This document discusses ureteric injury as a complication of gynecologic surgery. It covers the incidence, risk factors, applied anatomy of the pelvic ureter, common sites of injury, prevention strategies, and management approaches. Ureteric injury can occur in 0.03-6% of hysterectomies, with laparoscopic hysterectomy having the highest risk. The pelvic ureter has variable anatomy and is susceptible to injury at sites like the pelvic brim. Prevention focuses on proper identification and dissection of the ureter during surgery. Management depends on the severity and timing of injury but may involve stenting, urinary diversion, or ureteral reimplantation

1. URETERIC INJURY
Dr. Jograjiya

2. INRODUCTION
• 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 highest

3. INCIDENCE
• Accepted incidence 0.35% to 0.4%
• Incidences of all hysterectomy range
from 0.03 to 6.0 percent
• (1) vaginal hysterectomy 0.2/1000,
• (2) supracervical abdominal hysterectomy
0.5/1000,
• (3) total abdominal hysterectomy
0.9/1000,
• (4) laparoscopic hysterectomy 7/1000.

4. APPLIED ANATOMY OF
PELVIC URETER

5. • The 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.

6. PELVIC URETERFirst strait 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.

7. Second or oblique part

8. • At the level of ischial spines
it runs in the broad
ligament and enter the
ureteric canal formed by
the cardinal ligament,
crossed by the uterine
vessels running anterior to
ureter.
• Here, It is 1.5 cm lateral to
cervix.
• The ureter runs medially
and enter the bladder close
to the anterior vaginal wall .
On left side it even can
cross the vaginal angle .
Ureters while running at
base of broad ligament ,are
also very close to utero
sacral ligament.

9. Third Intramural part

14. • The ureter is supplied
by : Renal , Gonadal,
Common iliac ,
Internal iliac, vescical
Uterine arteries and
the Abdominal aorta.
• The venous drainage
generally follows the
arterial supply.
BLOOD SUPPLY

15. LYMPHATIC DRAINAGE
• Lymph drains into sub mucosal
,intramuscular and adventitial plexuses
,which all communicates.
INNERVATION
• The ureter is supplied from the T10 ,T11,
T12 ,L1, S1 and S2 segment of spinal cord
by branches from the renal and aortic
plexuses and the superior and inferior
hypogastric plexuses.

17. Most common
• Most common site: Pelvic brim near the
infundibulopelvic ligament
• Most common type of injury: Obstruction
• Most common activity leading to injury:
Attempts to obtain hemostasis
• Most common time of diagnosis: None:
50-50 during intraoperative and
postoperative

18. Common sites of ureteric injury
1.At the pelvic brim during
clamping of infundibulopelvic
ligament.

23. 2. At the bifurcation of
common iliac artery during
internal iliac artery ligation.

25. 3. Lateral pelvic wall above
the uterosacral ligament.

27. 4. Base of broad ligament ,
ureter passes under the
uterine artery.

29. 5. Ureteric canal-During
Wertheim hysterectomy.

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

34. 7. Upper vagina during
clamping of vaginal angle.

36. RISK FACTORS FOR
URETERIC INJURIES
1. ANATOMICAL RISK FACTORS.
2. PATHOLOGICAL RISK FACTORS.
3. TECHNICAL RISK FACTORS

37. 1.ANATOMICAL RISK FACTORS:
A)THE URETER:
• Has close attachment to the
peritoneum.
• Closely related to female genital
tract.
• Has variable course.
• Not easily seen or palpated.

38. 2.PATHOLOGICAL RISK FACTORS:
1. Congenital anomalies of ureter or Kidney.
2. Ureteric displacement by:
Uterine size ≥12 weeks.
Prolapse.
Tumour{ovarian neoplasm}.
Cervical fibroid/Ca.
broad ligament swellings(fibroids , incarcirated
ovarian tumours or hematomas)
3.Adhesions:
Previous pelvic surgery.
Endometriosis.
PID.
Extention of carcinomatous indurations in broad
ligaments , post irradiation.
4.Distorted pelvic anatomy.

39. 3.TECHNICAL RISK FACTORS
• Massive intraoperative haemorrhage.
• Coexistent bladder injury.
• Technical difficulties.
• Inexperienced surgeon.

40. TYPES{CAUSES}OF INJURY
INTRAOPERATIVE
• Crushing from misapplication
of a clamp.
• Ligation with a suture.
• Transection{partial or
complete}
• Angulation of the ureter with
secondary obstruction.
• Ischemia from ureteral
stripping , LASER or
electrocoagulation.
• Resection of a segment of
ureter.
• Any combination of these
injuries may also occur.
POSTOPERATIVE
• Avascular necrosis
following werthiem.
• Kinking-peritonisation of
vaginal stump after
hysterectomy.
• Subsequent obstruction
over:
-Haematoma or
-Lymphocele

41. In ½ OF THE cases URETERIC
INJURy is not identified at the
time of primary injury during
surgery

42. ABDOMINAL
• Hysterectomy.
• Wertheim’s hysterectomy.
• Oophorectomy.
• Uterine suspension.
• Burch colposuspension.
• Vesicovaginal fistula repair.
LAPROSCOPIC
• Division of adhesions.
• Electrocoagulative injury
while uterine arteries are
coagulated or ligated.
• Transection of uterosacral
ligament.
• Colposuspension
• Treatment of
endometriosis.
• Sterilisation
(electrocoagulation)
PROCEDURE ASSOCIATED WITH URETERIC
INJURIES
VAGINAL
• Hysterectomy.
• Anterior colporrhaphy
• Vesicovaginal fistula
repair.
• Culdoplasty

43. Prevention strategies to reduce the risk of
ureteric injuries
• General preventive strategies:
Preoperative
Intraoperative
• Specific Preventive strategies:

44. GENERAL PREVENTIVE STRATEGIES
A .Preoperative measure:
• Intravenous urogram(IVU).
• Ultrasound scan.
• Previous investigations ,can identify
ureteric dilatation and disclose
anatomical variations.
• Preoperative stenting in conditions of
anatomical distortion.

45. INTRAOPERATIVE PREVENTION
• Surgeon is to constantly and equivocally know
where ureter is all times.
• Appropriate operative approach.
• Adequate exposure.
• Avoid blind clamping and ligature of blood
vessels.
• Mobilise bladder away from operative site
• Stay outside vascular sheath.
• Limit the zone of coagulation to avoid thermal
injury.
• Ureteric dissection and direct visualisation.

46. IDENTIFICATION OF URETER
• The peritoneal reflection anterior to
the uterus is incised and the bladder
is pushed down with blunt or sharp
dissection.
• Pelvic ureter is identified on the
medial aspect of the broad ligament
during the opening of perivescical
spaces while performing extended
hysterectomy or removing broad
ligament tumors.

49. IMAGING
• No proof that
preoperative IVU or CE-
CT reduces risk of injury.
• Endometriosis , PID
uterovaginal prolapse
and previous intra -
abdominal surgery are
associated with
increased prevalence of
abnormal IVU finding.

50. A}During Abdominal
hysterectomy:-
Clamp infundibulopelvic ligament
after lifting up the ligament
dissection and palpation ,clamp
near to the ovary.
-Always clamp{cardinal ,
Uterosacral} ligaments close to
the uterus.
-Never to open vagina unless
urinary bladder is dissected down
properly and sufficiently.
-Use of intrafacial technique.
SPECIFIC PREVENTIVE STRATEGIES

51. B}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 :as the distance between needle and
ureter in upper vagina ≤0.9 cm.

52. • C)During laparoscopy: can be achieved by:
• -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.

71. MANAGEMENT

72. AIM OF MANAGEMENT
• Preservation of function.
• Anatomical continuity.
• Decision depends on-
Time of detection
Extent of injury
Site of injury
General condition of patient

83. STENTING Insert a silicone internal
stent through the
anastomosis before
closure.
Advantages :
1. Maintenance of a straight
ureter with a constant
caliber during early
healing,
2. The presence of a conduit
for urine during healing,
3. Prevention of urinary
extravasation,
4. Maintenance of urinary
diversion,
5. Easy removal

84. Urinary diversion
• To divert urine from the
bladder to a new exit site.
• Usually through a surgically
created opening (stoma) in
the skin.

85. Introduction
• Diversion of urinary pathway
from its natural path
• Types:
–Temporary
–Permanent

86. Temporary urinary diversion
• Suprapubic cystostomy
• Pyelostomy or
nephrostomy or
urethrostomy (with
indwelling catheters)

87. Illustration of suprapubic tube
placed to aid bladder drainage
Suprapubic Cystostomy

88. A nephrostomy is
a surgical
procedure by
which a tube,
stent, or catheter
is inserted
through the skin
and into the
kidney.

89. Permanent urinary diversion
• Uretero - sigmoidostomy
• Ileal conduit
• Colon conduit
• Ileocaecaecal segment
• Lowsley’s operation

90. Types of urinary
diversions
Cutaneous urinary
diversions
•Ileal conduit (ileal loop)
•A 12 cm loop of ileum
led out through
abdominal wall
•Stents used
•The space at cystectomy
site drained by a drainage
system
•After surgery a skin
barrier and a transparent
disposable urinary
drainage bag
•Constantly drains

92. Complications of ileal conduit
• Wound infection
• Wound dehiscence
• Urinary leakage
• Ureteric obstruction
• Small bowel obstruction
• Ileus
• Stomal gangrene
• Narrowing of the stoma
• Pyelonephritis
• Renal calculi

93. Cutaneous
Ureterostomy…

94. Vescicostomy

95. Nephrostomy…

96. Uretero- sigmoidostomy
• Complications:
–Reflux of urine
–Hyperchloraemic acidosis
–Renal infection
–Stricture formation

97. Continent Urinary Diversions
• Continent Ileal Urinary Reservoir
Indiana Pouch
• Most common continent urinary diversion
• Periodically catheterized
Koch Pouch
Charleston Pouch
Ureterosigmoidostomy
• Voiding occurs from rectum

100. Koch
Pouch II

101. ureterosigmoi
dostomy

103. Bladder reconstruction

104. Recto sigmoid pouch

105. Potential complications
• Peritonitis due to disruption of
anastomosis
• Stomal ischaemia and necrosis due to
compromised blood supply to stoma
• Stoma retraction and separation of
mucocutaneous border due to tension
or trauma