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.
IN THIS ARTICLE
Intraoperative detection
Two main types of ureteral injury occur during gynecologic surgery: transection and destruction. The latter includes ligation, crushing, devascularization, and thermal injury.
Intraoperative detection of ureteral injury is more likely when the surgeon recognizes at the outset that the operation places the ureter at increased risk. When dissection has been difficult or complicated for any reason, be concerned about possible injury.
In general, ureteral injury is first recognized by careful inspection of the surgical field. Begin by instilling 5 ml of indigo carmine intravenously. Once the dye begins to appear in the Foley catheter, inspect the area of dissection under a small amount of irrigation fluid, looking for extravasation of dye that indicates partial or complete transection.
If no injury is identified, cystoscopy is the next step. I perform all major abdominal operations with the patient in the low lithotomy position, which provides easy access to the perineum. Cystoscopic identification of urine jetting from both ureteral orifices confirms patency. When only wisps of dye are observed, it is likely that the ureter in question has been partially occluded (e.g., by acute angulation). Failure of any urine to appear from one of the orifices highly suggests injury to that ureter.
During inspection of the operative field, attempt to pass a ureteral stent into the affected orifice. If the stent passes easily and dyed urine is seen to drip freely from it, look for possible angulation of the ureter. If you find none, remove the stent and inspect the orifice again for jetting urine.
If the ureteral stent will move only a few centimeters into the ureteral orifice, ligation (with or without transection) is likely. In this case, leave the stent in place. If the operative site is readily accessible, dissect the applicable area to identify the problem. Depending on the circumstances, you may wish to infuse dye through the stent to aid in operative identification or radiographic evaluation.
Intraoperative IVP may be useful, especially when cystoscopy is unavailable.
Fundamentals of repair
Repair of major injury to the pelvic ureter is generally best accomplished by ureteroneocystostomy or, in selected cases involving injury to the proximal pelvic ureter, by ureteroureterostomy.
When intraoperatively recognized injury to the pelvic ureter appears to be minor, it can be managed by placing a ureteral stent and a closed-suction pelvic drain. Also consider wrapping the injured area with vascularized tissue such as perivesical fat. Minor lacerations can be closed perpendicular to the axis of the ureter using interrupted 4-0 delayed absorbable suture.
Most injuries to the pelvic ureter are optimally managed by ureteroneocystostomy (FIGURE 3). When a significant portion of the pelvic ureter has been lost, ureteroneocystostomy usually requires a combination of:
- extensive mobilization of the bladder
- conservative mobilization of the ureter
- elongation of the bladder
- psoas hitch.
When necessary, mobilization of the kidney with suturing of the caudal perinephric fascia to the psoas muscle will bridge an additional 2- to 3-cm gap.
Major injury to the distal half of the pelvic ureter is repaired using straightforward ureteroneocystostomy.
When there is no significant pelvic disease and the distal ureter is healthy, injury to the proximal pelvic ureter during division of the ovarian vessels may be repaired via ureteroureterostomy. If the ureteral ends will be anastomosed on tension or there is any question about the integrity of the distal portion of the ureter, as when extensive distal ureterolysis has been necessary, consider ureteroneocystostomy.
FIGURE 3 When the distal ureter is injured
Most injuries to the pelvic ureter are managed optimally by ureteroneocystostomy.
Ureter injured during emergent hysterectomy
A 37-year-old woman, para 4, undergoes her fourth repeat cesarean section. When the OB attempts to manually extract the placenta, the patient begins to hemorrhage profusely. Conservative measures fail to stop the bleeding, and the patient becomes hypotensive. The physician performs emergent hysterectomy, taking large pedicles of tissue. Although the patient stabilizes, the doctor worries that the ureters may have been injured.
Resolution: Cystoscopy is performed to check for injury. Because indigo carmine does not spill from the left ureteral orifice, the physician passes a stent with the abdomen still open, and it stops within the most distal ligamentous pedicle. Upon deligation, indigo carmine begins to drain from the stent, which then passes easily.
The stent is withdrawn to below the site of injury, and dilute methylene blue is instilled through it while the ureter is observed under irrigation. No extravasation is noted. Because the ligature had been around a block of tissue that was thought to have acutely angulated rather than incorporated the ureter, the physician concludes that severe damage is unlikely. He places a 6 French double-J stent, wraps the damaged portion of the distal ureter in perivesical fat, and places a closed-suction pelvic drain. Healing is uneventful.
Obstruction is confirmed. Now the surgeon must find it
A 45-year-old woman, para 3, who has a symptomatic 14-weeks’ size myomatous uterus, undergoes vaginal hysterectomy. The surgeon ligates and divides the uterine vessel pedicles before beginning morcellation. At the completion of the procedure, during cystoscopy, indigo carmine fails to spill from the right ureteral orifice, suggesting injury to that ureter. The surgeon passes a stent into the ureter, and it stops approximately 6 cm from the orifice. A retrograde pyelogram confirms complete obstruction.
Resolution: With the stent left in place, the surgeon performs a midline laparotomy, tracing the ureter to the uterine artery pedicle in which it has been incorporated and transected. The distal ureter with the stent is found within soft tissue lateral to the cardinal ligament pedicle, and the transected end is securely ligated using 2–0 silk suture. After the bladder is mobilized, a ureteroneocystostomy is performed. The patient recovers fully.
