Avoiding and Managing Ureteral Injury During Pelvic Surgery

Bladder and ureteral injury are serious iatrogenic complications during abdominal and pelvic surgery but are poorly investigated in the general surgery literature. The objective of this study was to examine rates, trends, and patient and surgical characteristics present in lower urinary tract injuries during gastrointestinal surgery using the Nationwide Inpatient Sample (NIS) database. The NIS database was queried from 2002 to 2010 for gastrointestinal surgery procedures including small/large bowel, rectal surgery, and procedures involving a combination of the two. These were crossreferenced with bladder and ureteral injury using International Classification of Diseases, 9th Revision, Clinical Modification codes. Multivariate regression analysis was used to calculate odds ratios for hypothesized risk factors. From 2002 to 2010, total average rates of bladder injury and ureteral injury were 0.15 and 0.06 per cent, respectively. Small/large bowel procedures had lower annual rates of ureteral (0.05 to 0.07%) and bladder (0.12 to 0.14%) injuries compared with ureteral (0.11 to 0.25%) and bladder (0.27 to 0.41%) injuries in rectal procedures. Presence of metastatic disease was associated with the greatest risk for bladder (odds ratio, 2.0; 95% confidence interval, 1.8 to 2.2) and ureteral (2.2; 1.9 to 2.5) injury in small/large bowel surgery, and for bladder (3.1; 2.5 to 3.9) and ureteral (4.0; 3.2 to 5.0) injury in combination procedures. Injury rates were significantly greater in open surgeries compared with laparoscopic procedures for both bladder injury (0.78 vs 0.26%, P < 0.0001) and ureteral injury (0.34 vs 0.06%, P < 0.0001). The incidence of genitourinary (GU) injury in gastrointestinal surgery is rare, less than 1.0 per cent, and is less than the incidence of GU injury reported in gynecologic surgery. This risk is increased by operations on the rectum and the presence of malignancy.

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A Review of Laparoscopic Ureteral Injury in Pelvic Surgery

Obstetrical & Gynecological Survey ◽

10.1097/01.ogx.0000097781.79401.0b ◽

2003 ◽

Vol 58 (12) ◽

pp. 794-799 ◽

Cited By ~ 123

Author(s):

Adam Ostrzenski ◽

Bartholomew Radolinski ◽

Katarzyna M. Ostrzenska

Keyword(s):

Ureteral Injury ◽

Pelvic Surgery

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Causes and prevention of Iatrogenic fistula during Gynaecologic Surgery

Nepal Journal of Obstetrics and Gynaecology ◽

10.3126/njog.v13i2.21875 ◽

2018 ◽

Vol 13 (2) ◽

Author(s):

Ashudeep Sharma

Keyword(s):

Ureteral Injury ◽

Pelvic Surgery ◽

Minimal Risk ◽

Predisposing Factor ◽

Advanced Malignancy ◽

Ureteral Injuries ◽

Severity Of Injury ◽

Bladder Injuries ◽

Urologic Injury

Pelvic surgery is most common cause of iatrogenic ureteral injury. The incidence of ureteric range from 0.2 to 1% during various gynaecological procedure including laparoscopic surgery. The majority of ureteral injury has no identifiable predisposing factor and occurs more frequently for procedure forbenign lesion. Two third of injury are diagnosed postoperative period. When the injury is recognized intra-operatively, the lesion can be repaired immediately with minimal risk of long term sequelae. Urological injuries to urinary bladder & ureter- uncommon but important. Surgical complications during various obstetric & gynecological open and laparoscopic procedures. One of the important factors is anatomic proximity of ureters & bladder to genital tract. Bladder injuries- most frequent urologic injury. Bladder injuries usually recognized and repaired immediately, and potential complications are typically minor. But ureteral injuries(70%) typically are not recognized immediately & can lead to long term complications. Risk factors are Enlarged uterus, Previous pelvic surgery or radiation, Advanced malignancy Endometriosis, PID ,Pelvic adhesions, distorted pelvic anatomy. Iatrogenic urologic injuries can be prevented by adequate pre-operative assessment, good surgical technique, and visualization of the bladder & ureters. Anticipation and high index of suspicion, early urological referral, and appropriate investigation of suspected urologic injury is of paramount importance. Post-operatively they may present with fever, flank pain and tenderness, oligouria, anuria, uremia, ileus, peritonitis, urinary leakage and hematuria depending upon severity of injury. To prevent ureteral injury surgeon must have thorough knowledge of anatomy and location of ureter during various gynaecological procedure and the specific sites where it is most susceptible to injury.

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Ureteric Injury in Gynecology Surgery

10.5772/intechopen.99649 ◽

2021 ◽

Author(s):

Rama Garg

Keyword(s):

Urinary Tract ◽

Fluid Collection ◽

Signs And Symptoms ◽

Ureteral Injury ◽

Pelvic Surgery ◽

Absorbable Suture ◽

Ureteric Injury ◽

Systematic Assessment ◽

Free Closure ◽

Rigid Instruments

It is the most serious and trouble-some complication of pelvic surgery and common reason for medico-legal action by the patient. It can be unilateral or bilateral. Lowest 3 cm of ureter is usually injured. 75% of injuries result from gynecological operations - 3/4th during abdominal and 1/4th during vaginal operations. As most injuries can be diagnosed intraoperatively, systematic assessment of urinary tract integrity should be part of the surgical plan. Intraoperative cystoscopy using either flexible or rigid instruments can aid in the diagnosis or exclusion of urinary tract injury. Identification of the mechanism of injury and its location guides immediate or delayed repair. Mobilization should be sufficient to allow a tension-free closure. Tissue interposition is typically recommended. Common sites for ureteral injury are found beneath the uterine vessels near the cardinal ligament and beneath the infundibulopelvic ligament and the tunnel of Wertheim. Successful ureteral repair relies on careful mobilization, wide spatulation, use of fine absorbable suture (4-0, 5-0), and temporary stenting. Postoperative signs and symptoms of ureteral injury may include unilateral flank pain, fever, prolonged ileus, and abdominal or pelvic fluid collection (urinoma).

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Ureteral injury during abdominal and pelvic surgery: immediate versus deferred repair

Central European Journal of Urology ◽

10.5173/ceju.2019.1782 ◽

2019 ◽

Keyword(s):

Ureteral Injury ◽

Pelvic Surgery

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Ureteral injury in pelvic surgery: Report of a case

American Journal of Obstetrics and Gynecology ◽

10.1016/0002-9378(57)90012-1 ◽

1957 ◽

Vol 74 (6) ◽

pp. 1266-1269 ◽

Cited By ~ 1

Author(s):

James A. Crowell

Keyword(s):

Ureteral Injury ◽

Pelvic Surgery

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Iatrogenic Ureterovaginal Fistulae: Difficulties in Diagnosis and Treatment in Our Case series

10.36811/gju.2019.110001 ◽

2019 ◽

pp. 01-06

Author(s):

Cristina Palmer, DO ◽

Bilal Farhan, MD ◽

Gamal Ghoniem, MD FACS

Keyword(s):

Case Series ◽

Ureteral Injury ◽

Pelvic Surgery ◽

Fistula Formation ◽

Gynecologic Surgery ◽

Ureterovaginal Fistula ◽

Vaginal Cuff ◽

Ureterovesical Junction ◽

Ureteral Injuries ◽

Damage Risk

Ureteral injury is a known complication of pelvic surgeries, including gynecological, urologic, colorectal, and vascular surgeries. This can occur by transvaginal, laparoscopic, or transabdominal approach [1,2]. Gynecological surgery remains by far the most common means of injury (75%), followed by colorectal surgeries (14%) [3-5], with reports of ureteral injury during gynecologic surgery from 0.35% to 1.5% [4,6]. Total abdominal and laparoscopic hysterectomies are the most common procedures where ureteral injury occurs [1,5]. Injury occurs most often at the level where the ureter courses under the uterine vessels, followed by the ureterovesical junction and the base of the infundibulopelvic ligament [4,7,8]. Many ureteral injuries occur during uncomplicated, routine surgery [8,9]. An abnormal connection between the ureter and vagina, or ureterovaginal fistula, allows for a conduit through which urine can continually leak. This is specific to the combination of ureteral injury and hysterectomy where the urine finds its way to the freshly closed vaginal cuff. Genitourinary fistula formation remains one of the most feared complications of pelvic surgery, with lasting emotional damage, risk for infections, infertility, reoperation, and increased hospital stay [5,10]. Our objective is to present the difficulties encountered in management of our cases and how to rectify them.

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