Management of iatrogenic ureteric injuries associated with gynecological surgery.

Abstract

This retrospective study defines the presentation and management of iatrogenic ureteric injuries consequent upon gynecological surgery in a teaching hospital in Punjab, Pakistan. 18 patients with median age 35 years (range 18-80 years) with iatrogenic ureteric injuries associated with gynecological surgery were referred to the department of urology at Nishtar Hospital Multan Pakistan. Main presenting symptoms were urinary incontinence, loin pain and anuria. Median time since injury and presentation was 3 weeks (range 1 day to 7 years). In 16 (88%) patients injury resulted from abdominal hysterectomy. Other causes included ovarian cystectomy (one patient) and vaginal hysterectomy (one patient). 11 (61%) patients had ureterovaginal fistula, 5 (28%) patients had complete unilateral ureteric obstruction and 2 (11%) patients had bilateral ureteric obstruction and anuria. In 11 patients with ureterovaginal fistula ureteroneocystostomy was performed. In five patients with unilateral ureteric obstruction, one had end to end anastomosis of ureter, three had ureteroneocystostomy only and one had ureteroneocystostomy and psoas hitch done. Two had anuria secondary to bilateral ureteric obstruction. In one of these patients Boari flap and ureteroneocystostomy was carried out. The second patient had deligation of catgut sutures on ipsilateral side and ureteroneocystostomy on the contra-lateral side. In 17 patients no major complication occurred. One patient who had deligation of catgut sutures, the distal ureter sloughed and re-exploration and ureteroneocystostomy was performed. Renal salvage was achieved in all cases. Open surgical procedures for repair of iatrogenic ureteric injuries are associated with good outcome. Strategies to prevent these injuries include adequate surgical training and meticulous surgical techniques.