Management of Ureteral Injuries
Ureteral injuries are relatively uncommon, and may be more common with gynecologic than other types of abdominopelvic surgery. The incidence of ureteral injury ranges from < 0.1% to over 1% depending on the surgery being performed and approach, including laparoscopy, robotic assisted surgery and laparotomy. Reported rates of ureteral injury are higher for abdominal hysterectomy than for vaginal hysterectomy. A Cochrane meta-analysis of surgical approach to hysterectomy for benign gynecological diseases showed higher risks of urinary tract injuries from laparoscopic hysterectomy compared to abdominal approach; however, no differences were found in rates between robotic and laparoscopic or between laparoscopic and vaginal approaches because of low event rates. A more recent systematic review and meta-analysis of urinary tract injuries in gynecologic laparoscopy for benign indications showed an overall ureteric injury rate of 0.08%; laparoscopic hysterectomy and laparoscopy assisted vaginal hysterectomy had the highest risks of injury to the ureter. Risk factors for injury include prior surgery, malignancy, infection, a large uterus, endometriosis, and pelvic organ prolapse.
Prevention of injury is critical; however, there are no well-established methods for most surgical settings. Preoperative stenting has not been generally shown to reduce risk of injury. Lighted stents have been described, but have not been well-studied in gynecology. Intraoperative identification is key to avoid permanent injury. Ureteric identification is best accomplished by incising the peritoneum lateral to the infundibulopelvic ligament and dissecting the avascular space (peri-rectal space) bounded medially by ureter, laterally by the internal iliac artery, and the cardinal ligament at the apex; the ureter can be traced on the medial leaf of the broad ligament as it courses through to the ureteric tunnel. This dissection will suffice for most gynecologic procedures involving removal of adnexal structures.
Ureteric injuries can be related to kinking, contusion, crush injury, laceration, transection, ligation, devascularization, or thermal injury. Electro-cautery is the most common etiology of ureteric injury during laparoscopic surgery. Diagnosis is best accomplished in the acute setting, although the majority of injuries are diagnosed in the post-operative recovery phase. If injury is suspected, intraoperative evaluation including careful evaluation for type and extent of injury, cystoscopy, and possible ureteral catheterization is indicated. In the acute or near postoperative period, retrograde pyelography is the most sensitive study. If undiagnosed, the most common presenting signs and symptoms include abdominal pain, ileus, possible peritonitis, leukocytosis, and fever. Flank pain may or may not be present. If ureteral injury is suspected postoperatively, CT urogram, cystoscopy or retrograde pyelography should be performed.IVP may be used if these studies cannot be conducted. When ureteral injury is diagnosed postoperatively, especially when delayed, urology consultation for percutaneous nephrostomy with delayed repair may be most appropriate.
In gynecologic surgery, the distal aspect is the most commonly injured location, typically near the bladder at the proximity of the ureter and uterine artery. Other locations may include near the pelvic brim and near the utero-ovarian ligament.
Some injuries, such as incomplete obstruction and kinking, may be treated with stent placement. If suture has caused the obstruction, suture removal may be required. For more significant injuries, including crush injuries and transection, the surgical approach depends on the location. For distal injuries, ureteroneocystotomy is appropriate, in which the distal ureter is re-implanted into the bladder. The re-implanted ureter is stented and the bladder drained; the stent is typically left in place for 6 weeks. An abdominal drain (such as a J-P drain) should be placed in the event an anastomotic leak may occur. A psoas hitch may be necessary to avoid tension on the re-implanted ureter.
More proximal ureteral injuries may necessitate a ureteroureterostomy, usually for small (2-3 cm) defects in which the injured ureter may be resected and a primary anastomosis performed. In a proximal injury in which the distal segment cannot be used, a Boari flap (creating a “tubular” flap to function as a “distal ureter”) may be needed. If the length of damaged ureter prevents consideration of a ureteroneocystotomy or ureteroureterostomy, then a transureteroureterostomy may be indicated, in which the injured ureter is anastomosed into the contralateral ureter. Finally, in extreme cases, renal autotransplantation or the use of “substitute” materials such as gastrointestinal segments may be necessary.
Sharp HT, Adelman MR., Prevention, Recognition, and Management of Urologic Injuries During Gynecologic Surgery. Obstet Gynecol. 2016 Jun;127(6):1085-96. doi: 10.1097/AOG.0000000000001425.
Aarts JWM, Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2015 Aug 12;(8):CD003677. doi: 10.1002/14651858.CD003677.pub5.
Wong JM, Bortoletto P, Tolentino J, et al.; Urinary tract injury in gynecologic laparoscopy for benign indication: a systematic review. Obstet Gynecol. 2018 Jan;131(1):100-108. doi: 10.1097/AOG.0000000000002414.
Initial Approval June 2012; Revised January 2020.
********** Notice Regarding Use ************
The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.
This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.
Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. SASGOG reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. SASGOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither SASGOG nor its respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.
Copyright 2020 The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. All rights reserved. No re-print, duplication or posting allowed without prior written consent.
Back to Search Results