The document discusses ureteric injuries during gynecologic surgery. It notes that ureteric injuries can lead to serious complications like ureterovaginal fistulas and renal impairment. The document outlines risk factors for injury including surgical complexity, patient anatomy, and surgeon experience. It provides details on injury prevention, identification, and various surgical and nonsurgical management strategies depending on injury characteristics and timing of detection. The key message is that most ureteric injuries can be prevented through anatomical knowledge and early detection improves prognosis.

1. Dr.Mai Banakhar
Assistant Professor Urology
Neuromodulation & Pelvic Reconstructive Surgery

2. o Introduction
o Applied anatomy
o Types of injury
o Common sites of injury
o Predisposing factors
o Identification of injury
o Prevention
o Management
o Take home message

3. } Injury to pelvic ureters is serious operative
complications of gynecologic surgery.
} High morbidity.
} Ureterovaginal fistulas .
} Potential loss of kidney function.
} Renal function impairment is greater risk in Ureteric
injuries as compared to bladder injuries .

4. } Urinary tract operative injuries occur in the course of
gynecological procedures due top the close
development (embryological) and proximity of the
urogenital systems.
} 52-82% of operative Ureteric injuries occur during
gynecologic surgery.
} 30% gynaec-onco surgery

5. Abdominal
1. Hysterectomy
2. Wertheim s hysterectomy
3. Oophorectomy
4. Uterine suspension
5. Vesicovaginal fistulae repair
Laparoscopic
1. Transection of uterosacral
ligament
2. Colposuspension
3. Treatment of
endometriosis
4. Sterilization (especially
Electrocoagulation)
Vaginal
1. Hysterectomy
2. Anterior colporrhaphy
3. Cervical biopsy
4. Culdoplasty
5. Vesicovaginal fistulae replair

6. } Hysterectomy is frequently performed .
} It is associated with a small but significant risk of
surgical morbidity and between 2 -10 / 1000 suffer
Ureteric injury.
Garry, R. The future of Hysterectomy. BJOG Feb 2005; volume 112; PP 133-139

7. } 1.3-2.2% abdominal hysterectomies
} 1.3% laparoscopic hysterectomies
} 0.03% vaginal hysterectomies
} As the experience increased with operative
laparoscopy ,the incidence of all major complications
has declined but Ureteric injuries have stayed constant
at 1%
Purandare C N. Urological injuries in gynecology. J Obstet Gynecol India 2007; 57 (3); 203-204.
Harkki-Siren P, Sjoberg J, Kurki T. Major complication of laparoscopy; A follow up Finnish study. Obstetrics & Gynecology 1999; 94-98

9. } The ureter enter the pelvis at the common iliac
bifircation, then courses along the lateral side of the
uterosacral ligament to enter the base of the broad
ligament .Approximately 1.5 cm lateral to the cervix
the ureter passes underneath the uterine artery (at the
level of internal cervical os).It then passes medially
over the anterior vaginal fornix before entering the
trigone of the bladder .

14. The ureters may be injured open and /or laparoscopic
hysterectomy due to:
Intraoperative:
1. Crushing injury (clamp)
2. Ligation (suture)
3. Transsection ( partial,
complete)
4. Angulation
5. Ischemia (ureteral
stripping,
Electrocoagulation)
6. Resection of ureteral
segment.
Postoperative
1. Avascular necrosis
2. Obstruction:
Haematoma, lymphocele

16. Four anatomical locations:
} Along the lateral border of uterosacral ligament
} At or below the infundibulopelvic ligament
} Base of the broad ligament
} Tunnel of Wertheim in the broad ligament
} Cardinal ligament where the ureter passes under the
uterine vessels
} Where the ureter lies in close proximity to the anterior
vaginal wall and enters the base of the bladder
Gao JS, Leng JH, Lang JH, Liu ZF, Shen K, Sun, DW, Zhu L. Ureteral injury in Gynecologic laparoscopies. Chin Med Sci J, 2007; 22(1); 13-6.
Santucci, R A. Ureteral Trauma, http// www.emedicine.com. Feb 2008.
Purandare C N. Urological injuries in gynecology. J Obstet Gynecol India 2007; 57 (3); 203-204.
Jha S, Coomarasamy A . Chan K K. Ureteric injury in obstetric and gynaecological surgery. The Obstetrician and Gynaecologist 2004; 6; 203-208.
Thompson JD. Operative injuries to the ureter: prevention, recognition, and management Te Linde s Operative Gynecology. 8th ed. 1997:1135-73.

17. Anatomical Risk factors
1. Ureter attached peritoneum
2. Close to female genital Tract
3. Ureter has variable course
4. Not easily seen or palpated
Pathological risk factors
1. Congenital anomalies of ureter/
kidney
2. Ureteric displacement: (uterus
size ≥12 weeks, prolapse, Tumors
(ovarian),cervical or broad
ligament swelling.
3. Adhesions (previous pelvic
surgery, Endometriosis, PID)
4. Distorted pelvic anatomy
Technical Risk Factors
1. Massive intraoperative hemorrhage
2. Coexisting bladder injury
3. Technical difficulties
4. Inexperienced surgeon
½ of ureteric injuries has no
identifiable risk factors

18. } Most commonly the ureter is injured in the lower third
of its pelvic course .
} Two thirds of ureteric injuries are not recognized intra
operatively.
Intraoperative recognition important to be repaired &
renal functional compromise can be avoided
Prevention & Intraoperative recognition

19. General strategies
} Preoperative
1. To identify ureteral abnormalities
IVP ????? Risk of injury
2. Preoperative stenting
} Intraoperative
1. Where is the ureter
2. Adequate exposure
3. Stay outside the vascular sheath
zone of thermal injury
4. Ureteric dissection and direct
visualization
Specific strategies
Identify the ureter
Incise the peritoneal reflection between the
uterus and bladder & the bladder is reflected
inferiorly with sharp dissection
Ureteric stenting aid in the
intraoperative detection of Ureter,but
NO reduction in risk

20. Specific preventive strategies

26. The venial sin is injury to the ureter
, the moral sin is failure of recognition
Higgins

27. } Intraoperative
} Post operative
Almost ½ of ureteric injuries can be prevented ,out of
these ½ can be detected Intraoperativly

28. } Any suspicion… clarified
} Identify the nature and severity of injury
} Look for obstruction/ devascularization
} Dye test: intravenous methyleneblue, indigocarmine,
phenazopyridine, Extravasates at the site of injury 3-5
min
} Intraoperative Cystoscopy: RGP
} Non-obstructive, partially obstructive, late injuries
( ischemia, a vascular necrosis can be missed

29. } Spontaneous resolution and healing
} Hydronephrosis and gradual loss of renal function
} Urinoma, urinay ascites, infection in transection or
necrosis with urinary extravasation
} Fistula formation
} Uretero vaginal, uretero-uterine, uretero cutaneous
} Stenosis with insidious loss of renal function

30. } Loin flank pain 0-21 d
} Fever 0-21d
} Peritonitis, paralytic ileus 0-7d
} Fistula 0-30d
} Lower abdominal pain/ pelvic mass 20-40d
} Anuria if bilateral < 24h
} Asymptomatic incidental
} Frank discharge of urine from drain, vagina, or
abdominal wound

31. } Wbc
} U& electrolyte
} Ivp
} Rgp,
} Ultrasound
} Ct scan
} Fistulogram
} Cystoscopy
} Fluid analysis from drain, ascitic collection

32. } Ivp
} Gold standards for post op Dx
} Non visualized
} Dilatation
} Delayed dye spillage
} Peritoneal extravasation
} urinoma

33. Aim:
} Reservation of renal function
} Anatomical continuity
Decision depend on
} Time of detection
} Extend of injury
} Site of injury
} General condition of the patient

34. Conservative:
} If small injury, no obstruction, patient stable
} Time >5 days
} Ureteral stinting via PCN for 6-8 weeks
} When to operate?

35. } If injury detected within 5 days ,operate immediately
} After 5 days tissue edema, inflammation makes repair
difficult & definitive therapy is planned after 6 weeks
} To reserve renal function PCN immediately

36. } Miticulus dissection, preserving ureteral sheath with the
blood supply
} Tension free anastomosis ( ureteral mobilization)
} Water tight closure , absorbable suture.
} Peritonium or omentum to surround the anastomosis
} Drain ( closed, suction) to prevent urine collection
} Stenting the anastomotic site
} Consider proximal diversion with PCN if the ureteric
injury is large, completely transected,or the ureter lies
in bed of inflammation or fibrosis

37. } Distal ureter
Ureteric reimplannation

38. Middle ureters
} Short segment: end to end anastomosis
Ø Long defect:
q reimplannation
q Psoas hitch
q Boari flap

39. Upper ureter:
} Short segment: end to end anastomosis
} Long segment:
} Transureteroureterostomy
} Ilial replacement
} Auto transplantation
} Nephrectomy

41. } Mucosa sparing wall injury, oversewing with
absorbable suture
} Ureteral ligation, assessment of viability, stenting
} Partial transaction 1ry repair over stent
} Total transection:
Uncomplicated upper and middle: end to end
anastomosis over stent
} Complicated: TUU,ilial interposition,nephrectomy
} Lower third reimplantation over stent
} Thermal injury resection & then manage according to
the resected part
Call Urology team

42. } Ureteric stricture formation
} Stent and nephrostomy related problem
} Urinary tract infection
} Wound infection
} leakage from anastomotic site and haematoma
formation

43. } Most ureteric injuries can be prevented by mastering
the knowledge of ureteric anatomy.
} Suspicion and intraoperative detection improves
prognosis.
} Any suspicion… clarified
} Early involvement of urologist in decision making
during ureteric repair. Skilled postoperative monitoring
helps detect ureteric injury before renal compromise.