SURGICAL TECHNIQUES How to safeguard the ureter 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: 16 OBG Management | November 2008 | Vol. 20 No. 11 For mass reproduction, content licensing and permissions contact Dowden Health Media. 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, cystoscopy, 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 obgmanagement.com Vol. 20 No. 11 | November 2008 | OBG Management 17 17_OBGM1108 17 10/21/08 12:14:21 PM SURGICAL TECHNIQUES / URETERAL INJURY 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 urethropexy 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 ureters 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- 18 OBG Management | November 2008 | Vol. 20 No. 11 18_r1_OBGM1108 18 10/23/08 12:02:01 PM SURGICAL TECHNIQUES / URETERAL INJURY 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.