URETERIC INJURY

Dr. Jograjiya

INRODUCTION• Serious complication of gynecologic

surgery

• Significant morbidity and long-term sequelae

• Uncommon in benign gynecologic surgery

• Vaginal hysterectomy has the lowest rateof ureteral injury

• Laparoscopic hysterectomy has the highest

INCIDENCE

• Accepted incidence 0.35% to 0.4%• Incidences of all hysterectomy range

from 0.03 to 6.0 percent• (1) vaginal hysterectomy 0.2/1000,• (2) supracervical abdominal hysterectomy

0.5/1000, • (3) total abdominal hysterectomy

0.9/1000, • (4) laparoscopic hysterectomy 7/1000.

APPLIED ANATOMY OF PELVIC URETER

• The ureters are the muscular ,thick walled narrow tubes(Right and Left)

• Each measures 25-30 cm in length and extends from renal pelvis to its entry in the bladder.

PELVIC URETERFirst strait part– Enter the pelvis by crossing the common iliac vessel from lateral to medial aspect at their bifurcation just medial to ovarian vessel and run downwards along with greater sciatic notch & reaches ischial spine.

Second or oblique part

• At the level of ischial spines it runs in the broad ligament and enter the ureteric canal formed by the cardinal ligament, crossed by the uterine vessels running anterior to ureter.

• Here, It is 1.5 cm lateral to cervix.

• The ureter runs medially and enter the bladder close to the anterior vaginal wall . On left side it even can cross the vaginal angle . Ureters while running at base of broad ligament ,are also very close to utero sacral ligament.

Third Intramural part

• The ureter is supplied by : Renal , Gonadal, Common iliac , Internal iliac, vescical Uterine arteries and the Abdominal aorta.

• The venous drainage generally follows the arterial supply.

BLOOD SUPPLY

LYMPHATIC DRAINAGE

• Lymph drains into sub mucosal ,intramuscular and adventitial plexuses ,which all communicates.

INNERVATION

• The ureter is supplied from the T10 ,T11,

T12 ,L1, S1 and S2 segment of spinal cord by branches from the renal and aortic plexuses and the superior and inferior hypogastric plexuses.

Most common

• Most common site: Pelvic brim near the infundibulopelvic ligament

• Most common type of injury: Obstruction

• Most common activity leading to injury: Attempts to obtain hemostasis

• Most common time of diagnosis: None: 50-50 during intraoperative and postoperative

Common sites of ureteric injury

1.At the pelvic brim during

clamping of infundibulopelvic

ligament.

2. At the bifurcation of

common iliac artery during

internal iliac artery ligation.

3. Lateral pelvic wall above

the uterosacral ligament.

4. Base of broad ligament ,

ureter passes under the

uterine artery.

5. Ureteric canal-During

Wertheim hysterectomy.

6. Intramural portion near

the insertion into the trigon

when base of bladder is

injured or repaired.

7. Upper vagina during

clamping of vaginal angle.

RISK FACTORS FOR URETERIC INJURIES

1. ANATOMICAL RISK FACTORS.

2. PATHOLOGICAL RISK FACTORS.

3. TECHNICAL RISK FACTORS

1.ANATOMICAL RISK FACTORS:

A)THE URETER:

• Has close attachment to the

peritoneum.

• Closely related to female genital

tract.

• Has variable course.

• Not easily seen or palpated.

2.PATHOLOGICAL RISK FACTORS:

1. Congenital anomalies of ureter or Kidney.

2. Ureteric displacement by:

Uterine size ≥12 weeks.

Prolapse.

Tumour{ovarian neoplasm}.

Cervical fibroid/Ca.

broad ligament swellings(fibroids , incarcirated ovarian tumours or hematomas)

3.Adhesions:

Previous pelvic surgery.

Endometriosis.

PID.

Extention of carcinomatous indurations in broad ligaments , post irradiation.

4.Distorted pelvic anatomy.

3.TECHNICAL RISK FACTORS

• Massive intraoperative haemorrhage.

• Coexistent bladder injury.

• Technical difficulties.

• Inexperienced surgeon.

TYPES{CAUSES}OF INJURYINTRAOPERATIVE

• Crushing from misapplication of a clamp.

• Ligation with a suture.

• Transection{partial or complete}

• Angulation of the ureter with secondary obstruction.

• Ischemia from ureteral stripping , LASER or electrocoagulation.

• Resection of a segment of ureter.

• Any combination of these injuries may also occur.

POSTOPERATIVE• Avascular necrosis

following werthiem.

• Kinking-peritonisation of

vaginal stump after

hysterectomy.

• Subsequent obstruction

over:

-Haematoma or

-Lymphocele

In ½ OF THE cases URETERIC INJURy is not identified at the time of primary injury during

surgery

ABDOMINAL• Hysterectomy.

• Wertheim’s hysterectomy.

• Oophorectomy.

• Uterine suspension.

• Burch colposuspension.

• Vesicovaginal fistula repair.

LAPROSCOPIC• Division of adhesions.

• Electrocoagulative injury while uterine arteries are coagulated or ligated.

• Transection of uterosacral ligament.

• Colposuspension

• Treatment of endometriosis.

• Sterilisation (electrocoagulation)

PROCEDURE ASSOCIATED WITH URETERIC INJURIES

VAGINAL• Hysterectomy.

• Anterior colporrhaphy

• Vesicovaginal fistula repair.

• Culdoplasty

Prevention strategies to reduce the risk of ureteric injuries

• General preventive strategies:

Preoperative

Intraoperative

• Specific Preventive strategies:

GENERAL PREVENTIVE STRATEGIES

A .Preoperative measure:• Intravenous urogram(IVU).

• Ultrasound scan.

• Previous investigations ,can identify ureteric dilatation and disclose anatomical variations.

• Preoperative stenting in conditions of anatomical distortion.

INTRAOPERATIVE PREVENTION• Surgeon is to constantly and equivocally know

where ureter is all times.

• Appropriate operative approach.

• Adequate exposure.

• Avoid blind clamping and ligature of blood

vessels.

• Mobilise bladder away from operative site

• Stay outside vascular sheath.

• Limit the zone of coagulation to avoid thermal

injury.

• Ureteric dissection and direct visualisation.

IDENTIFICATION OF URETER

• The peritoneal reflection anterior to

the uterus is incised and the bladder

is pushed down with blunt or sharp

dissection.

• Pelvic ureter is identified on the

medial aspect of the broad ligament

during the opening of perivescical

spaces while performing extended

hysterectomy or removing broad

ligament tumors.

IMAGING

• No proof that preoperative IVU or CE-CT reduces risk of injury.

• Endometriosis , PID uterovaginal prolapse and previous intra -abdominal surgery are associated with increased prevalence of abnormal IVU finding.

A}During Abdominal hysterectomy:-

Clamp infundibulopelvic ligament after lifting up the ligament dissection and palpation ,clamp near to the ovary.

-Always clamp{cardinal , Uterosacral} ligaments close to the uterus.

-Never to open vagina unless urinary bladder is dissected down properly and sufficiently.

-Use of intrafacial technique.

SPECIFIC PREVENTIVE STRATEGIES

B}During Vaginal surgery :

1. Prevention of ureteric injuries can be achieved by adequate development of vescico-uterine space , by:

-Downward traction on the cervix.

-Counter traction upward by Sim’s speculum below the bladder.

2. All clamp:-Small bites.

-Close to the uterus.

3. Avoid double clamping of uterosacral ligament.

4. Vaginal Oophorectomy should be avoided or done cautiously.

5. During anterior colporrhaphy:

-Avoid too lateral dissection .

-Avoid deep suture :as the distance between needle and ureter in upper vagina ≤0.9 cm.

• C)During laparoscopy: can be achieved by:

• -Moving the fallopian tubes away from pelvic side walls before coagulation.

• -The bleeding points at uterosacral ligaments should be secured with sutures or clips instead of electrocoagulation.

• -In LAVH place stapler or suture across uterine vessels and cardinal ligaments instead of electrocoagulation.

MANAGEMENT

AIM OF MANAGEMENT

• Preservation of function.

• Anatomical continuity.

• Decision depends on-

Time of detection

Extent of injury

Site of injury

General condition of patient

STENTING Insert a silicone internal stent through the anastomosis before closure.

Advantages :1. Maintenance of a straight

ureter with a constant caliber during early healing,

2. The presence of a conduit for urine during healing,

3. Prevention of urinary extravasation,

4. Maintenance of urinary diversion,

5. Easy removal

Urinary diversion

• To divert urine from the bladder to a new exit site.

• Usually through a surgically created opening (stoma) in the skin.

Introduction

• Diversion of urinary pathway from its natural path

• Types:

–Temporary

–Permanent

Temporary urinary diversion

• Suprapubic cystostomy

•Pyelostomy or nephrostomy or urethrostomy (with indwelling catheters)

Illustration of suprapubic tube placed to aid bladder drainage

Suprapubic Cystostomy

A nephrostomy is a surgical procedure by which a tube, stent, or catheter is inserted through the skin and into the kidney.

Permanent urinary diversion

• Uretero - sigmoidostomy

• Ileal conduit

• Colon conduit

• Ileocaecaecal segment

• Lowsley’s operation

Types of urinary diversions

Cutaneous urinary diversions

•Ileal conduit (ileal loop)

•A 12 cm loop of ileum led out through abdominal wall

•Stents used

•The space at cystectomy site drained by a drainage system

•After surgery a skin barrier and a transparent disposable urinary drainage bag

•Constantly drains

Complications of ileal conduit• Wound infection • Wound dehiscence• Urinary leakage• Ureteric obstruction• Small bowel obstruction • Ileus• Stomal gangrene• Narrowing of the stoma• Pyelonephritis • Renal calculi

Cutaneous Ureterostomy…

Vescicostomy

Nephrostomy…

Uretero- sigmoidostomy

• Complications:

–Reflux of urine

–Hyperchloraemic acidosis

–Renal infection

–Stricture formation

Continent Urinary Diversions

• Continent Ileal Urinary Reservoir

Indiana Pouch

• Most common continent urinary diversion

• Periodically catheterized

Koch Pouch

Charleston Pouch

Ureterosigmoidostomy

• Voiding occurs from rectum

Koch Pouch II

ureterosigmoidostomy

Bladder reconstruction

Recto sigmoid pouch

Potential complications

• Peritonitis due to disruption of anastomosis

• Stomal ischaemia and necrosis due to compromised blood supply to stoma

• Stoma retraction and separation of mucocutaneous border due to tension or trauma