Ureteral Injury During Gynecologic Surgery

Updated: Dec 29, 2016
  • Author: Sandip P Vasavada, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Overview

Background

Ureteral injury is one of the most serious complications of gynecologic surgery. Less common than injuries to the bladder or rectum, ureteral injuries are far more serious and troublesome and are often associated with significant morbidity, the formation of ureterovaginal fistulas, and the potential loss of kidney function, especially when not recognized until postoperatively. For these reasons, injuries to the urinary tract, particularly the ureter, are the most common cause for legal action against gynecologic surgeons.

Despite the close anatomical association between the female reproductive organs and the ureter, injury to the ureter is relatively uncommon. Nevertheless, when a ureteral injury does occur, quick recognition of the problem and a working knowledge of its location and treatment are essential in providing patients with optimal medical care. The purpose of this article is to elucidate how and why ureteral injuries occur and to review their surgical and nonsurgical treatments.

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History of the Procedure

Berard (1841) and Simon (1869) reported the earliest recorded repairs of ureteral injuries in gynecologic surgery. While the exact details of this procedure are unknown, the ureter and its course were poorly understood. In the early 1900s, Dr John Sampson, then a young faculty member at Johns Hopkins University, conducted the first systematic study of the ureter. During the next 100 years, as the surgical management for gynecologic disease progressed, many contributions were made to the understanding of the etiology, prevention, diagnosis, and treatment of iatrogenic ureteral injuries.

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Problem

A significant ureteral injury is defined as any recognized or unrecognized iatrogenic trauma to the ureter that prevents it from functioning properly or effectively. The injury may lead to acute ureteral obstruction (eg, a ureter that is inadvertently ligated) or discontinuity (ie, inadvertent ureteral resection). If an injury to the ureter has occurred and is unrecognized, it may lead to chronic ureteral obstruction (ie, crush injury, ischemia) or the formation of fistulas.

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Epidemiology

Frequency

The frequency of ureteral injury following gynecologic surgery is approximately 1%, with a higher percentage of injuries occurring during abdominal hysterectomies and partial vaginectomies. Patients who have received pelvic radiation or who have advanced pelvic cancers requiring extensive surgical procedures are more likely to experience a ureteral injury.

The rate of ureteral injuries in laparoscopic procedures varies. While some physicians report that laparoscopic procedures have an equivalent rate of ureteral stricture formation secondary to ureteral injury, other authors argue that the rate of ureteral strictures is significantly higher. [1, 2]

A systematic review of 79 studies of gynecologic surgery for benign conditions found an adjusted ureteric injury rate of 0.3%.Postoperative ureteric injury detection rates per 1,000 surgeries were estimated at 1.6 without routine cystoscopy and 0.7 with routine cystoscopy. [3]

A systematic review of 37 studies by Adelman et al found that laparoscopic hysterectomy had an overall urinary tract injury rate of 0.73% and a ureteral injury rate that ranged from 0.2% to 0.4%, depending on procedure type. These investigators concluded that contrary to earlier published findings citing unacceptably high urinary tract injury rates, laparoscopic hysterectomy was a safe procedure in terms of the bladder and ureter. [4]

A review of 208 uterosacral ligament suspension procedures by Barbier et al found that ureteral compromises occurred in six of the 60 patients in whom a vaginal approach was used, but in none of the 148 patients in whom a laparoscopic approach was used. Although some of the cases of ureteral compromise in the vaginal group required only suture removal and replacement, a number required stent placement. [5]

Lighted stents have been used to assist in identifying the location of the ureters during laparoscopic surgery to help prevent iatrogenic injury. If the lighted stents are not visible during laparoscopic surgery, four options are available, as follows:

  • Reduce the intensity of the laparoscopic lighting. By dimming the lights, the light from the stent may become visible
  • Change the camera to a different port
  • Identify the ureter where it is visible and follow it down to the surgical field
  • Convert to an open procedure so that the ureter can be palpated and identified
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Etiology

The 6 most common mechanisms of operative ureteral injury are as follows:

  • Crushing from misapplication of a clamp
  • Ligation with a suture
  • Transsection (partial or complete)
  • Angulation of the ureter with secondary obstruction
  • Ischemia from ureteral stripping or electrocoagulation
  • Resection of a segment of ureter

Any combination of these injuries may occur.

Factors that predispose a patient to iatrogenic urologic injury incllude the following:

Ureteral injuries can be either expected or unexpected. They may be the result of carelessness or due to a technically challenging procedure.

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Pathophysiology

The pathophysiology of ureteral injury depends on many factors, including the type of injury and when the injury is identified. Ureteral injuries may have numerous consequences, including the following:

  • Spontaneous resolution and healing of the injured ureter
  • Ureteral necrosis with urinary extravasation
  • Ureteral stricture formation

Spontaneous resolution and healing

If the injury to the ureter is minor, easily reversible, and noticed immediately, the ureter may heal completely and without consequence. Inadvertent ligation of the ureter is an example of such an injury. If this injury is noticed in a timely fashion, the suture can be cut off the ureter without significant injury.

Hydronephrosis

If complete ligation of the ureter occurs, the urine from the ipsilateral kidney is prevented from draining into the bladder, leading to hydronephrosis and progressive deterioration of ipsilateral renal function. These events may occur with or without symptoms. If the urine in this obstructed system becomes infected, the patient will almost certainly become septic with pyonephrosis.

Ureteral necrosis with urinary extravasation

In complete unrecognized ligation of the ureter, a section of the ureteral wall necroses because of pressure-induced ischemia. The ischemic segment of the ureter eventually weakens, leading to urinary extravasation into the periureteral tissues. If the urinary extravasation drains into the adjacent peritoneum, urinary ascites may develop. If the urinary ascites is infected, peritonitis may ensue. If the peritoneum has remained closed, a urinoma may form in the retroperitoneum.

Ureteral stricture

Ureteral stricture may occur when the adventitial layer of the ureter is stripped or electrocoagulated. When the adventitia, the outer layer of the ureter that contains the ureteral blood supply (see the image below), is disturbed by either stripping or electrocoagulation, ischemia to a particular segment of ureter may result. Ischemic strictures of the ureter may then develop, leading to obstruction and hydronephrosis of the ipsilateral kidney.

An illustration of the blood supply to the ureter An illustration of the blood supply to the ureter running within the adventitial layer.

Uremia

Uremia results when ureteral injury causes total urinary obstruction. This may result from bilateral ureteral injury or from a unilateral injury occurring in a solitary functioning kidney. Anuria is the only immediate sign of imminent uremia. These cases require immediate intervention to preserve renal function.

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Presentation

Iatrogenic ureteral injury during gynecologic surgery may present either intraoperatively or postoperatively. Routine use of intraoperative cystoscopy increases the intraoperative detection rate of urinary tract injuries, but does not appear to have much effect on rates of postoperative injury detection. [3]  Intraoperative consultation with a urologist must be obtained when the injury is recognized immediately; these patients are best treated with primary ureteral repair during the same operation.

More than 70% of the time, unilateral ureteral injury is noticed postoperatively, when the patient may present with flank pain, prolonged ileus, fever, watery vaginal discharge, or elevated serum creatinine levels. In cases of bilateral ureteral injury, anuria is the first clinical sign.

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Indications

The indications for evaluation of ureteral injury following gynecologic procedures include the following:

  • Loin or costovertebral angle tenderness
  • Unexplained fever
  • Persistent abdominal distention
  • Unexplained hematuria
  • Escape of watery fluid through the vagina
  • Appearance of a lower abdominal or pelvic mass
  • Oliguria or elevated serum creatinine levels
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Relevant Anatomy

The relevant anatomy of the ureter is shown in the images below. Note the close proximity of the distal ureter to the uterine vessels. This is the site where injuries most commonly occur during gynecologic procedures. The next most commonly injured area is at the pelvic brim, in the area of the infundibulopelvic ligament.

Relevant anatomy of the ureter, illustrating its c Relevant anatomy of the ureter, illustrating its course from the renal pelvis to the bladder. Note the ureter's proximity at the pelvic brim to the infundibulopelvic ligament.
Relevant anatomy of the ureter. Notice the proximi Relevant anatomy of the ureter. Notice the proximity of the ureter to the uterine vessels at the level of the cervix. Most ureteral injuries following gynecologic surgery occur in this area.
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Contraindications

Relative contraindications for immediate operative repair include sepsis, hemodynamic instability, and coagulopathy.

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