URETERIC INJURY IN OBGY

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URETERIC INJURY IN OBGY

  1. 1. URETERIC INJURY In OBGY Dr Mohit Satodia GMCH-32 Chandigarh
  2. 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. 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
  4. 4. Course of ureter
  5. 5. Blood supply of ureter
  6. 6. 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
  7. 7. Anatomical risk factors • Ureter…….. 1.Has close attachment to peritoneum 2.Has variable course 3.Not easily seen or palpated.
  8. 8. Pathological risk factors • Congenital anomalies of ureter or kidney • Ureteric displacement by: 1.Uterine size >/=12 weeks 2.Prolapse 3.Tumour 4.Cervical or broad ligament swellings • Adhesions 1.Previous pelvic surgeries 2.Endometriosis 3.PID • Distorted pelvic anatomy
  9. 9. Technical factors • • • • Massive intraoperative haemorrhage Coexistant bladder injury Technical difficulties Inexperienced surgeon
  10. 10. 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
  11. 11. • Post operative 1. 2. 3. • • Avascular necrosis Kinking Subsequent obstruction over: Haematoma Lymphocele
  12. 12. Procedures asso. with ureteric injuries • Abdominal 1. 2. 3. 4. 5. 6. Hysterectomy Werthiem’s hysterectomy Oopherectomy Uterine suspension Burch colposuspension Vesicovaginal fistula repair
  13. 13. • Vaginal 1.Hysterectomy 2.Anterior colporrhaphy 3.Vesicovaginal fistula repair 4.Culdoplasty
  14. 14. • Laparoscopic 1. 2. 3. 4. 5. Division of adhesions Transection of uteroscral ligaments Colposuspension Treatment of endometriosis Sterilisation(especially with electrocoagulation)
  15. 15. Preventive strategies • General preventive strategies 1.Preoperative 2.Intraoperative • Specific preventive strategies
  16. 16. 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
  17. 17. • 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
  18. 18. • surgeon is to constantly and equivocally know where the ureter is all times
  19. 19. 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
  20. 20. • 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
  21. 21. • 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.
  22. 22. • Caesarean hysterectomy Supracervical hysterectomy Hysterotomy incision can be extended caudally towards the cervix-allow tactile as well as visual guidance
  23. 23. • 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
  24. 24. • 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
  25. 25. • 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.
  26. 26. • 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.
  27. 27. 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
  28. 28. 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
  29. 29. When to operate? • If diagonosed immediate post op:-reoperation within 24 to 48 hrs • If diagonosed later:-delayed repair
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. Thanx……..

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