred by incision

adjacent to the ureter and cervix,staying within the myometrial capsule Bleeding from pedicles or vaginal angle should be controlled by a

“superficial”3-0 sutures Intrafascial hysterectomy,by creating a plane within the myometrium of LUS

and cervix after ligating uterine artery vessels Fearful of injury:-21 gauge butterfly needle technique.

• Caesarean hysterectomySupracervical hysterectomyHysterotomy incision can be extended

caudally towards the cervix-allow tactile as well as visual guidance

• Vaginal hysterectomyUncommon because traction on the cervix

pulls the uterus farther from the ureterCuldoplasty places the ureter at riskManeuvres:-1.Palpatory ureteral identification2.Placinng an allis clamp on the vaginal cuff in

the area of uterosacral ligament

• Bladder neck suspensionDuring retropubic repairHow can injury occur/-vigorous dissection of space of retzius and periurethral

tissues-high elevation of burch colposuspension suture-paravaginal defect repair in combination with burch

procedure-excessive lateral mobilisation of the bladder brings ureter

into thhhe operative field

• Pelvic organ prolapserelatively commondue to :1. Direct ligation2. Kinking as redundant tissues are plicated Cystoscopy with iv indigo carmine can be

routinely performed.

• Radical pelvic surgery Intentional ureteral surgery:1.MD Anderson type IV radical hysterectomy2. Total or anterior pelvic exenteration3.Resection of a fixed pelvic sidewall mass Accidental:1.MD Andersons type 3 radical hysterectomy2.Radical vaginal trachelectomyfor women with FIGO stage 1A1 to

1B1 cervical cancer 30 %risk of ureteral dysfunction following therapuetic radiation

therapy.

Aim of management

• Preservation of renal function• Anatomical continuity• Decision depends upon:-1.Time of detection2.Extent of injury3.Site of injury4.General condition of the patient

Conservative?

• Obstruction without intraperitoneal or retroperitoneal leakage

• No major degree of obstruction• Obstruction is not the result of a permanent

agent• Small ureteral leak in the setting of prior pelvic

radiation• For patient waiting for definite repair

When to operate?

• If diagonosed immediate post op:-reoperation within 24 to 48 hrs

• If diagonosed later:-delayed repair

General guidelines for the Mx of ureteral injuries identified at the time of surgery

• Ureteral ligation:-Deligation,assessment of the viability,stent placement• Partial transection:-Primary repair over a ureteric stent• Total transection:- Uncomplicated upper third and middle third:-Ureteroureterostomy over ureteral stent Complicated upper third and middle third:-Ureteroileal interposition Lower third:-Ureteroneocystostomy with psoas hitch over ureteral stent• Thermal injury:-Resection with Mx as per a transection

Ureteral ligation Angulation or kinking is much more common if sutures are within the

paraurethral tissues or partially placed through the ureter First management approach:-PCN Contrast is injected to see if even a small trickle of dyr gets past the

obstruction;if yes,a thin guidewire is passed down th ureter past the obstruction;if successful,larger catheters are passed over it;finally a double J stent left in place for 6 to 8 weeks till the sutures causing obstruction have dissolved

If obstruction is too tight to be stented or ureter is partially or completely ligated:-surgical ureterolysis

If the concerned segment is viable:stent(ureterostomy,cystoscopy,cystostomy)

if dead:-resect

Partial transection

Repair is easiest and fastest(ureterotomy has already occurred)

A stent is placed up and down through the ureterotomy

A small hole:-stent is not necessaryExcessive suture placement is avoidedHealing is usually rapid and completeA closed suction drain is placed at the base of

the repair

Note……..

Be sure that ureteroureterostomy is completely tension free

During spatulation be sure that vessals running in the ureteral sheath are not transected

Spatulation if done on opposing sides ,ensures a complete water tight seal

Thanx……..