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.
Urinary Tract Fistulas -(VVF) Etiology, Diagnosis, ManagementVikas V
Urinary Tract Fistulas - Etiology, Diagnosis, Management
Surgical and Relevant Anatomy, Classification, eitiology, VVF in Detail, Examination and Diagnosis, Management of VVF - Both Conservative And Surgical Management - Steps of Surgical Management, Post operative Management.
Ureteric injury in Gyenec Surgery, Serious complication of gynecologic surgery
Significant morbidity and long-term sequelae
Uncommon in benign gynecologic surgery
Vaginal hysterectomy has the lowest rate of ureteral injury
Laparoscopic hysterectomy has the highestThe ureters are the muscular ,thick walled narrow tubes(Right and Left)
Each measures 25-30 cm in length and extends from renal pelvis to its entry in the bladder.The ureter are located retroperitonealy and run from the renal pelvic to urinary bladder.
First part –Enter the pelvis by crossing the common iliac vessel from lateral to medial aspect at their bifurcation just medial to ovarian vessel and run downwards along with greater sciatic notch & reaches ischial spine.
Urinary Tract Fistulas -(VVF) Etiology, Diagnosis, ManagementVikas V
Urinary Tract Fistulas - Etiology, Diagnosis, Management
Surgical and Relevant Anatomy, Classification, eitiology, VVF in Detail, Examination and Diagnosis, Management of VVF - Both Conservative And Surgical Management - Steps of Surgical Management, Post operative Management.
Ureteric injury in Gyenec Surgery, Serious complication of gynecologic surgery
Significant morbidity and long-term sequelae
Uncommon in benign gynecologic surgery
Vaginal hysterectomy has the lowest rate of ureteral injury
Laparoscopic hysterectomy has the highestThe ureters are the muscular ,thick walled narrow tubes(Right and Left)
Each measures 25-30 cm in length and extends from renal pelvis to its entry in the bladder.The ureter are located retroperitonealy and run from the renal pelvic to urinary bladder.
First part –Enter the pelvis by crossing the common iliac vessel from lateral to medial aspect at their bifurcation just medial to ovarian vessel and run downwards along with greater sciatic notch & reaches ischial spine.
Classification & conservative surgeries for prolapseIndraneel Jadhav
Stage 0
no prolapse
- Aa,Ba,Ap,Bp are all at -3
- C or D between tvl and < tvl -2
Stage I
most distal portion > 1cm above level of hymen
Stage II
<1cm proximal to or distal to the plane of hymen
Stage III
>1cm below the plane of the hymen
Stage IV
complete eversion, distal portion at least (tvl -2 cm)
In cases of Nulliparous prolapse or even patients deserving child bearing uterus preserving surgeries are done.
Recently even for prolapse if women want to preserve uterus for variety of reasons ,with newer minimally invasive methods it is now gaining popularity.Larger studies and longer followup is required.
Classification & conservative surgeries for prolapseIndraneel Jadhav
Stage 0
no prolapse
- Aa,Ba,Ap,Bp are all at -3
- C or D between tvl and < tvl -2
Stage I
most distal portion > 1cm above level of hymen
Stage II
<1cm proximal to or distal to the plane of hymen
Stage III
>1cm below the plane of the hymen
Stage IV
complete eversion, distal portion at least (tvl -2 cm)
In cases of Nulliparous prolapse or even patients deserving child bearing uterus preserving surgeries are done.
Recently even for prolapse if women want to preserve uterus for variety of reasons ,with newer minimally invasive methods it is now gaining popularity.Larger studies and longer followup is required.
Maternal birth canal injury following child birth process are quite common and significant to maternal morbidity and even to death. Also, a second most frequent cause of PPH.
Urinary diversion procedures are performed to divert urine from the bladder to a new exit site, usually through a surgically created opening (stoma) in the skin.
These procedures are primarily performed when a bladder tumor necessitates removal of the entire bladder (cystectomy).
Urinary diversion has also been used in managing pelvic malignancy, birth defects, strictures, trauma to ureters and urethra, neurogenic bladder, chronic infection causing severe ureteral and renal damage, and intractable interstitial cystitis and as a last resort in managing incontinence.
There are two categories of urinary diversion:
1. Cutaneous urinary diversion : in which urine drains through an opening created in the abdominal wall and skin.
2. Continent urinary diversion : in which a portion of the intestine is used to create a new reservoir for urine.
Ureteral injury is one of the most serious complications of gynecologic surgery. Ureteral injury during laparoscopic surgery has become more common as a result of the increased number of laparoscopic hysterectomies and retroperitoneal procedures that are being performed.
A lecture about the management approaches for abdominal vascular injuries. Injury to the major arteries and veins in the abdomen are technical challenge to the surgeon and are often fatal. All vessels are susceptible to injury with penetrating trauma. Vascular injuries in blunt trauma are far less common and usually involve the renal arteries and veins, though all other vessels, including the aorta, can be injured. Blunt trauma results from deceleration, AP compression or pelvic fractures.
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VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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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
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
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
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
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.