Ureter relevance in pregnancy
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The ureter is at risk of injury during gynecologic surgeries, especially at the pelvic brim near the infundibulopelvic ligament during procedures like hysterectomy. The most common type of injury is obstruction, which can result from attempts to obtain hemostasis in the pelvic area. Ureteral injuries may be diagnosed intraoperatively or postoperatively, and long term sequelae include complications like reflux or hydronephrosis if not repaired. Laparoscopic procedures can also cause thermal injuries to the ureter, especially during coagulation of uterine vessels or transection of the infundibulopelvic ligament. Careful identification and protection of the ure
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The document describes the anatomy of the ureter, bladder, and urethra. It discusses the length, parts, relations, blood supply, and lymph nodes of the ureter. It outlines the ligaments, relations, sphincter, blood supply, nerves, and lymph nodes of the bladder. It details the sphincters, parts, blood supply, and lymph nodes of the male and female urethra.
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Ureteric injury (1)
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Ureter relevance in pregnancy
- 2. HISTOLOGY
- 8. BLOOD SUPPLYOF URETER Dissect from lateral side Dissect from medial side
- 9. NERVE SUPPLYAND LYMPHATIC DRAINAGE SYMPATHETIC NERVE SUPPLY= T10 – L2 Pelvic plexus Inferior mesenteric plexus Ovarion plexus LYMPHATIC DRAINAGE: Abdominal part – Lumbar LN Pelvic part – External and Internal iliac LN
- 10. IDENTIFICATION PALE GLISTENING STRUCTURE PERISTALSIS LONGITUDINALVESSELSONTHE SURFACE UNIQUE SNAP
- 12. TYPESOF OPERATIVE URETERAL INJURIES 1. Crushing with clmap(necrosis) 2. Ligation (suture/stapler) 3. Transection 4. Angulation (with secondary obstruction) 5. Ischemia (diathermy /stripping of adventitia) 6. Resection
- 13. URETERAL INJURY LOCATIONS 1. Cardinal ligament where the ureter crosses under the uterine artery 2. Tunnel ofWertheim 3. Intramural portion of the ureter 4. Dorsal to the infundibulo-pelvic ligament near or at the pelvic brim 5. Lateral pelvic sidewall above the uterosacral ligament
- 14. URETERAL INJURY ASSOCIATED WITH GYNECOLOGIC SURGERY: “MOST COMMONS” 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 Most common long-term sequelae: None
- 15. Laparoscopy- Associated Ureteral Injuries Uncommon-0.3% to 0.4% Result of a thermal injury than incision, transaction, or encroachment/ligation- extreme caution! Delayed diagnosis- 2 to 5 days after the surgery A) decreases the probability of a successful immediate primary repair and B) increases the risk of a long-term complication M/c sites of injury- laparoscopic hysterectomy- i)When the uterine vessels are stapled or electrocoagulated Ii)When the infundibulopelvic ligament is transected
- 16. OTHER SURGICAL RISKS SIMPLE HYSTERECTOMY- i) Reapplication of clamp to uterine artery Ii) Suturing at vaginal fornices OBSTETRIC HYSTERECTOMY- i) Distorted anatomy ii)Vascularity ADNEXECTOMY INCONTINENCE SURGERY- i) Burch colposuspension(high sutures) Ii) Overzealous dissection of space of ritzeous Iii) Excessive mobilisation of bladder
- 17. SURGICAL RISKS VVF REPAIR-Transvescical approach WERTHEIM’S HYSTERECTOMY- i) Below uterine artery Ii)At tunnel ofWherthim Iii) Over anterior fornix RADICALTRACHELECTOMY- (more risk than werthim’s)
- 18. THANKYOU