Re: Urinary tract injuries in laparoscopic gynaecological surgery; prevention, recognition and management

Abstract

Dear Sir We read with interest the review by Minas et al and wish to comment on the subject of ureteric injury. Ureteric injury is a serious complication of gynaecologic laparoscopic surgery because the majority of cases are not recognised intra-operatively and repair generally requires laparotomy, even nephrectomy in extreme cases. We therefore whole heartedly agree with the authors’ recommendation that ‘in complex cases which carry increased risk of ureteric injury . . .it is useful and often mandatory to expose the ureter’. In fact, it has been our practice for a long time to locate the pelvic course of both ureters visually at all laparoscopies as a matter of routine, not merely to ensure their safety but as a means of habituating ourselves to their location so that in difficult cases, we know where to find them more easily. There is one approach for identifying the ureters that the authors have not mentioned but which is particularly useful when there is major distortion of the anatomy of the pelvic side wall secondary to, for instance, dense adhesions or severe endometriosis. In such cases, it is often impossible to visualise the ureter transperitoneally or see any fasciculation, so opening the pelvic side wall medially and essentially blindly with regard to the ureter, risks injury to the very structure we are trying to protect. It is just in such situations, when the ureter cannot be seen, that the risk of ureteric damage is the greatest. In our view, a safer option is to open the pelvic peritoneum laterally, that is between the round and infundibulo-pelvic ligaments, and then develop the retroperitoneal space down to the ureter. The ureter will always be found running along the medial leaf of the broad ligament, and once identified, it can then be traced into the pelvis and dissected away if needed. This is a well recognised technique at laparotomy, and there is no reason why it cannot be employed usefully at laparoscopy.