1. URETERIC INJURY
In
OBGY
Dr Mohit Satodia
GMCH-32
Chandigarh

2. incidence
• 75 % of the ureteric injuries occur during
gynaecological surgeries
• Incidence is .3 to .4 %
• Most common procedure :total abdominal
hysterectomy(.5 to 1%)
• Vaginal hysterectomy(.1%)
• Gynae-oncosurgery(30%)

3. Interesting facts……
• Most common site:-pelvic brim near the
infundibulopelvic ligament
• Most common type of injury:-obstruction
• Most common activity leading to injury:attempts to obtain haemostasis
• Most common time of diagonosis:-none
• Most common long term sequele:-none

4. Course of ureter

9. Blood supply of ureter

11. Common sites of injury
• Lateral pelvic sidewall above the uterosacral
ligament
• Dorsal to infundibulopelvic ligament near or at
the pelvic brim
• Cardinal ligament
• Tunnel of Wertheim
• Intramural portion of the ureter

13. Anatomical risk factors
• Ureter……..
1.Has close attachment to peritoneum
2.Has variable course
3.Not easily seen or palpated.

14. Pathological risk factors
• Congenital anomalies of ureter or kidney
• Ureteric displacement by:
1.Uterine size >/=12 weeks
2.Prolapse
3.Tumour
4.Cervical or broad ligament swellings
• Adhesions
1.Previous pelvic surgeries
2.Endometriosis
3.PID
• Distorted pelvic anatomy

15. Technical factors
•
•
•
•
Massive intraoperative haemorrhage
Coexistant bladder injury
Technical difficulties
Inexperienced surgeon

16. Types of injuries
• Intraoperative
1. Crushing(misapplication of a clamp)
2.Ligation(with a suture)
3.Angulation(with secondary obstruction)
4.Ischaemia(stripping,laser,electrocoagulation)
5.Transection(partial or complete)
6.Resection

17. • Post operative
1.
2.
3.
•
•
Avascular necrosis
Kinking
Subsequent obstruction over:
Haematoma
Lymphocele

18. Procedures asso. with ureteric injuries
• Abdominal
1.
2.
3.
4.
5.
6.
Hysterectomy
Werthiem’s hysterectomy
Oopherectomy
Uterine suspension
Burch colposuspension
Vesicovaginal fistula repair

19. • Vaginal
1.Hysterectomy
2.Anterior colporrhaphy
3.Vesicovaginal fistula repair
4.Culdoplasty

20. • Laparoscopic
1.
2.
3.
4.
5.
Division of adhesions
Transection of uteroscral ligaments
Colposuspension
Treatment of endometriosis
Sterilisation(especially with
electrocoagulation)

21. Preventive strategies
• General preventive strategies
1.Preoperative
2.Intraoperative
• Specific preventive strategies

22. General preventive strategies
• Preoperative measures
1.Intravenous urogram
2.Ultrasound scan
Identify ureteric dilatation and disclose anatomic
variations
3.Preop stenting in case of anatomic distortion

23. • Intraoperative measures
1.Appropriate operative approach
2.Adequate exposure
3.Avoid blind clamping of blood vessals
4.Mobilise bladder away from the operative site
5.Stay outside the vascular sheath
6.Zone of thermal injury
7.Dissection should preferably be done under direct
visualisation

24. • surgeon is to constantly
and equivocally know
where the ureter is all
times

29. Specific preventive measures
• Laparoscopy associated injuries
 .3 to .4 % of all the cases
 More likely result of thermal injury
 More likely to be diagonosed 2 to 5 days after the
surgery
 Most commonly during laparoscopic hysterectomy
---when uterine vessals are stapled or electrocoagulated
---infundibulopelvic ligament is transected
 Extreme caution when using cautery or laser near or
over the ureter

30. • Complex adnexectomy
 Between pelvic brim to tunnel of werthiem
 Ureter is commonly injured
 Injuries can be avoided using retroperitoneum
approach…..advantages:
1.Access the pelvic vessals for haemostasis
2.Adhesion and pathology free space to operate
 If an adnexal mass is adherant to the medial half of the
broad ligament or pelvic peritoneum overlying the
ureter ,the ureter can be safely dissected laterally from
the peritoneum

31. • Abdominal hysterectomy
 From where ureter enters tunnel under uterine artery ,lateral to the
uterosacral ligaments,until ureter terminates in the bladder
 High risk of injury
-LUS fibroid or cervical fibroid,protruding into broad ligament
-bleeding from pedicals ,esp at the vaginal corners
 Myomectomy of a broad ligament fibroid should be preferred by
incision adjacent to the ureter and cervix,staying within the
myometrial capsule
 Bleeding from pedicles or vaginal angle should be controlled by a
“superficial”3-0 sutures
 Intrafascial hysterectomy,by creating a plane within the
myometrium of LUS and cervix after ligating uterine artery vessels
 Fearful of injury:-21 gauge butterfly needle technique.

32. • Caesarean hysterectomy
Supracervical hysterectomy
Hysterotomy incision can be extended
caudally towards the cervix-allow tactile as
well as visual guidance

33. • Vaginal hysterectomy
Uncommon because traction on the cervix
pulls the uterus farther from the ureter
Culdoplasty places the ureter at risk
Maneuvres:1.Palpatory ureteral identification
2.Placinng an allis clamp on the vaginal cuff in
the area of uterosacral ligament

34. • Bladder neck suspension
 During retropubic repair
 How can injury occur/
-vigorous dissection of space of retzius and
periurethral tissues
-high elevation of burch colposuspension suture
-paravaginal defect repair in combination with
burch procedure
-excessive lateral mobilisation of the bladder brings
ureter into thhhe operative field

35. • Pelvic organ prolapse
relatively common
due to :
1. Direct ligation
2. Kinking as redundant tissues are plicated
 Cystoscopy with iv indigo carmine can be
routinely performed.

36. • Radical pelvic surgery
 Intentional ureteral surgery:
1.MD Anderson type IV radical hysterectomy
2. Total or anterior pelvic exenteration
3.Resection of a fixed pelvic sidewall mass
 Accidental:
1.MD Andersons type 3 radical hysterectomy
2.Radical vaginal trachelectomyfor women with FIGO
stage 1A1 to 1B1 cervical cancer
 30 %risk of ureteral dysfunction following therapuetic
radiation therapy.

44. Aim of management
• Preservation of renal function
• Anatomical continuity
• Decision depends upon:1.Time of detection
2.Extent of injury
3.Site of injury
4.General condition of the patient

45. Conservative?
• Obstruction without intraperitoneal or
retroperitoneal leakage
• No major degree of obstruction
• Obstruction is not the result of a permanent
agent
• Small ureteral leak in the setting of prior pelvic
radiation
• For patient waiting for definite repair

46. When to operate?
• If diagonosed immediate post op:-reoperation
within 24 to 48 hrs
• If diagonosed later:-delayed repair

47. General guidelines for the Mx of
ureteral injuries identified at the time
of surgery
• Ureteral ligation:Deligation,assessment of the viability,stent placement
• Partial transection:Primary repair over a ureteric stent
• Total transection: Uncomplicated upper third and middle third:Ureteroureterostomy over ureteral stent
 Complicated upper third and middle third:Ureteroileal interposition
 Lower third:Ureteroneocystostomy with psoas hitch over ureteral stent
• Thermal injury:Resection with Mx as per a transection

49. Ureteral ligation
 Angulation or kinking is much more common if sutures are within
the paraurethral tissues or partially placed through the ureter
 First management approach:-PCN
 Contrast is injected to see if even a small trickle of dyr gets past the
obstruction;if yes,a thin guidewire is passed down th ureter past
the obstruction;if successful,larger catheters are passed over
it;finally a double J stent left in place for 6 to 8 weeks till the
sutures causing obstruction have dissolved
 If obstruction is too tight to be stented or ureter is partially or
completely ligated:-surgical ureterolysis
 If the concerned segment is
viable:stent(ureterostomy,cystoscopy,cystostomy)
if dead:-resect

50. Partial transection
 Repair is easiest and fastest(ureterotomy has
already occurred)
 A stent is placed up and down through the
ureterotomy
 A small hole:-stent is not necessary
 Excessive suture placement is avoided
 Healing is usually rapid and complete
 A closed suction drain is placed at the base of the
repair

52. Note……..
Be sure that ureteroureterostomy is
completely tension free
During spatulation be sure that vessals
running in the ureteral sheath are not
transected
Spatulation if done on opposing sides
,ensures a complete water tight seal

60. Thanx……..