1. URETERIC INJURIESURETERIC INJURIES
DURINGDURING
GYNAECOLOGICALGYNAECOLOGICAL
SURGERIESSURGERIES
Dr. SARITA SABHARWALDr. SARITA SABHARWAL
SENIOR CONSULTANTSENIOR CONSULTANT
MATA CHANAN DEVI HOSPITALMATA CHANAN DEVI HOSPITAL

2. INTRODUCTIONINTRODUCTION
 Gynaecological diseases can involve the ureter directlyGynaecological diseases can involve the ureter directly
or cause the course of the ureter to deviateor cause the course of the ureter to deviate
 Moreover, the anatomical proximity of the femaleMoreover, the anatomical proximity of the female
urinary and genital tracts makes injury to the ureters aurinary and genital tracts makes injury to the ureters a
constant threat during gynaecological surgeriesconstant threat during gynaecological surgeries
 Ureteric injuries are far more serious and troublesomeUreteric injuries are far more serious and troublesome
than injury to the bladder and the rectum, they beingthan injury to the bladder and the rectum, they being
the other two important sites of potential surgicalthe other two important sites of potential surgical
trauma during pelvic surgerytrauma during pelvic surgery

3.  Common surgical procedures leading to ureteric injuriesCommon surgical procedures leading to ureteric injuries
could becould be
 During colorectal surgery for cancerDuring colorectal surgery for cancer
 Inflammatory bowel diseaseInflammatory bowel disease
 With appendicectomyWith appendicectomy
 With iliac endarterectomyWith iliac endarterectomy
 Other procedures done by urological surgeonsOther procedures done by urological surgeons
However 75% of the injuries result fromHowever 75% of the injuries result from
gynaecological operationsgynaecological operations

4. INCIDENCEINCIDENCE
 It is one of the most serious complications of a majorIt is one of the most serious complications of a major
gynaecological procedure with incidence varying fromgynaecological procedure with incidence varying from
0.4 – 2.5%0.4 – 2.5% as reported in different studiesas reported in different studies for benignfor benign
conditionsconditions, but can be as high as, but can be as high as 30% in operations30% in operations
for malignanciesfor malignancies
 About 75% of ureteric injuries occur during abdominalAbout 75% of ureteric injuries occur during abdominal
gynaecological procedures with incidence ofgynaecological procedures with incidence of 0.5 – 1%0.5 – 1%
for abdominal hysterectomy compared with 0.1%for abdominal hysterectomy compared with 0.1%
for vaginal hysterectomyfor vaginal hysterectomy

5. MAGNITUDE OF THEMAGNITUDE OF THE
PROBLEMPROBLEM
Can be easily missed , particularly whenCan be easily missed , particularly when
unilateralunilateral
ONLY 1/3 OF CASES ARE DIAGNOSEDONLY 1/3 OF CASES ARE DIAGNOSED
INTRAOPERATIVELYINTRAOPERATIVELY
Delay in diagnosis can lead to severeDelay in diagnosis can lead to severe
morbidity and even loss of renal functionmorbidity and even loss of renal function
Also the most common cause forAlso the most common cause for
medicolegal action against gynaecologistsmedicolegal action against gynaecologists

6. ANATOMICALANATOMICAL
CONSIDERATIONSCONSIDERATIONS
Ureter has three layersUreter has three layers
1. The transitional epithelium lining the lumen
2. The smooth muscle comprising of longitudinal,
circular and spiral fibres providing regular and
peristaltic waves
3. The adventitious sheath containing and
protecting the blood vessels

8.  25 – 30cm25 – 30cm in length, traversesin length, traverses retroperitoneallyretroperitoneally
from the renal pelvis to the bladderfrom the renal pelvis to the bladder
 The abdominal part lies on the anterior surfaceThe abdominal part lies on the anterior surface
of the psoas muscle, and crosses over the iliacof the psoas muscle, and crosses over the iliac
vessels to the pelvic inletvessels to the pelvic inlet
 They are crossed anteriorly by the ovarianThey are crossed anteriorly by the ovarian
vessels as they approach the pelvisvessels as they approach the pelvis

9.  Within the pelvis , the ureter lies close to theWithin the pelvis , the ureter lies close to the
iliac vesselsiliac vessels
 It passes beneath the uterine artery about 1.5cmIt passes beneath the uterine artery about 1.5cm
lateral to the cervix at the level of the internal oslateral to the cervix at the level of the internal os
 It enters the tunnel in the cardinal ligamentIt enters the tunnel in the cardinal ligament
 It passes medially over the anterior vaginalIt passes medially over the anterior vaginal
fornix before entering the wall of the bladder,fornix before entering the wall of the bladder,
just above the trigone –just above the trigone – “ knee of the ureter ”“ knee of the ureter ”

13. Blood SupplyBlood Supply
 UPPER SEGMENTUPPER SEGMENT – renal and ovarian arteries– renal and ovarian arteries
 MIDDLE SEGMENTMIDDLE SEGMENT – directly from aortic– directly from aortic
branches and the common iliac arteriesbranches and the common iliac arteries
 LOWER SEGMENTLOWER SEGMENT (Pelvic ureter)(Pelvic ureter) – uterine ,– uterine ,
vaginal , middle haemorrhoidal , vesical andvaginal , middle haemorrhoidal , vesical and
hypogastric arterieshypogastric arteries

15. ANATOMICAL LOCATIONS OFANATOMICAL LOCATIONS OF
URETERIC INJURIESURETERIC INJURIES
Unilateral is more common than bilateral (5-10%)Unilateral is more common than bilateral (5-10%)
 At theAt the pelvic brimpelvic brim during ligation of theduring ligation of the
infundibulopelvic ligamentinfundibulopelvic ligament
 At theAt the base of the broad ligamentbase of the broad ligament, where the ureter, where the ureter
passes beneath the uterine arterypasses beneath the uterine artery
 Beyond the uterine vessels as the ureter passes throughBeyond the uterine vessels as the ureter passes through
itsits tunnel in the cardinal ligamenttunnel in the cardinal ligament at the level of theat the level of the
internal osinternal os

16.  At theAt the anterolateral fornix of the vaginaanterolateral fornix of the vagina as theas the
ureter enters the bladderureter enters the bladder
 Along the course of the ureter on the lateralAlong the course of the ureter on the lateral
pelvic sidewallpelvic sidewall just above the uterosacraljust above the uterosacral
ligamentligament
 Lateral pelvic sidewall over the iliac vesselsLateral pelvic sidewall over the iliac vessels
during lymphnode dissectionduring lymphnode dissection

17. GYNAECOLOGICAL PROCEDURES ASSOCIATEDGYNAECOLOGICAL PROCEDURES ASSOCIATED
WITH URETERIC INJURIESWITH URETERIC INJURIES
AbdomianlAbdominal Vaginal Laparoscopic
Hysterectomy
Wertheim’s hysterectomy
Oopherectomy
Uterine suspension
Burch colposuspension
Vesicovaginal fistula repair
Hysterectomy
Anterior colporrhaphy
VVF repair
Division of adhesions
Transection of
Uterosacral ligaments
Colposuspension
Treatment of endometriosis
Sterilisation
(especially electrocoagulation)

18. TYPES AND CAUSE OF INJURYTYPES AND CAUSE OF INJURY
Intraoperative injury to the ureter may result fromIntraoperative injury to the ureter may result from::
 Ligation with sutureLigation with suture
 Crushing with misapplication of a clampCrushing with misapplication of a clamp
 Transection (partial or complete)Transection (partial or complete)
 Angulation with secondary obstructionAngulation with secondary obstruction
 Ischaemia – Due to diathermyIschaemia – Due to diathermy
 Intensional resection during operations for malignancyIntensional resection during operations for malignancy
 Electrical , thermal , or laser energy, or from linearElectrical , thermal , or laser energy, or from linear
stapler during laproscopystapler during laproscopy

19. Factors predisposing to ureteric injuryFactors predisposing to ureteric injury
 Presence of large ovarian masses, Fibroids (esp.Presence of large ovarian masses, Fibroids (esp.
broad ligament fibroid), endometriosis and PIDbroad ligament fibroid), endometriosis and PID
 Previous pelvic surgeriesPrevious pelvic surgeries leading to adhesionsleading to adhesions
 Pelvic irradiationPelvic irradiation for cancersfor cancers
 Congenital anomaliesCongenital anomalies such as uretericsuch as ureteric
duplication (in 1%), mega-ureter,and ectopicduplication (in 1%), mega-ureter,and ectopic
ureter or kidneyureter or kidney

20.  Two large retrospective studies by Goodno JATwo large retrospective studies by Goodno JA etet
alal and Liapis Aand Liapis A et alet al in the year 2001 showed thatin the year 2001 showed that
pelvic malignancies were presentpelvic malignancies were present in 44%in 44% ofof
ureteric injuries - due to pelvic adhesions, largeureteric injuries - due to pelvic adhesions, large
masses displacing the ureters and anatomicalmasses displacing the ureters and anatomical
changes distorting the course of the ureterchanges distorting the course of the ureter
Half of all ureteric injuries occur duringHalf of all ureteric injuries occur during
““simple” hysterectomysimple” hysterectomy

21. PREVENTION

22. Primary preventionPrimary prevention
 Proper preoperative evaluation of the diseaseProper preoperative evaluation of the disease
 Proper surgical techniquesProper surgical techniques
However even the most skilful gynaecologicalHowever even the most skilful gynaecological
surgeon will injure the ureter inadvertentlysurgeon will injure the ureter inadvertently
but on rare occasions!!but on rare occasions!!

23. Abdominopelvic surgeryAbdominopelvic surgery
 Adequate incisionAdequate incision
 Tracing of uretersTracing of ureters before clamping tissuesbefore clamping tissues
 Ureter can be seen crossing the iliac arteries ,Ureter can be seen crossing the iliac arteries ,
which is identified by peristalsiswhich is identified by peristalsis
 Adequate mobilization of bladderAdequate mobilization of bladder

24.  Clamping the uterines close to the uterus.Clamping the uterines close to the uterus.
 Blind reclamping of the tissues to be avoidedBlind reclamping of the tissues to be avoided
 Use of intrafascial technique in hysterectomyUse of intrafascial technique in hysterectomy
 Leaving the adventitious sheath intact duringLeaving the adventitious sheath intact during
ureteric dissectionureteric dissection

27. Vaginal SurgeryVaginal Surgery
 In anterior colporrhaphy, during cystoceleIn anterior colporrhaphy, during cystocele
repair, sutures should not be inserted too deeplyrepair, sutures should not be inserted too deeply
while plicating the bladderwhile plicating the bladder
 In vaginal hysterectomy – develop adequateIn vaginal hysterectomy – develop adequate
vesico-uterine space before clampingvesico-uterine space before clamping
 Care in placing posterior culdoplasty suturesCare in placing posterior culdoplasty sutures

30. Laproscopic surgeryLaproscopic surgery
 Uncommon – seen 0.3-0.4% of all casesUncommon – seen 0.3-0.4% of all cases
 Avoiding electrocoagulation of bleeding pointsAvoiding electrocoagulation of bleeding points
around uterosacral ligaments and use of suturesaround uterosacral ligaments and use of sutures
or clips insteador clips instead
 In Laparoscopic Assisted Hysterectomy, it isIn Laparoscopic Assisted Hysterectomy, it is
better to ligate uterine and cardinal ligamentbetter to ligate uterine and cardinal ligament
pedicles vaginally if width and length of staplerpedicles vaginally if width and length of stapler
makes application difficultmakes application difficult

31. Other preventive measuresOther preventive measures
Ureteric stentingUreteric stenting
 Preoperative placement if a difficult surgery isPreoperative placement if a difficult surgery is
anticipatedanticipated
 Benefit is controversialBenefit is controversial
 KunoKuno et al.,et al., in their study did not find stenting toin their study did not find stenting to
affect rate of injuryaffect rate of injury
 BothwellBothwell et al.,et al., found 1% risk of iatrogenicfound 1% risk of iatrogenic
uterine injury. They mentioned that cathetersuterine injury. They mentioned that catheters
may aid in intraoperative detection of injuriesmay aid in intraoperative detection of injuries

32.  Lighted uterine stents are popular in advancedLighted uterine stents are popular in advanced
laproscopic surgeries allowing visualisation oflaproscopic surgeries allowing visualisation of
the ureter , but are of limited value in presencethe ureter , but are of limited value in presence
of masses or dense adhesions.of masses or dense adhesions.

33. ImagingImaging
 Preoperative IVP or Contrast Enhanced CTPreoperative IVP or Contrast Enhanced CT
when distorted anatomy is anticipatedwhen distorted anatomy is anticipated
 Normal IVP has not found to decreaseNormal IVP has not found to decrease
incidence and dispel surgeon’s responsibilityincidence and dispel surgeon’s responsibility

34. DIAGNOSISDIAGNOSIS

35. Intra-operativeIntra-operative
 Prompt identification of injury is importantPrompt identification of injury is important
 Dye testDye test - intravenous pyridium, indigo carmine- intravenous pyridium, indigo carmine
or methylene blue (5 ml) can be used.or methylene blue (5 ml) can be used.
Urinary extravastion is seen within 3-5 mts.Urinary extravastion is seen within 3-5 mts.

36.  Cystoscopy- detects only obstructive injuriesCystoscopy- detects only obstructive injuries
The disadvantage is that it does not recogniseThe disadvantage is that it does not recognise
 non obstructivenon obstructive
 partially obstructivepartially obstructive
 late injuries secondary to ischaemia andlate injuries secondary to ischaemia and
avascular necrosisavascular necrosis

37.  Use of perioperative laproscopic ultrasoundUse of perioperative laproscopic ultrasound
probeprobe
Ureteric complication should be suspectedUreteric complication should be suspected
 ureteric diameter exceeds 3.0mmureteric diameter exceeds 3.0mm
 no peristaltic activity is visible during 5 min ofno peristaltic activity is visible during 5 min of
follow-upfollow-up
 clear echodense caudally progressing contractionclear echodense caudally progressing contraction
segments are absent.segments are absent.

38. POSTOPERATIVEPOSTOPERATIVE
SYMPTOMS AND SIGNS OF URETERIC INJURYSYMPTOMS AND SIGNS OF URETERIC INJURY
SYMPTOMSSYMPTOMS TIME OFTIME OF
PRESENTATIONPRESENTATION
Loin or flank painLoin or flank pain 0-21days0-21days
FeverFever 0-21days0-21days
Adynamic ileus/peritonitisAdynamic ileus/peritonitis 0-7days0-7days
FistulasFistulas 0-30days0-30days
Lower abdominal or pelvicLower abdominal or pelvic
massmass
20-40days20-40days
AnuriaAnuria <24hrs<24hrs
AsymptomaticAsymptomatic Incidental findingIncidental finding

39. InvestigationsInvestigations
 White cell count - leucocytosisWhite cell count - leucocytosis
 Urea, creatinine and electrolytesUrea, creatinine and electrolytes
 IVPIVP
HydronephrosisHydronephrosis
Delayed functionDelayed function
Non-visualisationNon-visualisation
ExtravasationExtravasation
UrinomaUrinoma
StrictureStricture

40.  Retrograde/antegrade ureterogram/nephrogramRetrograde/antegrade ureterogram/nephrogram
ExtravasationExtravasation
FistulaFistula
ObstructionObstruction
 USG abdomen & pelvis may show hydronephrosis,USG abdomen & pelvis may show hydronephrosis,
 CT Scan urinoma or ascitesCT Scan urinoma or ascites
 Fistulogram/ double dye test – with methylene blue in theFistulogram/ double dye test – with methylene blue in the
bladder and Pyridium intravenouslybladder and Pyridium intravenously
 Cystoscopy – As a rule, the ureteric orifice will not spurt urineCystoscopy – As a rule, the ureteric orifice will not spurt urine
on the affected sideon the affected side
 Fluid analysis from drains, ascitic collection- will confirm theFluid analysis from drains, ascitic collection- will confirm the
presence of urine in cases of urinoma or ureterocutaneouspresence of urine in cases of urinoma or ureterocutaneous
fistulasfistulas

41. MANAGEMENTMANAGEMENT
 The aims of treatment are preservation ofThe aims of treatment are preservation of
renal function and restoration of anatomicalrenal function and restoration of anatomical
continuitycontinuity

42. KEY POINTSKEY POINTS
 Proper counselling of patientProper counselling of patient
 Thorough knowledge of the anatomy of theThorough knowledge of the anatomy of the
ureter and the possible sites of injuryureter and the possible sites of injury
 Early diagnosis and management of injuries toEarly diagnosis and management of injuries to
reduce morbidity and save renal lossreduce morbidity and save renal loss

43. “ THE VENIAL SIN IS INJURY TO
THE URETER; THE MORAL SIN
IS FAILURE OF RECOGNITION”

44. THANK
YOU!