Urinary tract injury during female pelvic surgery occurs in 0.3-1% of procedures but can be as high as 2.4%. Risk factors include prior pelvic surgery, endometriosis, and pelvic masses. The ureters pass through the pelvis and can be injured at various points, most commonly when ligating the ovarian or uterine vessels. Identifying and isolating the ureters and bladder during surgery is important to prevent injury from other surgical maneuvers.

1. URETERIC INJURIES IN GYNECOLOGICAL
SURGERIES

3. • Urinary tract injury during female pelvic surgery occurs in approximately 0.3 to
1 percent, and may be as high as 2.4 percent of procedures. Injury rates vary
by procedure type and anatomic location
• Ureteric injuries at the time of hysterectomy, both recognized and
unrecognized, are a significant cause of morbidity and mortality

4. Acute Urological Injuries During Obstetric & Gynecological.
Trauma Journal 2016

5. RISK FACTORS
• ●Prior pelvic surgery
• ●Endometriosis
• ●Urinary tract abnormalities (eg, duplicated ureter, pelvic kidney)
• ●History of pelvic irradiation
• ●Obesity
• ●Large pelvic mass
• ●Fibroids, including in the cervix and broad ligament
• ●Large uterus (>250 g)

6. ANATOMY
The pelvic ureters are
retroperitoneal structures that run
from the renal pelvis to the bladder
and can be injured during pelvic
surgery at any point along their
distal course

7. ABDOMINAL PART
• The ureters arise from the renal pelvis – a funnel like structure located within
the hilum of the kidney
• After the ureteropelvic junction, the ureters descend down the abdomen,
along the anterior surface of the psoas major. Here, the ureters are
a retroperitoneal structure
• At the area of the sacroiliac joints, the ureters cross the pelvic brim,
thus entering the pelvic cavity. At this point, they also cross the bifurcation of
the common iliac arteries.

8. PELVIC PART
• Once within the pelvic cavity, the ureters run down the lateral pelvic walls. At
the level of the ischial spines, they turn anteromedially, moving in a
transverse plane towards the bladder.
• Upon reaching the bladder wall, the ureters pierce its lateral aspect in
an oblique manner. This creates a one way valve, where high intramural
pressure collapses the ureters, preventing the back-flow of urine.

9. Ureter:
•Passes lateral to the uterosacral ligament and beneath the uterine artery lateral to the cervix
•Travels in an endopelvic fascia tunnel medially and anteriorly along the upper part of the vagina, and enters into
the bladder wall and then opens into the trigone

10. COURSE OFURETER
Protecting the ureter during pelvicsurgery

14. SITES OF INJURY
1) The ureters enter the pelvis at the pelvic brim where they cross from
lateral to medial, and anterior to the bifurcation of the common iliac arteries.
At this point, the ureter runs just medial to the ovarian vessels .
2) The ureters then descend into the pelvis within a peritoneal sheath
(ureteric fold) attached to the medial leaf of the uterine broad ligament and
the lateral pelvic sidewall .

15. 3) Just inferior to the internal cervical os, the ureter passes under the uterine
arteries in the cardinal ligament through a tunnel of areolar tissue to the
anterolateral surface of the cervix
4) The ureters then pass close to the anterolateral fornix of the vagina and
enter the posterior aspect of the bladder.
• During laparoscopic surgery specifically, the ureter is at greatest risk of injury
at the IP ligament, in the ovarian fossa, and in the ureteric canal

17. RETROPERITONEALANATOMY

19. MECHANISMS OF INJURY
• There are many ways the lower urinary tract can be compromised during or
after surgery.
• Thermal damage from electrosurgery or other energy sources, such as laser
or harmonic scalpel, is becoming a more frequent cause of injury to the
urinary tract

20. • Additional potential mechanisms of intraoperative ureteral injury include :
• ●Crushed with a clamp
• ●Kinked or ligated with a suture or staple
• ●Lacerated or transected during sharp or blunt dissection or while using an
energy source
• ●Devascularization or denervation

21. SEQUELAE OF INJURY
• Potential consequences of lower urinary tract injury include ureteral
obstruction (resulting in hydronephrosis and possible irreversible injury
which, if bilateral, can lead to renal failure), genitourinary fistula, and urinoma
• All of these immediate consequences can lead to readmission, sepsis, and
death

22. APPROACH TO PREVENTION
• Primary – avoiding urinary tract injury
• Primary prevention is optimal.
• The most important method for primary prevention is intraoperative
identification of the bladder and ureters and avoidance of injury through
meticulous surgical technique.
• In addition, preoperative identification and evaluation are used to select
appropriate patients for placement of prophylactic ureteral catheters.

23. • Secondary – intraoperative recognition and repair of injury
• When injuries do occur, prompt intraoperative diagnosis and management
help to avoid sequelae such as ureteral obstruction and ureterovaginal or
vesicovaginal fistula formation.
• This is accomplished through surgeon inspection of pedicle and urinary tract
structures and awareness of potential signs of injury (eg, urine in the
operative field). Routine use of cystoscopy is another option.

24. • Tertiary – postoperative diagnosis and treatment of urinary tract injury

25. GENERAL MEASURES
• Patient positioning
• Bladder catheter
• Prophylactic ureteral catheters

26. SURGICAL TECHNIQUE
• The most important principle for prevention of urinary tract injury is to
develop and divide tissue planes to identify and isolate the structures of the
lower urinary tract before operating on other pelvic structures.
• Anatomic variation and pelvic pathology may obscure tissue planes, thereby
increasing the risks of an injury

27. AVOIDING URETERAL INJURY
• The most common mechanism of ureteral injury is accidental ligation or
transection while operating on other structures. Identification of the ureter at
each step in a procedure avoids injury .
• The highest risk of denervation and /or devascularization is during
ureterolysis therefore, removal of all tissue surrounding the ureter should be
avoided during gynecologic surgery performed for benign indications.

28. • During oophorectomy or hysterectomy, the steps of the procedure in which the
ureter is most likely to be injured are:
• ● Cauterisation/Ligation of the ovarian vessels
• ● Cauterisation/Ligation of the uterine vessels
• ● Closure of the angles of the vagina cuffs
• The most common site of ureteral injury is the distal ureter at the level of the
uterine arteries

29. OVARIAN VESSELS
• To avoid ureteral injury when the ovarian vessels are ligated during
oophorectomy (with or without hysterectomy), there are several methods of
identifying the ureter:
• opening the retroperitoneum to visualize the ureter directly,
• visualizing the ureter through the peritoneum,
• palpating the ureter.

30. • There are no high quality data regarding which method is associated with a
lower risk of ureteral injury.
• However, opening the retroperitoneum and visualizing and /or palpating the
ureter prior to isolating, clamping, and ligating the ovarian vessels is the
method that best ensures accurate identification and protection of the ureter.

31. UTERINE ARTERIES
• At the level of the uterine arteries, the uterine vessels are skeletonized
before cauterisation/ ligation to visualize the ureter.
• If the vessels have been isolated, it is not required to completely dissect out
the ureter.

32. • Perhaps more importantly, mobilizing the bladder from the anterior cervix and
displacing it inferiorly will also shift the ureters inferior to the uterine arteries
prior to clamping.

33. • The ureters pass below the
uterine vessels, and once these
vessels are ligated, the ureter will
pass just inferior and lateral to this
pedicle. Thus, to protect the ureter
during subsequent dissection of
the cardinal ligament, the clamp is
placed medial to the uterine artery
pedicle

34. VAGINAL CUFF CLOSURE
• The ureters enter the bladder posteriorly, along its interface with the anterior
vaginal wall.
• Thus, care must be taken during closure of the vaginal cuff to avoid both the
ureters and bladder.
• As the bladder is dissected off the surface of the vagina or cervix and
displaced inferiorly, the ureters will descend with the bladder to a level safely
below the superior aspect of the cuff.

35. • Identifying a pelvic kidney —
A pelvic kidney, which occurs in from 1 in 500 to 1 in 3000
individuals, may be encountered during gynecologic surgery. They are usually
unilateral, retroperitoneal, irregular in shape, and may occur anywhere below
the pelvic brim.

36. MANAGEMENT
• Urinary tract injury recognized during surgery should be treated
intraoperatively rather than delaying until after surgery or performing a
second procedure.

37. ANTIBIOTIC PROPHYLAXIS
• Most surgeons do not administer additional antibiotic prophylaxis when a
urinary tract injury occurs, whether it is recognized intra- or postoperatively.
• Urinary tract injury is most likely to occur in major gynecologic procedures for
which routinely used antibiotic prophylactic agents

38. • A bladder catheter is used for several days or weeks in many women
following a urinary tract injury.
• Repair of ureteral injuries often involves ureteral stenting or advanced surgical
repair.

39. SUMMARY
• Urinary tract injury during female pelvic surgery occurs in approximately 0.3
to 1 percent, and may be as high as 2.4 percent of procedures. Injury rates
vary by procedure type and anatomic location.
• For women with known or suspected urinary tract anomalies, retroperitoneal
cysts, and/or cervical/broad ligament fibroids, we suggest a preoperative
imaging study of the ureters.
• Urinary tract injury may occur through direct contact with a surgical
instrument, a suture or a stapling device, or as a result of devascularization
or denervation

40. • For most women undergoing gynecologic surgery, we recommend not using
prophylactic ureteral catheters
• During hysterectomy, constant upward tension (for open hysterectomy) or
elevation (for laparoscopic hysterectomy) of the uterus causes inferior
displacement of the ureters and decreases risk of urinary tract injury when
ligating the uterine arteries, cardinal, and uterosacral ligament complexes
• The most important principle for prevention of urinary tract injury is to
develop and divide tissue planes to identify and isolate the structures of the
lower urinary tract before operating on other pelvic structures.