Litigation following Ureteral Injuries associated with Gynaecological Surgery

Abstract

Ureteral injury is one of the complications inherent in any gynaecological pelvic surgery. From the beginning of this century, the range of ureteral injuries during standard gynaecological surgery has been reported to be between 0.04 and 1.46 percent, with a mean of 0.21 percent (234 injuries in 110,351 operations, 1902–1998). The mean ureteral complication rate is essentially the same for the three kinds of hysterectomies performed by most gynaecologists (laparascopic-assisted vaginal hysterectomy [LAVH]-0.42%, total abdominal hysteroctomy [TAH]-0.18%, vaginal hysterectomy [VH]-0.25%). Ureteral injuries occur across the range of pathological conditions, operators and operative techniques which suggest that there is a critical incidence of ureteral injury below which gynaecological surgery has not been able to fall (in the range of 0.1 to 0.5 percent). This may be because the exact position of the ureter is not constant. The course of the ureter as it crosses beneath the uterine artery, as close as one to two cm from the lateral aspect of the uterus, is such that the margin for error is very small.In this report, we summarize the circumstances, allegations and conclusions of 13 Canadian resolved cases of litigated ureteral injuries sustained during gynaecological surgery. By reviewing these cases, surgeons may familiarize themselves with the most frequent allegations brought by plaintiffs, and the questions and principles that judges apply in reaching their conclusions. In all 13 cases, the allegation of informed consent failed as a reasonable person would have agreed to surgery under the conditions, even if the risk of ureteral injury had been disclosed. Furthermore, the risk of ureteral injury does not have to be disclosed because it is a known complication with a frequency of occurrence of less than 0.5 percent and it is not considered a material risk. The use of a pre-operative IVP, ureteral stenting or intra-operative dyes is of little value in preventing ureteral injuries. In nine of the 13 cases (70%) the judge ruled in favour of the defendant.The cardinal rules in the management of ureteral injuries during gynaecological surgery are prevention, identification of the injury intra-operatively and a high index of suspicion postoperatively.