Ureteral Injury During Gynecologic Surgery Workup
- Author: Sandip P Vasavada, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
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- If the ureteral injury is noted intraoperatively, additional laboratory tests are rarely, if ever, needed. Imaging studies are of greater benefit.
- If ureteral injury is suspected postoperatively, laboratory tests, including a complete blood cell count (CBC) with manual differential and an electrolyte panel with blood urea nitrogen (BUN) and serum creatinine level, are needed to assess for possible infection and renal dysfunction.
- In the event that a CT-guided aspiration of an abdominal or pelvic fluid collection has occurred or if pelvic drain output is high through a surgically placed drain, a creatinine measurement of the fluid may be helpful in distinguishing whether the fluid is urine (as would be indicated by an elevated creatinine level).
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- If the ureteral injury is noted intraoperatively and an imaging study is necessary to localize the lesion, the best choice is retrograde ureteropyelography. After placement of a cystoscope in the bladder and cannulation of the affected ureteral orifice with a ureteral catheter, dilute diatrizoate (eg, Cystografin) is injected into the ureter under fluoroscopy or while taking a kidneys, ureters, bladder (KUB) image. If the dye is seen in the renal pelvis without any ureteral extravasation or significant narrowing along the ureter, the ureter is in continuity and the case may be managed conservatively, with either observation or stent placement.
- If ureteral injury is suspected postoperatively, imaging studies evaluating for hydronephrosis, ipsilateral renal function, and continuity of the ureter are necessary. These imaging studies may include intravenous urography (IVU), abdominal and pelvic CT scan with intravenous contrast, renal ultrasonography, and/or retrograde ureteropyelography.
- While IVU largely has fallen out of favor in the evaluation of stone disease, many urologists believe that an IVU is the best imaging study to evaluate for continuity of the ureter in cases of ureteral injury. Unlike renal ultrasonography and a retrograde ureteropyelography, IVU is used to assess for function of the ipsilateral kidney and the drainage of the ureter in a series of sagittal images. Hydronephrosis, ureteral integrity, and any extravasation can usually be seen readily with IVU.
- A computed tomography (CT) scan can also be used to assess for both function of the ipsilateral kidney and drainage of the ureter. Because CT images are a series of cross sections, visualizing ureteral integrity and continuity is often more difficult with CT scanning than with IVU. However, CT scanning has the advantage of imaging for concomitant conditions at the same time.
- Renal ultrasonography is perhaps the best noninvasive method to visualize the kidney and shows hydronephrosis with great sensitivity. Renal ultrasonography cannot be used to assess kidney function or the continuity of the ureter. Therefore, if renal ultrasonography is performed, retrograde ureteropyelography is often necessary to evaluate the course of the ureter.
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- Postoperatively, if any drainage is noted from the vagina, an attempt should be made to diagnose a ureterovaginal or vesicovaginal fistula. This may be accomplished with a bedside test. In this test, a tablet of oral phenazopyridine (eg, Pyridium) is administered. The bladder is instilled via a catheter with saline that is colored with methylene blue. A vaginal tampon is inserted. Since phenazopyridine turns the urine orange, if an orange liquid is observed on the end of the tampon, a presumptive diagnosis of a ureterovaginal fistula can be made. Alternatively, if the tampon absorbs a blue liquid, the diagnosis of vesicovaginal fistula can be made. However, since both types of fistulas may be present simultaneously, this test may not be completely reliable.
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- If the patient is unsuitable for surgery because of sepsis or hemodynamic instability, urinary diversion in the form of a percutaneous nephrostomy tube placement should be performed. This allows decompression of an enclosed and potentially infected space and helps to treat a urinary source of sepsis.
In very rare cases, ureteral injuries are first diagnosed based on identification of the ureter histologically in the pathologic specimen.
Saidi MH, Sadler RK, Vancaillie TG, et al. Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol. 1996 Feb. 87(2):272-6. [Medline].
Tamussino KF, Lang PF, Breinl E. Ureteral complications with operative gynecologic laparoscopy. Am J Obstet Gynecol. 1998 May. 178(5):967-70. [Medline].
Adelman MR, Bardsley TR, Sharp HT. Urinary tract injuries in laparoscopic hysterectomy: a systematic review. J Minim Invasive Gynecol. 2014 Jul-Aug. 21(4):558-66. [Medline].
Barbier HM, Smith MZ, Eto CU, Welgoss JA, Von Pechmann W, Horbach N, et al. Ureteral Compromise in Laparoscopic Versus Vaginal Uterosacral Ligament Suspension: A Retrospective Cohort. Female Pelvic Med Reconstr Surg. 2015 Nov-Dec. 21 (6):363-8. [Medline].
Davis, DM. Intubated ureterotomy: a new operation for ureteral and ureteropelvic strictures. Surg Gynecol Obstet. 1943. 76:851.
Gill H, Broderick GA. Urologic complications of gynecologic surgery. Vol 13. AUA Update Series. 1994:254-9.
Miller EA. Ureteroureterostomy and Transureteroureterostomy. Smith JA Jr, Howards SS, Preminger GM, Eds. Hinman's Atlas of Urologic Surgery. 3rd ed. Phiuladelphia PA: Saunders; 2012. 747-50.
Hodges CV, Barry JM, Fuchs EF, et al. Transureteroureterostomy: 25-year experience with 100 patients. J Urol. 1980 Jun. 123(6):834-8. [Medline].
Mathews R, Marshall FF. Versatility of the adult psoas hitch ureteral reimplantation. J Urol. 1997 Dec. 158(6):2078-82. [Medline].
Konigsberg H, Blunt KJ, Muecke EC. Use of Boari flap in lower ureteral injuries. Urology. 1975 Jun. 5(6):751-5. [Medline].
Abboudi H, Ahmed K, Royle J, Khan MS, Dasgupta P, N'Dow J. Ureteric injury: a challenging condition to diagnose and manage. Nat Rev Urol. 2013 Feb. 10(2):108-15. [Medline].
Lee Z, Kaplan J, Giusto L, Eun D. Prevention of iatrogenic ureteral injuries during robotic gynecologic surgery: a review. Am J Obstet Gynecol. 2015 Oct 28. [Medline].
Jones N, Fleming ND, Nick AM, Munsell MF, Rallapalli V, Westin SN, et al. Conversion from robotic surgery to laparotomy: a case-control study evaluating risk factors for conversion. Gynecol Oncol. 2014 Aug. 134(2):238-42. [Medline]. [Full Text].
Gellhaus PT, Bhandari A, Monn MF, Gardner TA, Kanagarajah P, Reilly CE, et al. Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes. BJU Int. 2014 Apr 21. [Medline].
Carlton CE, Scott R, Guthrie AG. The initial management of ureteral injuries: a report of 78 cases. J Urol. 1971 Mar. 105(3):335-40. [Medline].
Harkki-Siren P, Sjoberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol. 1998 Jul. 92(1):113-8. [Medline].
Anger JT. Bladder Flap Repair (Boari). Smith JA Jr, Howards SS, Preminger GM, Eds. Hinman's Atlas of Urologic Surgery. 3rd ed. Philadelphia PA: Saunders; 2012. 731-4.
Sherman ND. Psoas Hitch. Smith JA Jr, Howards SS, Preminger GM, Eds. Hinman's Atlas of Urologic Surgery. 2nd ed. Philadelphia PA: Saunders; 2012. 727-30.
Kim JH, Moore C, Jones JS, Rackley R, Daneshgari F, Goldman H, et al. Management of ureteral injuries associated with vaginal surgery for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2006 Sep. 17(5):531-5. [Medline].
Koo HP, Bloom DA. Lower ureteral reconstruction. Urol Clin North Am. 1999 Feb. 26(1):167-73, x. [Medline].
Mariotti G, Natale F, Trucchi A, et al. Ureteral injuries during gynecologic procedures. Minerva Urol Nefrol. 1997 Jun. 49(2):95-8. [Medline].
Nakada SY, Pearle MS, Clayman RV. Acucise endopyelotomy: evolution of a less-invasive technology. J Endourol. 1996 Apr. 10(2):133-9. [Medline].
Sieben DM, Howerton L, Amin M, et al. The role of ureteral stenting in the management of surgical injury of the ureter. J Urol. 1978 Mar. 119(3):330-1. [Medline].
Soong Y, Lim PH. Urological injuries in gynaecological practice--when is the optimal time for repair?. Singapore Med J. 1997 Nov. 38(11):475-8. [Medline].
Thompson JD. Operative injuries to the ureter: prevention, recognition, and management. Te Linde’s Operative Gynecology. 8th ed. 1997. 1135-73.
Wolf JS Jr, Elashry OM, Clayman RV. Long-term results of endoureterotomy for benign ureteral and ureteroenteric strictures. J Urol. 1997 Sep. 158(3 Pt 1):759-64. [Medline].