This document discusses ureteric injuries that can occur during hysterectomy and how they are detected and treated. It notes that the overall incidence of ureteric injury during hysterectomy is 0.4% and risk factors include previous surgery, endometriosis, and dense adhesions. Common sites of injury are where the ureter crosses the uterine artery and in the tunnel of Wertheim. Injuries can be detected by checking for urine efflux during cystoscopy and using retrograde pyelography to visualize the ureters with dye. Prevention involves thorough knowledge of pelvic anatomy, ligation techniques to avoid the ureters, and identifying the ureters before ligating other structures in complex

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

2. UROLOGIST USUALLY CALLED FOR…
 Urinary bladder injury
 Ureteral injury

3. HYSTETRECTOMY AND URETERIC INJURY
 Over all incidence 0.4%

4. RISK FACTORS
 Adhesion due to previous surgery
 Endometriosis
 Pelvic inflammatory disease
 Large uterus/myoma
 cutting dense adhesions and fibrotic scar tissue
 trying to stop bleeding close to the ureter with
bipolar cautery
 ligating the uterine vessels with bipolar
electrosurgery, staples, or suture

5. COMMON SITES OF URETERIC INJURY
 Cardinal ligament where ureter crosses under
uterine artery
 Tunnel of Wertheim’s
 Intramural ureter
 Dorsal to infundibulopelvic ligament at pelvic brim
 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 Linde’s operative Gynecology, 9th edition

7. INTROPERATIVE DETECTION
 Even gross injury can be
missed
 Injury near infundibulopelvic
ligament- collection of urine,
free lying ureter
 Injury near Uterine- difficult to
detect.
 In difficult cases- ureter
should be prospectively
identified and dissected and
preserved

8. SUSPICION OF URETERIC INJURY
• Immediate
cystoscopy before
laparoscope removed
• Check efflux of urine
• RGP (retrograde pyelogram)
• 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

10. SUSPICION OF URETERIC INJURY
• Immediate
cystoscopy before
laparoscope removed
• Check efflux of urine
• RGP (retrograde pyelogram)
• 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

12. RGP PICTURE

13. SUSPICION OF URETERIC INJURY
• Immediate
cystoscopy before
laparoscope removed
• Check efflux of urine
• RGP (retrograde pyelogram)
• 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

14. PREVENTION OF URETERIC INJURY
 Good anatomical knowledge of pelvic course of
ureter.

15. PREVENTION OF URETERIC INJURY
 Clamps or ligatures should be placed and elevated high
enough so that only targeted ligaments and vessels are
caught in the clamp.
• Extensive cauterion
•Stapling device
•Suture ligation

16. PREVENTION OF URETERIC INJURY
 The cardinal ligament should be cut close to the
cervix, after checking the panoramic view.

17. INTRAFASCIAL HYSTERECTOMY
COMPLEX ADNEXECTOMY
ENTER RETROPERITONEAL SPACE
DISSECTION OF VESSELS AND URETER

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
 492 patients
 92/492- bilateral ureteric cathetar – no injury
 Up down movement before firing stapler
 7/92 - complication
 400/492 – no ureteteric cathetar –no injury
 Routine use no warrented
Wood EC, Maher PJ, M P. Complications of ureteric catheters at laparoscopic
hysterectomy. J Am Assoc Gynecol Laparosc 1996; 3: 393–7.

20. INTRAOPERATIVE CYSTOSCOPY
 Total118 patients
 4 ureteric injury identified and dealt with.
 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.

21. DELAYED PRESENTATION
 Fever
 Flank pain
 Abdominal distention
 Paralytic ileus
 Leucocytosis
 Watery vaginal discharge

22. THANK YOU

23. INTRAFASCIAL HYSTERECTOMY
COMPLEX ADNEXECTOMY
ENTER RETROPERITONEAL SPACE
DISSECTION OF VESSELS AND URETER