Operative Injuries to the Ureter and Bladder

OPERATIVE INJURIES TO THE URETER

Dr Raina

“ The venial sin is injury to the ureter, but the mortal sin is failure of recognition”

Ureteric Injuries

Incidence:

0.2-1.0% during any abdominal or pelvic surgery

Obstetric or gynecological surgery accounts for approximately 50% of all these injuries

Ref: Jha S, Coomaraswamy A, Chan KK. Ureteric injury in obstetric and

gynecological surgery. The obstetrician and gynecologist 2004;6:203-208, RCOG

Risk of ureteric injury in obstetric and gynecological procedures

Obstetric Gynecological cesarean section hysterectomy(abdominal) cesarean hysterectomy vaginal hysterectomy forceps subtotal hysterectomy others Wertheims hysterectomy

Urogynecological Burch colposuspension Transvaginal tape

Laparoscopy Adnexectomy LAVH Adhesiolysis Ablation of endometriotic deposits

Anatomy of the Ureter

2 major components abdominal pelvic

25-30cm in length

Course of ureter

Course of the ureter

The distance between the uterine isthmus and the ureter is not always the same on each side

Blood supply to the ureter

Ovarian artery

Renal artery

Internal iliac

Sup vesicalInf vesical

Risk Factors

Certain factors have been found to increase the

risk of ureteric injury during surgery: An enlarged uterus Previous pelvic surgery Ovarian neoplasm Endometriosis Pelvic adhesions Distorted pelvic anatomy Massive intraoperative hemorrhage

However it is notable that more than half of all injuries have no identifiable predisposing factor

Types of Ureteral Injuries

CrushingLigation with a sutureTransectionAngulation with secondary obstructionIschemiaResection of a segment of ureter Laparoscopic

Anatomical Locations of Ureteric Injuries

Injury occurs most frequently in the lower third of the ureter

The most common sites of injury:• Lateral to the uterine vessels• The area of the ureterovesical junction• Base of the infundibulopelvic ligament as the ureters

cross the pelvic brim• At the level of the uterosacral ligaments

In the obstetric patient, ureteral injury can occur when suturing an extended uterine incision in an effort to control bleeding within the broad ligament or during a cesarean hysterectomy

Sequelae of Ureteral Injury

Spontaneous resolution and healing Posthydronephrotic renal atrophy with or without sepsis Ureteral necrosis, extravasation and fistula formation Secondary stenosis of the ureteral lumen/ stenosis of the fistula tract Uremia (b/l ureteral injury)

Ureterovaginal fistula formation

1. Ureteral necrosis and occlusion following injury

2. Loss of ureteral wall with urinoma formation

3. - Ureterovaginal fistula - Ascending periureteral

infection - Perinephric abscess

Prevention of ureteric injury

Pre operatively: • Careful evaluation of the patients gynecologic

disease and recognition of the risk to the ureter with the surgical procedure planned

• Preoperative IVU: no role in preventing ureteric injuries in routine procedures

• Prophylactic ureteric catheterization: not shown to reduce the risk of ureteric injury in routine cases

Prevention of ureteric injury…

Intra operative (general)

• Appropriate operative approach• Adequate exposure• Avoid blind clamping of vessels• Ureteric dissection and direct visualization• Mobilize bladder away from operative site• Short diathermy applications


Specific: Abdominal Hysterectomy -If the ovary is to be removed, the infundibulopelvic ligament

should be clamped with the first clamp being the lowest and most lateral clamp

-During clamping of uterine vessels, after skeletonization, place the lowest clamp first place it at right angles to the uterus place it at the level of the internal cervical os

- Intrafascial technique of removing the cervix (to avoid injury between the uterine vessels and the bladder base)

- adequate mobilization of the bladder downward and outward

- direct visualization of the ureters


Vaginal surgery:• Adequate vesicouterine space • Downward traction on the cervix and counter traction upward beneath the bladder• Small bits of parametrial and paracervical tissue

clamped, cut and ligated

Anterior colporrhaphy:• Avoid starting too laterally or inserting sutures

too deeply while plicating the bladder to prevent needle injury to the ureter

Symptoms and signs of ureteric injury

FeverFlank painHematuriaAbdominal distensionAbscess formation/sepsisUrinary leakageRetroperitoneal urinoma

Radiographic investigations for ureteric injuries

Intravenous urogramAbdominal and pelvic CT scan with intravenous contrastRetrograde ureterogramRenal ultrasoundCystoscopy

Management

Case presentation

Mrs A37 yrs with DUB for 10 yrs, failed medical managementTAH with rt salpingo oophorectomy on 18/5/07 Presented on 2/6/07 (16th POD) with c/o

fever – 1 day

spotting PV – 1 day

watery discharge PV – 2 days

Case presentation…

O/E: Febrile (103 F) vital signs stable systemic examination: NAD P/A: - soft - tenderness on deep palpation; left side - no mass palpable - pfannensteil scar-healed by primary intention - bluish ecchymosed patches around wound site


P/S: vault healthy

minimal watery discharge; clear

no purulent/blood stained discharge

no obvious fistulous site seen

P/V: no obvious mass felt


Initial Investigations: CBP: WNL

Urine R & M: Pus cells: 8 - 10

RFT: serum creatinine: 1.2 ( )

blood urea – Normal

USG: complex mass seen

Initial management:• Patient was catheterized; started on T pyridium and broad

spectrum antibiotic coverage• Urine was discolored suggesting the diagnosis of urogenital

fistula• Patient transferred to KMC Manipal for further management


Further investigations & management

• Cystourethroscopy: ? Vesico vaginal & lower ureteric fistula+

• IVP: confirmed the presence of vesicovaginal & ureterovaginal fistula; ureteral stenting attempted; not successful

• Percutaneous nephrostomy done; stenting re attempted; not succesful

• Follow up and surgery after 3 months


Why urogenital fistula??

• Risk factors: intra operative hemorrhage; blind

clamping of vessels• Ureter not identified during surgery• Badder not mobilized away from operative

site

References

Te Linde RW, Thompson JD, Rock JA. Te Linde’s operative gynecology. Philadelphia: Lippincott-Raven; 1997

Jha S, Coomaraswamy A, Chan KK. Ureteric injury in obstetric and gynecological surgery. The obstetrician and gynecologist 2004;6:203-208, RCOG press

Chan JK, Morrow J, Manetta A. Prevention of ureteral injuries in gynecologic surgery. Am J Obstet Gynaecol 2003;188:1273-1277

Thank you

Operative Injuries to the Ureter and Bladder

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