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How to safeguard the ureter and repair surgical injury

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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.



The author has no financial relationships relevant to this article.

CASE: Inadvertent ureteral transection

A gynecologic surgeon operates via Pfannenstiel incision to remove a 12-cm complex left adnexal mass from a 36-year-old obese woman. When she discovers that the mass is densely adherent to the pelvic peritoneum, the surgeon incises the peritoneum lateral to the mass and opens the retroperitoneal space. However, the size and relative immobility of the mass, coupled with the low transverse incision, impair visualization of retroperitoneal structures.

The surgeon clamps and divides the ovarian vessels above the mass but, afterward, suspects that the ureter has been transected and that its ends are included within the clamps. She separates the ovarian vessels above the clamp and ligates them, at which time transection of the ureter is confirmed.

How should she proceed?

The ureter is intimately associated with the female internal genitalia in a way that challenges the gynecologic surgeon to avoid it. In a small percentage of cases involving surgical extirpation in a woman who has severe pelvic pathology, ureteral injury may be inevitable.

Several variables predispose a patient to ureteral injury, including limited exposure, as in the opening case. Others include distorted anatomy of the urinary tract relative to internal genitalia and operations that require extensive resection of pelvic tissues.

This article describes:

  • prevention and intraoperative recognition of ureteral injury during gynecologic surgery
  • management of intraoperatively recognized ureteral injury.

Maintain a high index of suspicion

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The surgeon in the opening case has already taken the first and most important step in ensuring a good outcome: She suspected ureteral injury. In high-risk situations, intraoperative recognition of ureteral injury is more likely when the operative field is inspected thoroughly during and at the conclusion of the surgical procedure.

In a high-risk case, the combined use of intravenous indigo carmine, careful inspection of the operative field, cystoscopy, and ureteral dissection is recommended and should be routine.

Common sites of injury

During gynecologic surgery, the ureter is susceptible to injury along its entire course through the pelvis (see “The ureter takes a course fraught with hazard,”).

During adnexectomy, the gonadal vessels are generally ligated 2 to 3 cm above the adnexa. The ureter lies in close proximity to these vessels and may inadvertently be included in the ligation.

During hysterectomy, the ureter is susceptible to injury as it passes through the parametrium a short distance from the uterus and vaginal fornix.

Sutures placed in the posterior lateral cul de sac during prolapse surgery lie near the midpelvic ureter, and sutures placed during vaginal cuff closure, anterior colporrhaphy, and retropubic urethropexy are in close proximity to the trigonal portion of the ureter.

The ureter takes a course fraught with hazard

The ureter extends from the renal pelvis to the bladder, with a length that ranges from 25 to 30 cm, 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 layer surrounding the ureter.

The ureter is attached to the posterior lateral pelvic peritoneum running dorsal to ovarian vessels. At the midpelvis, it separates from the peritoneum to pierce the base of the broad ligament underneath the uterine artery. At this point, the ureter is about 1.5 to 2 cm lateral to the uterus and curves medially and ventrally, tunneling through the cardinal and vesicovaginal ligaments to enter the bladder trigone.

Risky procedures

In gynecologic surgery, ureteral injury occurs most often during abdominal hysterectomy—probably because of how frequently this operation is performed and the range of pathology managed. The incidence of ureteral injury is much higher during abdominal hysterectomy than vaginal hysterectomy.1-4

Laparoscopic hysterectomy also has been associated with a higher incidence of ureteral injury, especially in the early phase of training.5,6 Possible explanations include:


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