Management of Ureteral Injuries
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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 the 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 (pararectal 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. The role for routine cystoscopy continues to be evaluated 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. IV Pyelogram (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 of the ureter is the most commonly injured location, typically near the bladder in 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 case 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):1085-1096. doi: 10.1097/AOG.0000000000001425. PMID: 27159741.
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 JMK, Bortoletto P, Tolentino J, Jung MJ, Milad MP. 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. PMID: 29215524.
Initial Approval June 2012; Revised January 2020. Minor Revision May 2023.
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