Urological complication during obstetrical and gynecological surgeries

Urological complication during Obstetrical
and Gynecological Surgeries
by
Hassaan Ali Gad
Assistant lecturer of urology
Aswan University
hassaan.ali@aswu.edu.eg

OUTLINES
• INTRODUCTION
• APPLIED ANATOMY
• INCIDENCE
• RISK FACTORS
• SITES OF INJURY
• MECHANISM OF INJURY
• MANAGEMENT
• PREVENTION

• INTRODUCTION
• APPLIED ANATOMY
• INCIDENCE
• RISK FACTORS
• SITES OF INJURY
• MANAGEMENT
• PREVENTION

INTRODUCTION
 The female genital and urinary tracts are anatomically
closely related.
 The potential for injury to the urinary system must always
be considered when operating on the genital system
 Bladder injuries are the most frequent urologic injury
usually recognized and repaired immediately,
 Ureteral injuries(70%) typically are not recognized
immediately & can lead to long term complications
 Injury to urinary tract in medical practice was first
described on 1030 ADby Avicenna Ibn Sina
in his first medical textbook which called “Al-Kanoun”.

APPLIED ANATOMY OF URINARY SYSTEM
KIDNEY -> regulate blood volume and composition,
regulate pH, hormones and excrete waste
URETERS -> Transport urine from kidney to bladder
BLADDER -> store urine and expels through urethra
URETHRA -> discharge urine from the body

Ureteral anatomy Abdominal Part
The ureters are bilateral tubular structures
responsible for transporting urine from the
renal pelvis to the bladder ,they are generally
22 to 30 cm in length
The abdominal part lies on the anterior
surface of the psoas muscle, and crosses over
the iliac vessels to the pelvic inlet
They are crossed anteriorly by the ovarian
vessels as they approach the pelvis

Ureteral anatomy Pelvic 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.
 It passes under the uterine artery about 1.5cm lateral to
the cervix at the level of the internal os
 It enters the tunnel in the cardinal ligament
 It passes medially over the anterior vaginal fornix before
entering the wall of the bladder, just above the trigone

IDENTIFICATION
• Tubular longitudinal reteroperitoneum structures
• Pale glistening appearance
• Longitudinal vessels on the surface
• Peristalsis movement

INCIDENCE
Summerton et al, 2018 Guidelines on Urological
Trauma EAU

Summerton et al, 2018 Guidelines on Urological Trauma
EAU

RISK FACTORS
• Enlarged uterus
• Previous pelvic surgery or radiation
• Advanced malignancy
• Endometriosis, PID
• Pelvic adhesions
• Distorted pelvic anatomy
• Coexistent bladder injury
• Massive intra-operative hemorrhage

SITES OF INJURY
The lower third of ureter is most frequent site (51%), upper
third(30%) and middle third(19%).
• Most common sites of injury are:
• open surgery
 Base of the infundibulo pelvic ligament as ureters cross
pelvic brim at ovarian fossa
 Base of broad ligament ureter passes under the uterine
artery
 Lateral pelvic wall above the uterosacral ligament
 Area of ureterovesical junction close to cardinal ligaments

SITES OF INJURY
• Laparoscopic surgeries
• Laser ablative endometriosis
• Laparoscopic-assisted vaginal hysterectomy (LAVH)
• Laparoscopic tubal ligation,
• Laparoscopic adnexectomy
• Laparoscopic uterosacral ligament ablation
• Most LAVH ureteral injuries occur near cardinal
and uterosacral ligaments.
• Caused by either thermal-electrocautery or sharp
dissection, CO2 laser, endoscopic linear stapler and loop
ligature

Base of the infundibulo pelvic ligament as ureters cross pelvic brim at
ovarian fossa

. Base of broad ligament ureter passes
under the uterine artery.

Lateral pelvic wall above the
uterosacral ligament

Upper vagina during clamping of
vaginal angle.

Ureteric canal-During hysterectomy

Intramural portion near the insertion into the trigon
when base of bladder is injured or repaired

Mechanism of injury
 Crushing with clamp- necrosis
 Ligature- sutures/ linear stapler
 Transection- Partial/ Complete
 Ischaemia- Diathermy Stripping of adventitia
 Segmental Resecton-
 Thermal burns- Diathermy (Mono > Bi-
Polar), Laser energy
 Angulation with secondary obstruction
partial/ complete

Americal Association for the Surgery of
Trauma(AAST) Ureteral injury grading scale:

• INTRODUCTION
• APPLIED ANATOMY
• INCIDENCE
• RISK FACTORS
• SITES OF INJURY
• PREVENTION
• MANAGEMENT

PREVENTION
• Primary prevention
• Proper preoperative evaluation of the disease
• Proper surgical techniques
• Ultrasound scan.
• Contrast study
• Preoperative stenting in conditions of anatomical
distortion
Makes Identification Easier
Cannot Prevent Injury
Cost-effectiveness ?
Fibrotic Condition(endometriosis) Makes Palpation Difficult

INTRAOPERATIVE PREVENTION
Proper anatomical knowledge of the surgeon
• Surgeon should know where ureter is in all times by direct visualization or
palpation
• Adequate exposure.
• Avoid blind clamping and ligature of blood vessels.
• Mobilize bladder away from operative site
• Stay outside vascular sheath.
• Limit the zone of coagulation to avoid thermal injury.
• Meticulous care during dissection
• Structures at risk should always be dissected sufficiently to alow
identification and retraction out of harm's way
• Dissection/ mobilization of ureters not always indicated But should be
identified at susceptible places, try to stay outside the adventitia

During Abdominal surgery
 Divide round ligament near lateral pelvic side wall ,lat to
ovarian vessels, then open the lateral peritoneum, then Identify
ureter on the medial leaf of the peritoneum
 Palpate ext iliac artery with index finger move the finger
upward- the first structure to be exposed, crossing and in contact
with it, will be the ureter
 Place index finger over the ureter while clamping IPL
 Ureter is followed towards the cardical ligament, where it
passes under the uterine artery-gently push it lateraly and
downward, moving it away from Cervix- with traction on the uterus to
expose the uterine artery

During Vaginal surgery
1. Prevention of ureteric injuries can be achieved by adequate
development of vescico-uterine space , by:
-Downward traction on the cervix.
-Counter traction upward by Sim’s speculum below the bladder.
2. All clamp:-
Small bites.
-Close to the uterus.
3. Avoid double clamping of uterosacral ligament.
4. Vaginal Oophorectomy should be avoided or done cautiously.
5. During anterior colporrhaphy:
- Avoid too lateral dissection .
- Avoid deep suture

C)During laparoscopy:
Moving the fallopian tubes away from pelvic side walls before
coagulation.
The bleeding points at uterosacral ligaments should be secured
with sutures or clips instead of electrocoagulation
In LAVH place stapler or suture across uterine vessels and
cardinal ligaments instead of electrocoagulation.

Special measures
 Complex adnexectomy
Use retroperitoneal space- ureter is seen on the medial leaf of Br
ligament
 If mass is adhered to the medial leaf
Dissect the ureter from the medial leaf
If not possible to mobilize ureter-
Leave a small portion of Tx adhered to the ureter (chance of future
obstruction)
Segmental resection-anastomosis of the ureter

Special measures
• Hysterectomy for difficult fibroid
• Myomectomy- incision adjacent to uterus/ Cx- stayvwithin myometrial capsule
• If myomectomy not possible, trace ureter along the whole length in
pelvic part
• Obstetric hysterectomy
• Supra cervical hysterectomy
• Total hysterectomy- extend hysterotomy incision caudally toward Cx- place
finger into endo cervical canal and vagina- place clamp adjacent to Cx

AIM OF MANAGEMENT
• Preservation of anatomical continuity of the ureter and normal
renal function
• Immediate repair of ureteral injury advisable.
• Optimal time for repair of a ureteral injury is during the
operation; the tissues are in their best condition, and likelihood
for success are greatest.
• Immediate repair provides better results and fewer
complications than in a delayed fashion

Principles of surgical repair of ureteral injury:
• Debridement of necrotic tissue.
• Ureteric dissection preserving adventitial sheath and its
blood supply.
• Spatulation of ureteral ends.
• Tension-free, water tight mucosa-to-mucosa anastomosis
with absorbable sutures.
• Internal stenting.
• External drain.

Sequalae Of Injury
• Spontaneous healing- minimum injury
• Hydroureter/ Hydronephrosis- gradual loss of renal function-
due to obstruction
• Urinoma (localized collection) / Urinary ascites , infection
• Fistula
Uretero-uterine
uretero-vaginal
uretero-cutaneous
• -Stenosis of fistula→ hydronephrosis

Take home messages
• Most ureteric injuries can be prevent by mastering
knowledge of ureteric anatomy
• Suspicion and intra operative detection improves
diagnosis
• Early involvement of urologist in decision making during
ureteric repair
• Skilled post operative monitoring help to detect ureteric
injury before renal compromise
• Ureter phobia can be over come by revision and re
revision of your anatomy text book and subsequent
application intraoprtive

Thank
you

Urological complication during obstetrical and gynecological surgeries

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