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Ureteric injury during gynaecological surgery
1. OPERATIVE URETERIC INJURIES
TO URETER
DR SANTOSH AGRAWAL
Chief Urologist and Kidney Transplant Surgeon
Bansal Hospital , Bhopal, MP
MBBS, MS, MCh (PGI, Chandigarh), FIAGES, FALS
Fellow in Robotic Surgery, Roswell Park Cancer Institute, Buffalo , USA
4. RISK FACTORS
๏ข Adhesion due to previous surgery
๏ข Endometriosis
๏ข Pelvic inflammatory disease
๏ข Large uterus/myoma
๏ข cutting dense adhesions and fibrotic scar tissue
๏ข trying to stop bleeding close to the ureter with
bipolar cautery
๏ข ligating the uterine vessels with bipolar
electrosurgery, staples, or suture
5. COMMON SITES OF URETERIC INJURY
๏ข Cardinal ligament where ureter crosses under
uterine artery
๏ข Tunnel of Wertheimโs
๏ข Intramural ureter
๏ข Dorsal to infundibulopelvic ligament at pelvic brim
๏ข Lateral pelvic sidewall above
uterosacral ligament
6. TYPE OF OPERATIVE INJURY
1. Crushing
2. Ligation
3. Transaction
4. Angulation
5. Ischemia/devascularisation
6. Resection
Te Lindeโs operative Gynecology, 9th edition
7. INTROPERATIVE DETECTION
๏ข Even gross injury can be
missed
๏ข Injury near infundibulopelvic
ligament- collection of urine,
free lying ureter
๏ข Injury near Uterine- difficult to
detect.
๏ข In difficult cases- ureter
should be prospectively
identified and dissected and
preserved
8. SUSPICION OF URETERIC INJURY
โข Immediate
cystoscopy before
laparoscope removed
โข Check efflux of urine
โข RGP (retrograde pyelogram)
โข Ureteric cathetar placement
Efflux present
Dye going freely
Ureteric cathetar going freely
No efflux
Dye not going
Ureteric cathetar not going
Contrast extravasation
No ureteric injury
Ureter ligation present
Try laparoscopic release
DJ stenting
Open repair /ureteroneocystostomy
If fails
9.
10. SUSPICION OF URETERIC INJURY
โข Immediate
cystoscopy before
laparoscope removed
โข Check efflux of urine
โข RGP (retrograde pyelogram)
โข Ureteric cathetar placement
Efflux present
Dye going freely
Ureteric cathetar going freely
No efflux
Dye not going
Ureteric cathetar not going
Contrast extravasation
No ureteric injury
Ureter ligation present
Try laparoscopic release
DJ stenting
Open repair /ureteroneocystostomy
If fails
15. PREVENTION OF URETERIC INJURY
๏ข Clamps or ligatures should be placed and elevated high
enough so that only targeted ligaments and vessels are
caught in the clamp.
โข Extensive cauterion
โขStapling device
โขSuture ligation
16. PREVENTION OF URETERIC INJURY
๏ข The cardinal ligament should be cut close to the
cervix, after checking the panoramic view.
18. PREVENTION OF URETERIC INJURY
Established operative techniques for
skeletonizing the uterine arteries
should be followed, so that the
ureters will fall away from the
operational field as the surgery
proceeds.
When severe pelvic adhesions
are present it is imperative to
identify the ureter prior to ligation
of the infundibulo-pelvic ligament.
19. PREOPERATIVE URETERIC CATHETAR
๏ข 492 patients
๏ข 92/492- bilateral ureteric cathetar โ no injury
๏ข Up down movement before firing stapler
๏ข 7/92 - complication
๏ข 400/492 โ no ureteteric cathetar โno injury
๏ข Routine use no warrented
Wood EC, Maher PJ, M P. Complications of ureteric catheters at laparoscopic
hysterectomy. J Am Assoc Gynecol Laparosc 1996; 3: 393โ7.
20. INTRAOPERATIVE CYSTOSCOPY
๏ข Total118 patients
๏ข 4 ureteric injury identified and dealt with.
๏ข No permanent disability
Ribiero et al.The value of intra-operative cystoscopy at the time of laparoscopic
hysterectomy. Hum. Reprod. (1999) 14 (7): 1727-1729.