SURGICAL TECHNIQUES

How to safeguard the and repair surgical injury Under certain circumstances, ureteral injury may not only be likely—it is unavoidable. Here’s what you need to know to minimize the risk and ensure recovery.

CASE Mitchel S. Hoffman, MD Inadvertent ureteral® transectionDowden Health Media A gynecologic surgeon operates via Pfannenstiel inci- Dr. Hoffman is Professor and Director, Division of Gynecologic sion to remove a 12-cm complex left adnexal mass from Oncology, Department of a 36-year-old obese woman. When she discovers that CopyrightFor personal use only Obstetrics and Gynecology, at IN THIS the mass is densely adherent to the pelvic peritoneum, ARTICLE the University of South Florida in the surgeon incises the peritoneum lateral to the mass Tampa. Obstructed and opens the retroperitoneal space. However, the size access raises and relative immobility of the mass, coupled with the low The author has no fi nancial relationships relevant to this article. risk transverse incision, impair visualization of retroperito- neal structures. page 18 The surgeon clamps and divides the ovarian vessels above the mass but, afterward, suspects that the ureter Uretero- has been transected and that its ends are included within neocystostomy the clamps. She separates the ovarian vessels above the page 23 clamp and ligates them, at which time transection of the ureter is confi rmed. Two cases, How should she proceed? two types of ureteral injury he ureter is intimately associated with the female ›› SHARE YOUR COMMENTS page 24 internal genitalia in a way that challenges the gy- Do you have a pearl to share about avoiding inadvertent necologic surgeon to avoid it. In a small percent- T ureteral injury? Let us know: age of cases involving surgical extirpation in a woman E-MAIL [email protected] who has severe pelvic pathology, ureteral injury may be FAX 201-391-2778 inevitable. Several variables predispose a patient to ureteral in- jury, including limited exposure, as in the opening case. Others include distorted anatomy of the urinary tract relative to internal genitalia and operations that require URETERAL REPAIR, LYSIS extensive resection of pelvic tissues. PAGE 28 Th is article describes:

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16_r1_OBGM1108 16 10/23/08 12:01:56 PM The ureter takes a course fraught with hazard

The ureter extends from the renal pelvis to the bladder, with a length Ureteral Adventitia mucosa that ranges from 25 to 30 cm, Muscularis depending on the patient’s height. It crosses the pelvic brim near the bifurcation of the common iliac artery, where it becomes the “pelvic” ureter. The abdominal and pelvic portions of the ureter are approximately equal in length. The blood supply of the ureter derives from branches of the major arterial system of the lower abdomen and pelvis. These branches reach the medial aspect of the abdominal ureter and the lateral side of the pelvic ureter to form an anastomotic vascular network protected by an adventitial At pelvic brim layer surrounding the ureter. The ureter is attached to the posterior lateral pelvic peritoneum Where running dorsal to ovarian vessels. the ureter At the midpelvis, it separates is especially Beneath from the peritoneum to pierce at risk of uterine artery injury the base of the broad ligament underneath the uterine artery. At this point, the ureter is about 1.5 Near uretero- to 2 cm lateral to the uterus and vesical junction curves medially and ventrally, tunneling through the cardinal and vesicovaginal ligaments

to enter the bladder trigone. ILLUSTRATIONS BY ROB FLEWELL FOR OBG MANAGEMENT

• prevention and intraoperative recogni- ensuring a good outcome: She suspected tion of ureteral injury during gyneco- ureteral injury. In high-risk situations, in- logic surgery traoperative recognition of ureteral injury • management of intraoperatively recog- is more likely when the operative fi eld is in- nized ureteral injury. spected thoroughly during and at the con- clusion of the surgical procedure. In a high-risk case, the combined use of Maintain a high index intravenous indigo carmine, careful inspec- of suspicion tion of the operative fi eld, , and Th e surgeon in the opening case has already ureteral dissection is recommended and taken the fi rst and most important step in should be routine. CONTINUED ON PAGE 18

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FIGURE 1 Access to the ureter is ureteral injury, especially in the early phase obstructed, putting it in jeopardy of training.5,6 Possible explanations include: • greater diffi culty identifying the ureter • a steeper learning curve • more frequent use of energy to hemo- statically divide pedicles, with the po- tential for thermal injury • less traction–countertraction, resulting in dissection closer to the ureter • management of complex pathology. Although the overall incidence of ureteral injury during adnexectomy is low, it is prob- ably much higher in women undergoing this Large tumors may limit the ability of the surgeon to visualize or palpate the ureter. procedure after a previous hysterectomy or in

PHOTO: MITCHEL S. HOFFMAN, MD the presence of complex adnexal pathology.

When injury is likely Common sites of injury Compromised exposure, distorted anatomy, During gynecologic surgery, the ureter is and certain procedures can heighten the risk susceptible to injury along its entire course of ureteral injury. Large tumors may limit the through the pelvis (see “Th e ureter takes a ability of the surgeon to visualize or palpate course fraught with hazard,” on page 17). the ureter (FIGURE 1). Extensive adhesions During adnexectomy, the gonadal ves- may cause similar diffi culties, and a small in- sels are generally ligated 2 to 3 cm above the cision or obesity may hinder identifi cation of adnexa. Th e ureter lies in close proximity to pelvic sidewall structures. In gynecologic these vessels and may inadvertently be in- A number of pathologic conditions can surgery, ureteral cluded in the ligation. distort the anatomy of the ureter, especially injury occurs During hysterectomy, the ureter is sus- as it relates to the female genital tract: most often during ceptible to injury as it passes through the • Malignancies such as ovarian cancer abdominal parametrium a short distance from the uter- often encroach on and occasionally en- us and vaginal fornix. case the ureter hysterectomy Sutures placed in the posterior lateral cul • Pelvic infl ammatory disease, endome- de sac during prolapse surgery lie near the triosis, and a history of surgery or pelvic midpelvic ureter, and sutures placed during radiotherapy can retract and encase the vaginal cuff closure, anterior colporrhaphy, ureter toward the gynecologic tract and retropubic are in close prox- • Some masses expand against the lower imity to the trigonal portion of the ureter. ureter, such as cervical or broad-liga- ment leiomyomata or placenta previa with accreta Risky procedures • During vaginal hysterectomy for com- In gynecologic surgery, ureteral injury oc- plete uterine prolapse, the fre- curs most often during abdominal hysterec- quently extend beyond the introitus well tomy—probably because of how frequently within the operative fi eld this operation is performed and the range of • Congenital anomalies of the ureter or pathology managed. Th e incidence of ure- hydroureter can also cause distortion. teral injury is much higher during abdominal Even in the presence of relatively normal hysterectomy than vaginal hysterectomy.1–4 anatomy, certain procedures predispose the Laparoscopic hysterectomy also has ureter to injury. For example, radical hyster- been associated with a higher incidence of ectomy involves the almost complete separa-

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FIGURE 2 During hysterectomy, operative intravenous pyelography (IVP). mobilize the bladder and ureter Th is measure does not appear to reduce the likelihood of ureteral injury, even in the face of obvious gynecologic disease. However, preoperative identifi cation of obvious ure- teral involvement by the disease process is useful. In such cases, the plane of dissection will probably lie closer to the ureter. One of the goals of surgery will then be to clear the urinary tract from the aff ected area. When there is a high index of suspicion of an abnormality such as obstruction, in- trinsic ureteral endometriosis, or congenital anomaly, preoperative IVP is indicated.

A stent may be helpful in some cases Ureteral stents are sometimes placed in or- der to aid in identifi cation and dissection Mobilize the soft tissues that contain the bladder and of the ureters during surgery. Some authors ureters caudally and laterally, respectively, creating a of reports on this topic, including Hoff man, U-shaped region. During division of the paracervical tissues, the surgeon must remain within this region. believe that stents are useful in certain situa- tions, such as excision of an ovarian remnant, radical vaginal hysterectomy, and when pel- vic organs are encased by malignant ovarian tion of the pelvic ureter from the gynecologic tumors. However, stents do not clearly reduce tract and its surrounding soft tissue. When the risk of injury and, in some cases, may in- At least 50% pelvic pathology is signifi cant, the plane of crease the risk by providing a false sense of of ureteral injuries dissection will always be near the ureter. security and predisposing the ureter to ad- reported during ventitial injury during diffi cult dissection. gynecologic surgery have occurred Prevention is the best strategy Anticipate the effects of disease At least 50% of ureteral injuries reported Th e surgeon must have a thorough knowl- in the absence of during gynecologic surgery have occurred edge of the gynecologic disease process as it a recognizable risk in the absence of a recognizable risk factor.2,7 relates to surgery involving the urinary tract. factor Nevertheless, knowledge of anatomy and the For example, an ovarian remnant will almost ability to recognize situations in which there always be somewhat densely adherent to the is an elevated risk for ureteral injury will best pelvic ureter. When severe endometriosis enable the surgeon to prevent such injury. involves the posterior leaf of the broad liga- When a high-risk situation is encoun- ment, the ureter will often be fi brotically re- tered, critical preventive steps include: tracted toward the operative fi eld. • adequate exposure Certain procedures have special chal- • competent assistance lenges. During resection of adnexa, for exam- • exposure of the path of the ureter through ple, it is important that the ureter be identifi ed the planned course of dissection. Dissecting in the retroperitoneum before the ovarian the ureter beyond this area is usually unnec- vessels are ligated. During hysterectomy, soft essary and may itself cause injury. tissues that contain the bladder and ureters should be mobilized caudally and laterally, Skip preoperative IVP in most cases respectively, creating a U-shaped region (“U” Th e vast majority of women who undergo for urinary tract, FIGURE 2) to which the sur- gynecologic surgery do not benefi t from pre- geon must limit dissection. CONTINUED ON PAGE 23

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Intraoperative detection FIGURE 3 When the distal ureter is injured Two main types of ureteral injury occur dur- ing gynecologic surgery: transection and destruction. Th e latter includes ligation, crushing, devascularization, and thermal injury. Intraoperative detection of ureteral in- jury is more likely when the surgeon recog- nizes at the outset that the operation places the ureter at increased risk. When dissection has been diffi cult or complicated for any rea- son, be concerned about possible injury. In general, ureteral injury is fi rst recog- nized by careful inspection of the surgical fi eld. Begin by instilling 5 ml of indigo car- mine intravenously. Once the dye begins to appear in the Foley , inspect the area of dissection under a small amount of irriga- tion fl uid, looking for extravasation of dye that indicates partial or complete transection. If no injury is identifi ed, cystoscopy is the next step. I perform all major abdominal operations with the patient in the low lithot- omy position, which provides easy access to the perineum. Cystoscopic identifi cation of urine jetting from both ureteral orifi ces con- fi rms patency. When only wisps of dye are observed, it is likely that the ureter in ques- tion has been partially occluded (e.g., by acute angulation). Failure of any urine to ap-

pear from one of the orifi ces highly suggests Most injuries to the pelvic ureter are managed optimally by ureteroneocystostomy. injury to that ureter. During inspection of the operative fi eld, attempt to pass a ureteral stent into the af- fected orifi ce. If the stent passes easily and dyed urine is seen to drip freely from it, look Fundamentals of repair for possible angulation of the ureter. If you Repair of major injury to the pelvic ureter is fi nd none, remove the stent and inspect the generally best accomplished by ureteroneo- orifi ce again for jetting urine. cystostomy or, in selected cases involving If the ureteral stent will move only a few injury to the proximal pelvic ureter, by ure- centimeters into the ureteral orifi ce, ligation teroureterostomy. (with or without transection) is likely. In this When intraoperatively recognized in- case, leave the stent in place. If the operative jury to the pelvic ureter appears to be minor, site is readily accessible, dissect the applica- it can be managed by placing a ureteral stent ble area to identify the problem. Depending and a closed-suction pelvic drain. Also con- on the circumstances, you may wish to in- sider wrapping the injured area with vascu- fuse dye through the stent to aid in operative larized tissue such as perivesical fat. Minor identifi cation or radiographic evaluation. lacerations can be closed perpendicular to Intraoperative IVP may be useful, espe- the axis of the ureter using interrupted 4-0 cially when cystoscopy is unavailable. delayed absorbable suture. CONTINUED ON PAGE 24

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Two cases, two types of ureteral injury

Ureter injured during the stent, which then passes easily. and divides the uterine vessel pedicles emergent hysterectomy The stent is withdrawn to below the before beginning morcellation. At the A 37-year-old woman, para 4, under- site of injury, and dilute methylene blue completion of the procedure, dur- goes her fourth repeat cesarean sec- is instilled through it while the ureter is ing cystoscopy, indigo carmine fails tion. When the OB attempts to manu- observed under irrigation. No extrava- to spill from the right ureteral orifi ce, ally extract the placenta, the patient sation is noted. Because the ligature suggesting injury to that ureter. The begins to hemorrhage profusely. Con- had been around a block of tissue that surgeon passes a stent into the ureter, servative measures fail to stop the was thought to have acutely angulated and it stops approximately 6 cm from bleeding, and the patient becomes rather than incorporated the ureter, the the orifi ce. A retrograde hypotensive. The physician performs physician concludes that severe dam- confi rms complete obstruction. emergent hysterectomy, taking large age is unlikely. He places a 6 French pedicles of tissue. Although the pa- double-J stent, wraps the damaged Resolution: With the stent left in place, tient stabilizes, the doctor worries that portion of the distal ureter in perivesi- the surgeon performs a midline lapa- the ureters may have been injured. cal fat, and places a closed-suction rotomy, tracing the ureter to the uter- pelvic drain. Healing is uneventful. ine artery pedicle in which it has been Resolution: Cystoscopy is performed incorporated and transected. The to check for injury. Because indigo distal ureter with the stent is found carmine does not spill from the left Obstruction is confi rmed. Now within soft tissue lateral to the cardinal ureteral orifi ce, the physician passes the surgeon must fi nd it ligament pedicle, and the transected a stent with the abdomen still open, A 45-year-old woman, para 3, who end is securely ligated using 2–0 silk and it stops within the most distal has a symptomatic 14-weeks’ size suture. After the bladder is mobilized, ligamentous pedicle. Upon deligation, myomatous uterus, undergoes vagi- a ureteroneocystostomy is performed. indigo carmine begins to drain from nal hysterectomy. The surgeon ligates The patient recovers fully.

Most injuries to the pelvic ureter are . If the ureteral ends optimally managed by ureteroneocystosto- will be anastomosed on tension or there is my (FIGURE 3, page 23). When a signifi cant any question about the integrity of the distal portion of the pelvic ureter has been lost, portion of the ureter, as when extensive dis- ureteroneocystostomy usually requires a tal has been necessary, consider combination of: ureteroneocystostomy. • extensive mobilization of the bladder • conservative mobilization of the ureter • elongation of the bladder Postoperative management • psoas hitch. After repair of a ureteral injury, leave a When necessary, mobilization of the closed-suction pelvic drain in place for 2 to with suturing of the caudal perineph- 3 days so that any major urinary leak can be ric fascia to the psoas muscle will bridge an detected; it also enhances spontaneous clo- additional 2- to 3-cm gap. sure and helps prevent potentially infected Major injury to the distal half of the pel- fl uid from accumulating in the region of vic ureter is repaired using straightforward anastomosis. ureteroneocystostomy. Th e cystotomy performed during ure- When there is no signifi cant pelvic dis- teroneocystostomy generally heals quickly ease and the distal ureter is healthy, injury with a low risk of complications. to the proximal pelvic ureter during division Leave a large-bore (20 or 22 French) ure- of the ovarian vessels may be repaired via thral Foley catheter in place for 2 weeks.

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How to code for ureterolysis, ureteral repair

The majority of payers consider ureterolysis integral to that case, the most appropriate code is 50949 (Unlisted good surgical technique, but there can be exceptions laparoscopy procedure, ureter). when documentation supports existing codes. Three When repair is necessary, you have several codes to CPT codes describe this procedure: choose from, but the supporting diagnosis code 998.2 (Accidental puncture or laceration during a procedure) 50715 Ureterolysis, with or without repositioning of ure- must be indicated. If a Medicare patient is involved, the ter for retroperitoneal fi brosis surgeon who created the injury would not be paid ad- 50722 Ureterolysis for ovarian vein syndrome ditionally for repair. 50725 Ureterolysis for retrocaval ureter, with reanasto- mosis of upper urinary tract or vena cava 50780 Ureteroneocystostomy; anastomosis of single ureter to bladder The key to getting paid will be to document the exis- 50782 Ureteroneocystostomy; anastomosis of duplicated tence of the condition indicated by each of the codes. ureter to bladder The ICD-9 code for both retroperitoneal fi brosis and 50783 Ureteroneocystostomy; with extensive ureteral tai- ovarian vein syndrome is the same, 593.4 (Other ure- loring teric obstruction). If the patient requires ureterolysis 50785 Ureteroneocystostomy; with vesico-psoas hitch for a retrocaval ureter, the code 753.4 (Other specifi ed or bladder fl ap anomalies of ureter) would be reported instead. Note, 50760 Ureteroureterostomy; fusion of ureters however, that these procedure codes cannot be report- 50770 Transureteroureterostomy, anastomosis of ureter ed if the ureterolysis is performed laparoscopically. In to contralateral ureter

›› MELANIE WITT, RN, CPC-OBGYN, MA

I recommend that a 6 French double-J been passed proximally into the renal pel- ureteral stent be left in place for 6 weeks. Po- vis and distally into the bladder. The stent tential benefi ts of the stent include: is removed 6 weeks postoperatively, and an • prevention of stricture IVP the following week demonstrates excel- • stabilization and immobilization of the lent patency. ureter during healing • reduced risk of extravasation of urine References • reduced risk of angulation of the ureter 1. St. Lezin MA, Stoller ML. Surgical ureteral injuries. Urology. • isolation of the repair from infection, 1991;38:497–506. retroperitoneal fi brosis, and cancer. 2. Liapis A, Bakas P, Giannopoulos V, Creatsas G. Ureteral inju- ries during gynecological surgery. Int Urogynecol J Pelvic Floor I perform IVP approximately 1 week af- Dysfunct. 2001;12:391–394. ter stent removal to ensure ureteral patency. 3. Vakili B, Chesson RR, Kyle BL, et al. Th e incidence of urinary tract injury during hysterectomy: a prospective analysis based on CASE RESOLVED universal cystoscopy. Am J Obstet Gynecol. 2005;192:1599–1604. 4. Sakellariou P, Protopapas AG, Voulgaris Z, et al. Man- Exposure is improved by widening the inci- agement of ureteric injuries during gynecological opera- sion and dividing the tendonous insertions tions: 10 years experience. Eur J Obstet Gynecol Reprod Biol. of the rectus abdominus muscles. The sur- 2002;101:179–184. 5. Assimos DG, Patterson LC, Taylor CL. Changing inci- geon then removes the mass, preserving the dence and etiology of iatrogenic ureteral injuries. J Urol. distal ureter, which is estimated to be 12 cm 1994;152:2240–2246. in length and to have intact adventitia. 6. Härkki-Sirén P, Sjöberg J, Titinen A. Urinary tract injuries af- The surgeon performs a double-spatu- ter hysterectomy. Obstet Gynecol. 1998;92:113–118. 7. Chan JK, Morrow J, Manetta A. Prevention of ureteral injuries lated end-to-end ureteroureterostomy over in gynecologic surgery. Am J Obstet Gynecol. 2003;188:1273– a 6 French double-J ureteral stent that has 1277.

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