2. 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%)
3. 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
11. 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
12.
13. Anatomical risk factors
• Ureter……..
1.Has close attachment to peritoneum
2.Has variable course
3.Not easily seen or palpated.
16. Types of injuries
• Intraoperative
1. 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
22. General preventive strategies
• Preoperative measures
1.Intravenous urogram
2.Ultrasound scan
Identify ureteric dilatation and disclose anatomic
variations
3.Preop stenting in case of anatomic distortion
23. • Intraoperative measures
1.Appropriate operative approach
2.Adequate exposure
3.Avoid blind clamping of blood vessals
4.Mobilise bladder away from the operative site
5.Stay outside the vascular sheath
6.Zone of thermal injury
7.Dissection should preferably be done under direct
visualisation
24. • surgeon is to constantly
and equivocally know
where the ureter is all
times
25.
26.
27.
28.
29. 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
30. • 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 haemostasis
2.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
31. • 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.
32. • Caesarean hysterectomy
Supracervical hysterectomy
Hysterotomy incision can be extended
caudally towards the cervix-allow tactile as
well as visual guidance
33. • Vaginal hysterectomy
Uncommon because traction on the cervix
pulls the uterus farther from the ureter
Culdoplasty places the ureter at risk
Maneuvres:1.Palpatory ureteral identification
2.Placinng an allis clamp on the vaginal cuff in
the area of uterosacral ligament
34. • Bladder neck suspension
During retropubic repair
How 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
35. • Pelvic organ prolapse
relatively common
due to :
1. Direct ligation
2. Kinking as redundant tissues are plicated
Cystoscopy with iv indigo carmine can be
routinely performed.
36. • Radical pelvic surgery
Intentional ureteral surgery:
1.MD Anderson type IV radical hysterectomy
2. Total or anterior pelvic exenteration
3.Resection of a fixed pelvic sidewall mass
Accidental:
1.MD Andersons type 3 radical hysterectomy
2.Radical vaginal trachelectomyfor women with FIGO
stage 1A1 to 1B1 cervical cancer
30 %risk of ureteral dysfunction following therapuetic
radiation therapy.
37.
38.
39.
40.
41.
42.
43.
44. Aim of management
• Preservation of renal function
• Anatomical continuity
• Decision depends upon:1.Time of detection
2.Extent of injury
3.Site of injury
4.General condition of the patient
45. 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
46. When to operate?
• If diagonosed immediate post op:-reoperation
within 24 to 48 hrs
• If diagonosed later:-delayed repair
47. 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
48.
49. 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
50. 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 necessary
Excessive suture placement is avoided
Healing is usually rapid and complete
A closed suction drain is placed at the base of the
repair
51.
52. 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