Avoiding lower urinary tract injury

Overall, the incidence of lower urinary tract injury during other types of urogynecologic surgery is higher than during hysterectomy. Evidence of the higher prevalence during urogynecologic surgery comes from several recent studies. Harris et al¹⁰ reported a 5.7% injury rate during reconstructive surgery for incontinence or prolapse. Importantly, 4% were unrecognized prior to urinary tract endoscopy.

Procedures most commonly associated with urinary tract injury were retropubic urethropexy and apical prolapse procedures using the uterosacral ligament in this series. This higher prevalence in urogynecologic procedures may explain the perceived increase in injuries overall.

How can a surgeon prevent bladder or ureteral injury during open hysterectomy?

BENT: Any procedure—regardless of the approach—demands careful dissection, good lighting, and exposure of appropriate structures. It is hard to avoid what you cannot see!

CUNDIFF: When I enter the peritoneal cavity, especially in patients undergoing reoperation, I make the incision more superiorly and avoid the bladder when extending the incision inferiorly. I always open the pararectal space and identify the ureters to ensure their safety during clamping.

Dissection of the vesicovaginal space is most effective when it is done sharply with adequate traction and countertraction. This can be achieved by gently pulling the bladder anteriorly with a Babcock clamp, using scissors to dissect close to the cervix.

For very large fundi, dissection of the vesicovaginal space can be difficult if the uterus is brought through the laparotomy. In these cases I generally take the round ligaments and infundibulopelvic ligaments first and then push the fundus into the upper abdomen. This helps keep the bowel out of the field and gives better visualization of the vesicovaginal space.

I generally enter the anterior fornix with a scalpel and then use Jorgensen scissors to excise the cervix. This helps protect the bladder, and also maximizes vaginal length.

By the way, I use a modified lithotomy position with universal stirrups to maintain access to the bladder for cystoscopy, in case it is needed later.

Follow the ureter

BARBER: During abdominal hysterectomy, I routinely identify the course of the ureter in the retroperitoneum and follow it from where it enters the pelvis until it disappears into the cardinal ligament and below the uterine artery. Following its course helps me avoid ureteral injury.

BENT: If there is scarring of the tube or ovary, or a mass is present, the ureter may have to be localized and dissected completely free of the adnexal structures before any clamps are placed. In addition, the bladder flap should routinely be mobilized using sharp dissection, never blunt dissection.

Mobilization of the bladder downward also pushes the ureters further out of the way during clamping of the uterine vessels. If bleeding occurs, secure hemostasis after observing the location of the ureters. If there is any concern about injury, cystoscopy with injected dye is required.

Next, as the uterosacral and cardinal ligaments are approached, the bladder must be reflected well inferior to this area. This will keep the ureters somewhat removed from the clamps.

Other tricks include performing intrafascial hysterectomy, in which the fascia is peeled away from the uterus and cervix, protecting the ureters.

Clamps placed across the cardinal and uterosacral ligament complexes must hug the uterus and roll off the cervix to protect the ureter.

When the cuff is sutured after removal of the uterus, clear planes of vagina must be seen anteriorly and posteriorly to avoid suturing the bladder into the vaginal cuff.

3 preventive strategies

KARRAM: For abdominal hysterectomy, I recommend 3 techniques:

• Skeletonize the infundibulopelvic ligament. Most surgeons do this routinely during the abdominal approach; I also recommend it for laparoscopic hysterectomy. Once there is a window in the broad ligament and the infundibulopelvic ligament is skeletonized, one can be sure the ureter is well below this area and probably out of harm’s way.
• Use sharp dissection to mobilize the bladder off the anterior cervix.
• Maintain awareness of the close proximity of the lower ureter to the uterosacral cardinal ligament. As the ureter enters the bladder, it can be as close as 1 cm lateral to the uterosacral ligament. This is an area where it is almost impossible to dissect out the ureter, so the surgeon needs to appreciate this anatomy and refrain from taking aggressive bites in the lateral direction when supporting or closing the vaginal cuff.

How can a surgeon prevent bladder or ureteral injury during laparoscopic hysterectomy?

BARBER: I think the ureter is best identified by direct visualization transperitoneally. The angle of the laparoscope makes visualizing the ureter much easier than from an abdominal approach, so retroperitoneal dissection is not necessary as often.