Risk Of Ureteral Injury Research Articles

Three cases of broad ligament myomas enucleated by a laparoscopic technique

It is important that the course of the ureter is noted during gynecologic surgery. Operations via laparoscopy are considered to be minimally invasive. However, such is not the case when other internal organs are injured during laparoscopic surgery, resulting in a deterioration in the patient's quality of life. We report here three cases of intraligamental uterine myomas which were removed laparoscopically without ureteral injury. The risk of ureteral injury is increased while enucleating broad ligament myomas. It is essential that gynecologic surgeons understand the local dissection of female pelvic organs. A water dissection technique is useful to avoid injury to the ureter.

Bilateral extraperitoneal uterosacral suspension: a new approach to correct posthysterectomy vaginal vault prolapse

Restoration of apical vaginal support remains a challenging problem for the pelvic reconstructive surgeon. The transvaginal use of the uterosacral-cardinal ligament complex is gaining increasing popularity in the surgical treatment of uterovaginal and posthysterectomy vault prolapse. We describe an extraperitoneal surgical approach using this ligamentous complex to reattach the vaginal apex in women with posthysterectomy vault prolapse and report our surgical experience with this procedure in 123 women over 5 years. The relevant anatomy related to the procedure and risk of ureteric injury with uterosacral suspension is also reviewed. Extraperitoneal vault suspension can be combined with the use of polypropylene mesh if required. The extraperitoneal approach is an alternative procedure in women with vault prolapse with or without concomitant enterocele or where access to the Pouch of Douglas is difficult particularly after previous pelvic surgery. We believe this procedure to have less risk of ureteral injury than the intraperitoneal approach.

Risk of Ureteral Obstruction With Transvaginal Uterosacral Suspension

Objective: The uterosacral–paracervical ligament complex supports the cervix, upper quarter of the vagina, and vaginal apex. Failure of this mechanism causes uterovaginal prolapse. Fixation of the uterosacral ligament to the vaginal cuff is therefore undertaken at the time of vaginal hysterectomy as a treatment and prevention of posthysterectomy vaginal vault prolapse. This study was undertaken to report the rate of ureteral obstruction in patients who underwent vaginal uterosacral suspension postvaginal hysterectomy. Design: The authors conducted a retrospective study at Weston General Hospital NHS Trust, Weston-super-Mare, U.K. Patients: One hundred sixty-six consecutive patients underwent vaginal hysterectomy with uterosacral suspension between August 1999 and February 2006. All patients were treated by the senior author (R.A.). Results: In all patients (166), uterosacral ligaments were identified and successfully used for vaginal cuff suspension. Two patients (1.2%) had postoperative ureteral obstruction attributed to uterosacral suspension. Conclusion: Proximity of the ureter to the uterosacral ligament makes it vulnerable during uterosacral suspension. High uterosacral vaginal vault suspension seems to decrease the risk of ureteric injury. Awareness of anatomic relation, operator experience, and proper instrumentation would all contribute to improve the outcome.

Cystoscopy After Total or Subtotal Laparoscopic Hysterectomy: The Value of a Routine Procedure

Injury of the ureter or bladder is one of the more serious complications of hysterectomy, and three fourths of ureteral injuries are associated with gynecologic operations. Most injuries involve the lower 3 cm of the ureter, and they usually are one-sided, This study is a retrospective review of ureteral injuries that occurred in the past 7 years in conjunction with total laparoscopic hysterectomy (TLH), performed in 106 women, or subtotal LH (STLH) in 232. Ureteral injuries were diagnosed by postoperative vaginal sonography and confirmed by intravenous pyelography (IVP). Cystoscopy was performed in some cases at the end of hysterectomy by injecting indigo carmine intravenously. In earlier cases, bipolar cautery was used to occlude the uterine artery, creating the possibility that a nearby thermal injury could be misdiagnosed. Subsequently, the artery was secured with a new hemoclip, the Hem-o-lok, which made possible exact closure of the uterine artery. Four of these women incurred ureteral injuries and one had a laceration of the bladder. None of the injuries occurred when cystoscopy was routinely performed or when bipolar cautery was avoided. The bladder injury, which complicated the TLH, was diagnosed intraoperatively and was repaired laparoscopically. Three of the ureteral injuries followed STLH, and one TLH. All these injuries were diagnosed 1 to 2 weeks postoperatively when patients described prolonged flank pain and lower abdominal pressure. None of the affected patients were febrile. Vaginal sonography demonstrated urinoma. After confirmation of the diagnosis by either IVP or computed tomography, 3 patients underwent nephrostomy for 3 weeks and then had the ureter reimplanted. The remaining patient had a ureteral stent placed. The investigators believe that the risk of ureteral injury during TLH or STLH can be minimized by using a clip rather than cautery to control the uterine vessels and by routinely performing cystoscopy after total or subtotal laparoscopic hysterectomy.

Efficacy of Dretler Stone Cone in the Treatment of Ureteral Stones with Pneumatic Lithotripsy

Introduction: Ureteroscopic pneumatic lithotripsy has been used to treat ureteral calculi for more than 10 years. Owing to its low price and high degree of effectiveness, it has become the most popular ureteroscopic lithotripsy device in use worldwide. The major limitation of the technique is the occurrence of proximal fragment migration during intracorporeal lithotripsy. The Dretler Stone Cone is a new device developed to prevent stone migration during ureteroscopic lithotripsy. The aim of this study was to assess the efficacy and safety of this device during ureteroscopic pneumatic lithotripsy. Patients and Methods: Twenty-three consecutive patients having ureteral stones were treated with a 10-Fr semirigid ureteroscope, a Stone Cone™ Nitinol Retrieval Device, and a pneumatic lithotriptor. In all patients Stone Cones were placed under visual guidance through the working channel of the ureteroscope. Outcomes of this device were then compared with the outcomes of 23 previous patients with stones of similar sizes and locations who had undergone ureteroscopic pneumatic lithotripsy prior to the Stone Cone being available at our clinic. Results: All patients in the study group were stone-free after the procedure. No stone fragments were noted to migrate to proximal segments. Conclusions: The Dretler Stone Cone effectively prevents proximal stone migration and facilitates stone fragmentation during pneumatic lithotripsy with no risk of ureteral injury. It has only a small extra cost.

Ureteric obstruction due to sigmoid diverticulitis.

Two cases in which the ureter was obstructed by an inflammatory diverticular mass are presented. The difficulties of distinguishing such a mass from a carcinoma both clinically and at operation are emphasized. In order to minimize the risk of ureteric injury and to facilitate planning of the operative procedure, it is recommended that intravenous pyelography should be performed before resection of a suspected diverticular mass.

The Techniques of Trocar Insertion and Intraoperative Urethrocystoscopy in Tension-Free Vaginal Taping: An Experience of 600 Cases

The author presents his experience with trocar insertion and urethrocystoscopy associated with the tension-free vaginal tape procedure (TVT). Over a 5-year period from November 1995 to March 2001, he performed TVT in 600 women with stress urinary incontinence with or without pelvic prolapse. All patients underwent preoperative urodynamic assessment. In addition, all patients had an intraoperative urethrocystoscopy to ascertain the integrity of the bladder and urethra. A concomitant procedure was performed in 169 (28%) cases. Of 188 women who had undergone previous pelvic surgery, 34 had procedures that posed a significant risk of ureteral injury. These patients were injected with 1% methylene blue solution before cystoscopy to confirm ureteral patency. The study population had a mean age of 53 years (range, 32-76 years) and a mean parity of 2.54 (range, 0-6). Of 270 (45%) women who were menopausal, 140 (51.9%) were taking hormone replacement therapy. Endoscopy findings included identification of 5 patients (0.8%) who had bladder perforation or near perforation that required reinsertion of the trocar. One woman had a biopsy of a benign granuloma. Sutures from a previous retropubic urethropexy were discovered in 1 patient and removed. Another subject required excision of an adhesion band in the urethra, which was placed during a previous excision of urethral diverticulum. A ureteral obstruction resulting from a previous laparoscopic Burch colposuspension was suggested by delayed dye emission in 1 of the 34 women who was injected with intravenous methylene blue dye. Ureteroscopy was performed and a stricture of the right distal ureter was identified and incised with electrocautery. A double-J catheter was inserted and left in place until a patent ureter was established.

Bilateral uterosacral ligament vaginal vault suspension with site-specific endopelvic fascia defect repair for treatment of pelvic organ prolapse

Objective: The anatomic and functional success of suspension of the vaginal cuff to the proximal uterosacral ligaments is described. Study Design: Forty-six women underwent vaginal site-specific repair of endopelvic fascia defects with suspension of the vaginal cuff to the proximal uterosacral ligaments for pelvic organ prolapse. Outcome measures included operative complications, pelvic organ prolapse quantitation, and assessment of pelvic floor symptoms. Results: After a median follow-up of 15.5 months (range, 3.5 months–3.4 years), 90% of patients had both resolution of vaginal bulging or prolapse symptoms and improvement of the stage of prolapse. There were improvements in all pelvic organ prolapse quantitation measurements except for total vaginal length, for which the median decrease was 0.75 cm. Intraoperatively, ureteral occlusion was noted in 11% (5/46) of patients with universal cystoscopy. In 3 patients the uterosacral suspension sutures were removed and replaced with resolution of the occlusion and in 2 patients ureteral reimplantation was required. Symptomatic prolapse (2 apical segment, 1 anterior, and 1 posterior) developed in 4 patients (10%), and 3 of them underwent reoperation. There were significant improvements in symptoms of bulging and pressure, voiding dysfunction, and vaginal and perineal splinting. Conclusion: Suspension of the vaginal vault to the proximal uterosacral ligaments combined with site-specific repair of endopelvic fascia defects provides excellent anatomic and functional correction of pelvic organ prolapse in most women. The risk of ureteral injury with this technique makes intraoperative cystoscopy essential. (Am J Obstet Gynecol 2000;183:1402-11.)

Major Complications of Laparoscopy

In Brief Objective To examine recent figures on major laparoscopic complications in Finland. Methods This was a nationwide record-linkage study from January 1995 through December 1996 including all Finnish hospitals performing gynecologic laparoscopies. Data files of the National Patient Insurance Association and the Finnish Hospital Discharge Register were used. Data were compared with previous results from 1990 to 1994. Results Among 32,205 gynecologic laparoscopies, 130 major complications were noted. The total complication rate was 4.0 per 1000 procedures: 0.6 per 1000 in diagnostic laparoscopies, 0.5 per 1000 in sterilization, and 12.6 per 1000 in operative laparoscopies. Intestinal injuries were reported in 0.7 per 1000, incisional hernias in 0.3 per 1000, urinary tract injuries in 2.5 per 1000, major vascular injuries in 0.1 per 1000, and other injuries in 0.5 per 1000 gynecologic laparoscopic procedures. Seventy-five percent (88 of 118) of the major complications in operative laparoscopies occurred during hysterectomies. The total major complication rate decreased from 4.9% in 1993 to 2.3% in 1996 (χ2 = 8.55, P = .003), but the incidence of ureteral injuries remained stable, at about 1% of laparoscopic hysterectomies. Ureteral injuries were most common in local hospitals (2.6%), followed by central (1.1%) and university hospitals (0.9%). From 1990 through 1996, the relative risk for ureteral injury in laparoscopic hysterectomies, compared with other operative laparoscopies was 29.0 (95% confidence interval [CI] 13.3, 63.0), for bladder injury 13.0 (95% CI 6.0, 28.2), for intestinal injury 1.3 (95% CI 0.6, 2.5), and for major vascular injury 0.4 (95% CI 0.1, 3.6). Compared with the figures for 1990–1994, all major complications in operative laparoscopies increased, from 0 per 1000 in 1990 to 14.0 per 1000 in 1996 (χ2 = 20.28, P < .001), but part of this increase was due to the increased proportion of laparoscopic hysterectomies. Conclusion Laparoscopic hysterectomies are still associated with a stable 1% risk of ureteral injury, whereas other major complications were decreasing until 1996. Complications in other laparoscopic procedures generally are rare. Without proper experience and training programs, laparoscopic hysterectomies are associated with the risk of major complications, unlike other laparoscopies.

Major complications of laparoscopy: a follow-up Finnish study

Objective: To examine recent figures on major laparoscopic complications in Finland. Methods: This was a nationwide record-linkage study from January 1995 through December 1996 including all Finnish hospitals performing gynecologic laparoscopies. Data files of the National Patient Insurance Association and the Finnish Hospital Discharge Register were used. Data were compared with previous results from 1990 to 1994. Results: Among 32,205 gynecologic laparoscopies, 130 major complications were noted. The total complication rate was 4.0 per 1000 procedures: 0.6 per 1000 in diagnostic laparoscopies, 0.5 per 1000 in sterilization, and 12.6 per 1000 in operative laparoscopies. Intestinal injuries were reported in 0.7 per 1000, incisional hernias in 0.3 per 1000, urinary tract injuries in 2.5 per 1000, major vascular injuries in 0.1 per 1000, and other injuries in 0.5 per 1000 gynecologic laparoscopic procedures. Seventy-five percent (88 of 118) of the major complications in operative laparoscopies occurred during hysterectomies. The total major complication rate decreased from 4.9% in 1993 to 2.3% in 1996 (χ 2 = 8.55, P = .003), but the incidence of ureteral injuries remained stable, at about 1% of laparoscopic hysterectomies. Ureteral injuries were most common in local hospitals (2.6%), followed by central (1.1%) and university hospitals (0.9%). From 1990 through 1996, the relative risk for ureteral injury in laparoscopic hysterectomies, compared with other operative laparoscopies was 29.0 (95% confidence interval [CI] 13.3, 63.0), for bladder injury 13.0 (95% CI 6.0, 28.2), for intestinal injury 1.3 (95% CI 0.6, 2.5), and for major vascular injury 0.4 (95% CI 0.1, 3.6). Compared with the figures for 1990–1994, all major complications in operative laparoscopies increased, from 0 per 1000 in 1990 to 14.0 per 1000 in 1996 (χ 2 = 20.28, P < .001), but part of this increase was due to the increased proportion of laparoscopic hysterectomies. Conclusion: Laparoscopic hysterectomies are still associated with a stable 1% risk of ureteral injury, whereas other major complications were decreasing until 1996. Complications in other laparoscopic procedures generally are rare.

Litigation following Ureteral Injuries associated with Gynaecological Surgery

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.

Urinary Tract Injuries After Hysterectomy

Objective: To evaluate the nationwide incidence and characteristics of urinary tract injuries after laparoscopic hysterectomy, total abdominal hysterectomy, supracervical abdominal hysterectomy, and vaginal hysterectomy. Methods: We analyzed retrospectively 142 urinary tract injuries after hysterectomy, reported to the National Patient Insurance Association in Finland from 1990 through 1995. The Finnish Hospital Discharge Register collects data on procedures from all hospitals, and 62,379 hysterectomies were carried out during the study period. Results: The total incidence of ureteral injury after all hysterectomies was 1.0 of 1000 procedures: 13.9 of 1000 after laparoscopic, 0.4 of 1000 after total abdominal, 0.3 of 1000 after supracervical abdominal, and 0.2 of 1000 after vaginal hysterectomy. Difficulties during an operation with a ureteral injury were encountered in 51%, 76%, 100%, and 100%; the failure rates of primary repair of a ureteral injury were 5%, 12%, 0%, and 0%; and the convalescence times after a ureteral injury were 86 days, 94 days, 71 days, and 47 days after laparoscopic, abdominal, supracervical abdominal, and vaginal hysterectomies, respectively. The incidence of bladder injury was 1.3 of 1000 procedures. Sixty-five percent of reported bladder injuries were fistulas, giving an incidence of vesicovaginal fistula of 0.8 of 1000 procedures after all hysterectomies: 2.2 of 1000 after laparoscopic, 1.0 of 1000 after total abdominal, 0 of 1000 after supracervical abdominal, and 0.2 of 1000 after vaginal hysterectomy. Difficulties during an operation with a bladder injury were encountered in 53%, 37%, 100%, and 0%; the failure rates of primary repair of a simple bladder injury were 5%, 18%, 0%, and 0%; the failure rates of primary repair of a vesicovaginal fistula were 17%, 20%, 0%, and 0%; and the convalescence times after a bladder injury were 51 days, 118 days, 71 days, and 99 days after laparoscopic, abdominal, supracervical abdominal, and vaginal hysterectomy, respectively. Conclusion: The risk of ureteral injury is higher after laparoscopic hysterectomy compared with traditional hysterectomies.

Iatrogenic Urological Injuries During Obstetrical and Gynaecological Surgery

Objective: to evaluate the incidence, nature, and treatment of intra-operative, urological injuries encountered in the performance of obstetrical and gynaecological surgical procedures.Setting: this review was conducted in a tertiary care hospital involved in resident teaching. In this setting, there are 1,500 gynaecological surgical procedures, 2,200 deliveries, and 395 Caesarean sections performed per year.Methods: the charts of all patients undergoing gynaecological surgery or Caesarean section between June, 1992 and June, 1994 were reviewed. Charts coded for injury to ureter or bladder were selected for review. Data were obtained about pre-operative diagnosis, surgical procedure, time of recognition of the injury, method of repair, and outcome.Results: there were no urological injuries associated with obstetrical surgery. Sixteen cases of urological injury were identified among a total of 3,147 gynaecological operations: a prevalence of 0.51 percent. Of these 3,147 procedures, 826 were major procedures (prevalence 1.9%), with the risk of ureteric injury (0.24%), and that of bladder injury (1.7%). Risk factors identified were previous abdominal or pelvic surgery and the presence of pelvic disease.Conclusions: careful attention to the exposure of the ureters during surgery and sharp dissection of the bladder from the surgical field, particularly in patients with previous pelvic surgery, may help to decrease the incidence of these injuries.

Prophylactic ureteral catheterization in colon surgery. A five-year review.

The preoperative placement of prophylactic ureteral catheters in operations of the distal colon is both commonplace and controversial. We assessed the frequency, safety, and effectiveness of their use over a five and one-half-year period in a teaching hospital. The charts of 561 consecutive patients who underwent sigmoid or rectosigmoid colectomy from 1986 to 1991 were analyzed for age, sex, diagnosis, type of colectomy, placement of ureteral catheters, and ureteral complications. Ureteral catheterization was attempted in 92 patients (16.4 percent); it was successful bilaterally in 80 patients (87 percent) and unilaterally in an additional 10 patients (98 percent). Four (0.71 percent) transmural ureteral injuries were identified. Two surgical injuries (0.43 percent) occurred in the 469 patients without prophylactic catheter placement (95 percent confidence interval = 0.00549-0.0153). Two injuries (2.2 percent), consisting of one surgical injury and one iatrogenic injury directly related to catheter placement, occurred in the 92 patients with prophylactic catheters (95 percent confidence interval = 0.00262-0.0764). This latter injury resulting from catheter placement represents a rate of 1.1 percent per patient and 0.55 percent per ureteral catheterization attempted. Using a 24-hour staged removal, these catheterizations were associated with a 0 percent incidence of reflux anuria. Experienced surgeons requested prophylactic ureteral catheter placement in 16.4 percent of their sigmoid and rectosigmoid colectomies. The risk of ureteral injury (1.1 percent) as a direct result of catheter insertion is small, but not insignificant. Prophylactic ureteral catheters do not assure the prevention of transmural ureteral injuries, but may assist in their immediate recognition.