3. INTRODUCTION
‘ THE VENIAL SIN IS INJURY TO THE URETER , THE MORTAL SIN IS
FAILURE OF RECOGNITION’
- Ureteric injuries – potential complication of gynaecologic
surgery.
- Over the years, unique surgical modifications of procedures have
been made to probability of ureteric injuries. Despite that,
ureteric injuries remains a very real complication .
- Incidence – 1%-2%
- It varies with the nature of surgery , skill of the surgeon,
complexity of patient’s anatomy.
4. GOALS:
A)Anatomy of ureter & to illustrate how it is prone to get injured
during gynaecologic surgery.
B)Review unique issues surrounding ureteric injury during
performance of specific groups of gynaecologic surgeries.
C)Recognition and management of ureteric injury.
D)Basic principles of avoiding injury.
5. ANATOMY OF URETER
• Retroperitoneal structure
• Length in adults – 25-30cm (10 in.) from renal pelvis to trigone of
the bladder ;3 mm in dm .
• Pelvic brim divides it into:
a) abdominal segment (12-15cm)
b) pelvic segment (12-15cm)
• Slightly constricted at 3places
a) At pelvi ureteric junction
b) At brim of true pelvis
c) At its opening in the lateral angle of trigone
6.
7. Histology: Has 3 distinct layers
1)mucosa with transitional epithelium
2)muscular layer – longitudinal,
circular, spiral ,smooth muscle fibres
3) adventitia which contains
intercommunicating network
of blood vessels
8.
9. COURSE OF THE URETER:
• Abdominal ureter runs ventral to psoas
muscle posterior to ovarian vessels to
the pelvic brim.
• Right ureter lies slightly lateral to IVC –
decends into pelvis—over common iliac
artery bifurcation
( rarely , it can be over IVC ,hence , during
para aortic node sampling before removing
nodes ureter must be identified)
• Left ureter runs lateral to aorta
,posterior to IMA, ovarian
vessels&colon. Its obscured by sigmoid
colon at pelvic brim.
• It mirrors right ureter at pelvic brim ,
entering pelvis over left common iliac
artery bifurcation
10.
11. • There is little variance between positions taken by pelvic
ureters.
• They decend into posterior lateral pelvis –lateral to
sacrum – ventral to internal iliac artery --medial to
internal iliac artery & its anterior branches
• Ureters pass beneath the uterine artery – WATER UNDER
THE BRIDGE.It lies 1.5cm lateral to cervix where it enters
paracervical tissues.
• Passes through paracervical tissue –THE TUNNEL OF THE
CARDINAL LIGAMENT / ANTERIOR BLADDER PILLAR ( also
referred as WEB OR TUNNEL OF WERTHEIM.
12.
13.
14.
15.
16.
17.
18. BLOOD SUPPLY:
• 3 sets of long arteries:
a) Upper part – branch from renal artery, gonadal / colic vessels
b)Mid part – branch from aorta ,gonadal / iliac vessels
c)Pelvic part – branch from vesical / middle rectal / uterine
vessels
• Arteries to ureter lie closely attached to peritoneum
• They divide into ascending and decending branches which
form plexus on surface of ureter and then supply it.
• Ureter is perfused by rich network with anastomoses within
adventitial sheath( relatively resistant to devascularisation)
,however such injuries occur & difficult to diagnose , as the
sequelae becomes apparent only in postop period.
19.
20. NERVE SUPPLY:
Sympathetic – T10- L1
Parasympathetic – S2-S4
All nerves – sensory in function.
They reach ureter through renal/aortic/hypogastric plexus.
EMBRYOLOGY:
Ureter develops from ureteric bud which is an outgrowth of
mesonephric duct.
21. • Above the pelvic brim, blood supply is derived from medial vessels,
distally blood supply originates laterally
• Hence , dissection and mobilisation to be done from the lateral
aspect above the pelvic brim & from the medial aspect below the
brim.
• In 10% cases, middle part of ureter is supplied only by minute twigs
From peritoneal vessels.
• In 2 % cases, although there are long arteries to the middle part ,
upper and lower parts are supplied by short vessels.
22. Risk factors
ANATOMICAL
• Has close attachment to peritoneum
• Closely related to FGT
• Variable course
• Not easily seen/palpated
PATHOLOGICAL
• Congenital anomalies of ureter/kidney
• ureteric displacement – uterine size > 12 weeks,
prolapse, tumor, cervical and broad ligament swellings
• Adhesions ( previous surgeries, endometriosis, PID)
• Distorted pelvic anatomy
23. TECHNICAL
• Massive intra op hemorrhage
• Co existent bladder injury
• Technical difficulties in view of pelvic pathology
• Technical fallacies –a) inadequate incision
b) improper abdominal packing
24. TYPES OF INJURY
INTRA OP:
a) Crushing (misapplication of clamp)
b) Ligation ( with a suture)
c) Transection ( partial / complete)
d) Angulation of ureter with secondary obstruction
e) Ischaemia from ureteral stripping /laser/electro coagulation
f) Resection of the segment
POST OP:
a) Avascular necrosis
b) Kinking
c) Subsequent obstruction due to overlying hematoma/
lymphocele.
25. URETERAL INJURY ASSOCIATED WITH
GYNAECOLOGIC SURGERY
• Most common site : Pelvic brim near the infundibulopelvic
ligament
• Most common procedure: Simple abdominal hysterectomy
• Most common type of injury: Obstruction
• Most common ‘activity’ leading to injury : Attempts to
obtain hemostasis
• Most common time of diagnosis : None -50-50 split
between intraoperative and postoperative.
26.
27. SITES OF URETERAL INJURIES:
1) Dorsal to infundibulopelvic
ligament near or at pelvic brim
2)Cardinal ligament where ureter
crosses under uterine artery
3) Tunnel of wertheim
4) Lateral pelvic sidewall above
uterosacral ligament
5) Intramural portion of ureter
34. VISUALISATION OF URETER DURING
SURGERY
• There is significant degree of interpatient variability in the anatomy
of ureter.
• Pale glistening appearance
• If inflammatory / adhesive changes are not present, ureter can be
seen from pelvic brim to parametrial tissue ,once it enters into tunnel of
wertheim ,they cant be seen / palpated ,they should be mobilised out of
the tissue.
• Ureteric peristalsis – helps in identification but following any degree of
trauma , it will have transient paralysis.
• Therefore , skill of accurately identifying the ureter is based on
understanding its anatomy and not its motion.
35. • Snap feeling when passed between fingers during laparotomy, will permit
one to follow ureter to tunnel without actually exposing it.
• In laparoscopic / robotic assisted procedures , camera magnification is
necessary to identify its course.
• Opening of parietal peritoneum is necessary to allow for accurate
inspection or to mobilise & separate from the site of operative
interest.Important in inflammatory comditions,-infection , neoplasia ,
post surgical changes
36. INTRAOP:
1) Any suspicion should be clarified – visualising peristalsis is
inadequate to exclude occlusion or extravasation
2) Dye test – IV phenazopyridine / indigo carmine/ methylene
blue (5ml) – extravasates at the site of injury in 3-5min(
abdominal )
3) Intra ureteric dye test- Identify ureter over common iliac artery,
stretch it, insert 21 G IV cannula into the lumen,5- 10 cc
methylene blue is injected.
Intact ureter – Dye comes into foley’s catheter
Ureteric leak- blue staining of pelvis
Obstruction- swelling+, no leakage
37. 4)Intra op cystoscopy –confirmation of urine efflux from ureteral
orifices . Non obstructive / partially obstructive / late injuries
due to ischaemia and avascular necrosis can be missed.
• Acute ureteral injuries are best recognised & managed
intraoperatively.
• Collaborative assistance from urology or urogynaecology
• Decisions regarding nature of repair and to proceed with intra
corporeal repair versus conversion to laparotomy in setting of
laparoscopic/ robot assisted procedures.
• Intraoperative repair reduces sequelae – stricture, fistulae,
loss of renal function, need for subsequent reoperation
38. • Cautery devices must be used with care.
Diffusion of thermal energy leads to occult ureteral injury
resulting in delayed stricture or urine leak presenting days to
weeks postoperatively.
39. POST OP:
SYMPTOMS TIME OF PRESENTATION
Anuria <24 hours
Adynamic ileus/peritonitis 0-7 days
Loin/ flank pain 0-21 days
Fever 0-21 days
Dribbling of urine from vagina, oliguria 0-30 days
Lower abdominal/ pelvis mass (urinoma) 20-40 days
Asymptomatic (incidental finding)
40. INVESTIGATIONS:
• WBC Count – Leucocytosis
• RFT , Electrolytes – Transient rise in Serum
Creatinine –should prompt further investigations.
• IVP – GOLD STANDARD FOR POST OP DIAGNOSIS-
Hydroureteronephrosis,stricture
• USG- Abdomen & Pelvis – HUN
• CT Scan - Hydroureteronephrosis /
ascites/urinoma/stricture/extravasation
• Cystoscopy – affected ureter- no urine spurt from the
ureteric orifice
41. • Retrograde ureteropyelography – diagnosis & initial therapy of
ureteral injury
• Contrast injection & opacification of ureter – defines site &
severity of leakage or obstruction & facilitates ureteral
stenting.
• Allows resorption of urinoma & spontaneous healing of ureter.
• If stenting is not possible, nephrostomy tube is placed – urine
drainage & prevent renal injury.
• Double dye test – with oral phenazopyridine Hcl + vesical
methylene blue & 3 swab test – fistula identification
• Fluid analysis from drains / ascitic collection –urine has
creatinine
> 10 mg/dL.
42. PREVENTIVE STRATEGIES TO REDUCE
THE RISK OF URETERIC INJURIES
1) General 2 ) specific
a) Pre op
b) Intra op
GENERAL PREVENTIVE STRATEGIES :PRE OP :
• IV Urogram
• USG
• Pre op stenting – There is no reduction in incidence ,
May aid in intra op reduction of ureteric injury
-But there’s no proof that pre-op IVP/CECT reduces the risk of
injury.
-Endometriosis ,PID, UV prolapse ,previous intra abdominal
surgery not associated with increased prevalence of abnormal
IVP findings
43. PREOPERATIVE STENT PLACEMENT:
• Facilitates identification of injury
rather than prevention
• Complications: perforation,stent
malposition,extravasation,hemat
uria,stricture
• Should be considered in
complex cases
44. • INTRA OP:
DICTUM – SURGEON SHOULD CONSTANTLY AND
EQUIVOCALLY KNOW WHERE THE URETER IS AT
ALL THE TIMES.
1)Adequate exposure of operative field
2)Avoid blind clamping of blood vessels
3) Mobilise bladder away from operative site
4) Stay outside vascular sheath of ureter
5) Cautious about thermal injury
6)Ureteric direct visualisation & mobilisation
45. SPECIFIC PREVENTIVE STRATEGIES
TAH :
• Upward traction on uterus during placement of clamps
• Apply second clamp always medial to first clamp
• Clamp infundibulopelvic ligament near the ovary after
dissection and palpation
• Skeletonise ,clamp and ligate uterine vessels close to uterus
– clamping immediately along the cervix
• Clamp cardinal and uterosacral ligaments close to uterus
• Never to 0pen vagina unless bladder is dissected
downwards and laterally
( careful dissection of the bladder off the cervix)
• Use of intrafascial technique
46.
47.
48. VH :
• Remarkably uncommon as VH is not performed for
conditions which distort ureteral anatomy ( endometriosis ,
malignancy)
• Compared to abdominal hysterectomy ,risk of ureteral
injury is reduced in VH – traction on the cervix pulls the
uterus farther from the ureter.
• Tension on the cervix is therefore critical during clamping
the pedicles.
• Adequate development of vesicouterine space
• All the clamps – apply close to uterus .
• Avoid double clamping of uterosacral ligaments
• Vaginal oopherectomy should be avoided / done cautiously
• During anterior colporraphy – avoid too lateral dissection
and deep sutures.
49.
50.
51. LAPAROSCOPIC HYSTERECTOMY :
• Its imperative to know the location of the ureter
• Bleeding points at Uterosacral ligaments should be secured
with sutures /clips instead of electro coagulation
• In LAVH, place stapler/suture across uterine vessels & cardinal
ligaments instead of electro coagulation.
• Use of harmonic scalpel.
52.
53.
54. SPECIFIC HIGH RISK PROCEDURES FOR
URETERAL INJURY
• LAPAROSCOPY ASSOCIATED URETERAL INJURIES:
-0.3-0.4%
-Thermal spread (extreme caution with use of cautery )– occult
injury
-Delayed diagnosis the probability of successful immediate
primary repair
-MC during laparoscopic hysterectomy , when uterine vessels are
stapled/ electro coagulated & IP ligament is transected
55. COMPLEX ADNEXECTOMY:
• Retroperitoneal approach( continues deep into pelvis as
pararectal space)
a)to access pelvic vessels to establish hemostasis
b)It’s adhesion and pathology free space
• Ureter lies on the medial leaf of broad ligament
• If adnexal mass is adherent to the peritoneum overlying ureter,
ureter can be safely dissected from peritoneum.
• After mobilisation of ureter, resection of mass can be performed.
• Rarely, its impossible to mobilise ureter from the pathology-
surgeon’s decision whether to leave residual tissue on ureter(
ureteral obstruction) or to resect segment of ureter & repair.
56.
57. TAH-HIGH RISK SITUATIONS:
• Cervical/ broad ligament fibroid can be challenging – ureter
can be anterior/lateral/posterior to fibroid.
• Clamping pedicles around the fibroid- Risk of ureteral injury
• Myomectomy – by incision adjacent to uterus or cervix(
staying within myometrial capsule of fibroid)
• Bleeding may occur- clamping adjacent to uterus.
• Rarely, if this is impossible, entire course of ureter must be
identified without clamping /cutting.
• Vigilant when there is bleeding from pedicles especially at vaginal
angles controlled by superificial 3-0 sutures so as not to incorporate
the ureter.
• Intrafascial hysterectomy technique is used
58. • CAESAREAN HYSTERECTOMY:
• Supracervical hysterectomy
• Placement of finger into endocervico-vaginal canal
• Simple to identify where to place a clamp adjacent to cervix
VAGINAL: CULDOPLASTY:
• Ureter is at risk.
• Can be prevented by identification of uterosacral ligaments by
palpation in paravesical space.
59. BLADDER NECK SUSPENSION:
• Injury during retropubic repair affects distal ureter
PREDISPOSING CONDITIONS:
• Vigorous dissection of space of retzius & periurethral tissue
• High elevation of burch colposuspension sutures
• Paravaginal defect repair with burch procedure
• Excessive lateral traction of bladder brings ureter into field of
operation
60. SURGERY FOR PELVIC ORGAN PROLAPSE :
• Ureter is damaged by direct ligation / kinking from plication of
redundant tissue
• In Mc Calls Culdoplasty , identification of uterosacral
ligaments & traction by Allis reduces chance of injury
• Cystoscopy with IV indigo carmine to check for ureter integrity
61. RADICAL PELVIC SURGERY:
Accidental
• Ureteral injury Intentional
• Intentional in MD Anderson type 4 radical hysterectomy,
anterior or total pelvic exenteration, resection of fixed
pelvic side wall mass involving ureter – ureteral resection
& reconstruction.
• Radical resection following radiation increases risk by
30%
• Increased rates during vaginal trachelectomy as fertility
sparing treatment for Ca Cervix FIGO 1A1 & 1B1.
62. MANAGEMENT
AIM:
a) preservation of renal function
b)restoration of anatomical continuity
DECISION DEPENDS ON:
a) Time of detection
b)Type of injury
c) Length of injury
d)Site of injury
d)General condition of patient
63. If ureteric injury goes unrecognised
POSSIBLE SEQUELAE :
1)When injury is minimal – spontaneous resolution & healing
2)Complete obstruction- Hydronephrosis & gradual loss of renal
function
3)Transection – Urinoma/ Urinary ascites/necrosis
4)Fistula formation
5)Stenosis
64. General principles of ureteric repair
• Ureteric dissection preserving adventitial sheath & its blood
supply
• Tension free anastomosis by ureteric mobilisation
• Spatulation ≥ 1 cm to create a wide caliber lumen
• Use of fine absorbable suture(4-0,5-0)to minimise
inflammatory response & subsequent stricture.
65. • Use of omentum to surround anastomosis
• Ureter must be stented at the time of reconstruction &left in
place for atleast 14 days
• Suction drain placed near but not in contact with the repair.
66. WHEN TO OPERATE:
• If detection of injuries is within 5 days ,operate
immediately
• After 5 days – tissue edema & inflammation makes
repair difficult &definitive surgery is to be planned after
6-8 weeks.
• To preserve renal function , PCN to be carried out.
67.
68.
69. PARTIAL TRANSECTION
• Closed loosely with fine (5-0) absorbable suture &
stented.
• Placement of stent – over a flexible guidewire using
intraoperative cystoscopy or directly through small
anterior cystotomy.
• Bladder drained 7-10days following repair
77. SEQUELAE:
• Stricture
• Stent and nephrostomy related problems
• UTI
• Ureteric obstruction / reflux
• Boari flap complication
• Hematoma
• Wound infection
78. • Sound knowledge of ureteral anatomy – to avoid injury
• If ureter is damaged during gynaecologic surgery, intraoperative
diagnosis allows for immediate repair in most cases.
• For this reason, INTRAOPERATIVE CONFIRMATION OF URETERAL
INTEGRITY SHOULD BE ROUTINE, whether the surgical approach
is transvaginal or transabdominal through open / laparoscopic/
robot assisted approach.
• Ureter may be assessed visually, by palpation, cystoscopically.
• Identification of mechanism of injury & its location guides
immediate / delayed repair.
• WITH PROPER RECOGNITION & THERAPY , URETERAL FUNCTION
CAN BE RESTORED & RENAL FUNCTION MAINTAINED.
TAKE HOME MESSAGE :
