It is the most serious and trouble-some complication of pelvic surgery and common reason for medico-legal action by the patient. It can be unilateral or bilateral. Lowest 3 cm of ureter is usually injured. 75% of injuries result from gynecological operations - 3/4th during abdominal and 1/4th during vaginal operations. As most injuries can be diagnosed intraoperatively, systematic assessment of urinary tract integrity should be part of the surgical plan. Intraoperative cystoscopy using either flexible or rigid instruments can aid in the diagnosis or exclusion of urinary tract injury. Identification of the mechanism of injury and its location guides immediate or delayed repair. Mobilization should be sufficient to allow a tension-free closure. Tissue interposition is typically recommended. Common sites for ureteral injury are found beneath the uterine vessels near the cardinal ligament and beneath the infundibulopelvic ligament and the tunnel of Wertheim. Successful ureteral repair relies on careful mobilization, wide spatulation, use of fine absorbable suture (4-0, 5-0), and temporary stenting. Postoperative signs and symptoms of ureteral injury may include unilateral flank pain, fever, prolonged ileus, and abdominal or pelvic fluid collection (urinoma).
Involuntary continuous leakage of urine after gynecological surgery comes as a bolt from blue to the patient and may cause suffering many times more than her previous disease. It is the most serious and trouble-some complication of pelvic surgery and common reason for medico-legal action by the patient .
|Laparoscopy associated ureteral injury||➔||0.3-0.4%|
Lowest 3 cm of ureter is usually injured.
75% of injuries from gynecological operations.
3/4 during abdominal operations.
1/4 during vaginal operations.
ligation with suture.
transection – partial or complete.
angulation with secondary obstruction - partial or complete.
ischemia from stripping of blood supply from the wall of ureter.
Cauterization – electrical, thermal, laser and stapler injuries in laparoscopic surgery.
4. Surgical anatomy and anatomical locations
Along the course of ureter on the lateral pelvic side wall just above the uterosacral ligament.
Where the ureter passes beneath the uterine vessels.
Beyond the uterine vessels as the ureter passes through the tunnel in the cardinal ligament and turns anteriorly and medially to enter the bladder.
Intramural portion of ureter when it traverses the bladder wall.
Devascularization especially in the lower 1/3rd.
5. Association with gynecological surgery
Most common site - pelvic brim near the infundibulopelvic ligament where it is crossed by common iliac artery, is more prone to injury due to adhesions especially in endometriosis and malignancy (Figures 4 and 5) [1, 2, 3, 4, 5, 6]
Most common procedure - Total abdominal hysterectomy
Most common type of injury - obstruction
Most common activity - attempts to achieve hemostasis.
Most common time of diagnosis-None: 50-50 split between intraoperative and post-operative.
Most common long term sequalae – None, however patient may need for repeat surgery.
Post hydronephrotic renal atrophy with complete ligation of a ureter.
If no sepsis ➔ asymptomatic kidney atrophy.
If sepsis ➔ becomes evident immediately.
Secondary stenosis and kidney damage.
Ureteral necrosis with urinary extravasation
urinary ascites (URINOMA)
Uraemia due to bilateral ureteric obstruction ➔ flank pain, unexplained or persistent fever with or without chills, BUN and creatinine levels rise.
Anuria for first 24-48 hours.
In first week ➔ Atrophy of distal nephrons.
In second week ➔ Atrophy of cortical region.
Renal Biopsy ➔ Protein casts in Bowman’s space are pathognomonic of obstruction.
7.1 Primary prevention
Prevention of injury before it occurs. As most injuries can be diagnosed intraoperatively, systematic assessment of urinary tract integrity should be part of the surgical plan.
Never cut/clamp /suture/apply energy before proper identification of ureter. always remember to preserve the blood supply of ureter. inadverent injury if suspected though not confirmed (blunt trauma/devascularization/ lateral damage due to thermal energy), ureteric stenting/catheterisation is to be done. always be proactive to involve the urogynaecologist at the earliest stage before, during or after surgery.
Careful evaluation of patient's gynecological disease and recognition of risk to the ureter with the surgical procedure is of foremost importance.
Preoperative excretory urogram- is mandatory in high-risk cases.
Ureteral catheterization by cystostomy or cystoscopically where ureter is at high risk, may be done. (Figure 6)
Adequate incision and proper exposure are most helpful.
Ureter must not be hidden in the operator’s subconscious mind - Never cut or clamp anything in and around ureter unless ureter is defined and stay outside the adventitial sheath when dissecting the ureter. Avoid energy sources near ureter especially monopolar cautery. Harmonic energy use is best near ureter next to cold scissors.
Before clamping infundibulopelvic ligament - surgeon must identify the ureter, lift the infundibulopelvic ligament and only then apply the clamp. First clamp should be lowest and lateral and second clamp above and medial.
3 rules after skeletonization of uterine vessels
Place the lowest clamp first.
Place it at right angle to uterus.
Place it at the level of internal os.
Ligation of uterine vessels should be medial to ureter so that ureteric branch of uterine artery can be preserved.
Dissection of bladder from upper vagina both inferiorly and laterally is required before excising cervix from vaginal vault.
Paracervical and paravaginal clamps or sutures should be as close as possible to cervix.
To support the vault with uterosacral ligament sutures should not be placed high or more laterally on side wall otherwise ureter may get kinked or ligated.
Carefully reperitonise the pelvis or one may leave reperitonisation.
To control the intraoperative bleeding best is to apply pressure with a pack or stick sponge or finger.
During vaginal hysterectomy
vesico-uterine space must be dissected adequately to allow displacement of ureters away from the clamp by downward traction on cervix and countertraction upward beneath the bladder.
Small-small bits of paracervical and parametrial tissues should be clamped, cut, and ligated.
Double clamping of cardinal ligaments and uterine vessels should be avoided as lateral clamp will come close to the ureter.
Perform a supracervical hysterectomy during caesarean section or extend the hysterotomy incision caudally to cervix.
During laparoscopic surgery:
If ureters are not visualized, retroperitoneal dissection should be done to decrease the incidence of complications (Figure 4). Visualization under Invisible near infrared (NIR) light after intravenous. or retrograde injection of ICG (Indigo carmine) dye is very useful if needed but it is expensive.
In tubal sterilization - Fallopian tubes should be taken away from pelvic wall before electrocoagulation.
In LAVH - if stapler application in cardinal and uterosacral ligament is not safe, then this part of operation should be done vaginally.
Note: Kinking is functionally similar to obstruction till it is undone. Be careful when clamping or suturing the uterosacral ligament and during reperitonisation.
7.2 Secondary prevention
Intraoperative cystoscopy using either flexible or rigid instruments can aid in the diagnosis or exclusion of urinary tract injury. Identification of the mechanism of injury and its location guides immediate or delayed repair.
Evaluation of ureter should be done before operative procedure is terminated by:
Inspection of peristaltic activity.
Dissection by reflecting peritoneum.
Ureteral catheterization. (Figure 6)
I/V chromogen test
2.5-5ml of indigo carmine 0.8% / Methylene Blue - within 3-5 minutes spurt from each ureteric orifice is there. If takes longer time - I/V fluids or diuretics are given.
If no spurting, ureter should be explored along its course to point out the site of obstruction or injury.
If transection is partial or complete - dye will leak into operative field.
If ligation by suture/kinking is complete - No dye will leak in operative field and there will be proximal dilatation of ureter which will increase progressively.
If ligation by suture/kinking incomplete - - No dye will leak in operative field and there will be proximal dilatation of ureter that will decrease slowly and slowly.
Intraoperative cystoscopy: Urine efflux from the ureteric orifice may be absent or slow on intraoperative cystoscopy. Almost 90% of ureteric injuries are diagnosed by cystoscopy. Partial obstruction and thermal injuries may be missed.
Note: if peristalsis seen, most probably injury is not there. but it cannot rule out ischaemic injury which will manifest postoperatibely only and may manifest after 7-10 days. so, if inadverent injury if suspected though not confirmed, ureteric stenting/catheterisation is to be done, to prevent further complications.
Surgical procedures as per need are to be done as given under tertiary prevention depending on individual factors like site of injury, extent of damage and integrity of opposite ureter provided patient’s condition allows. If unfit, temporary measures like closed drainage/PCN are taken till general condition is fit i.e., within 48-72hours or later after 6-8 weeks.
7.3 Tertiary prevention
Signs/Symptoms of patient: STORMY POSTOPERATIVE PERIOD
lower abdominal mass/ ascites- Paracentesis to be done for urea level.
unexplained fever with/without chills
watery discharge from vagina.
IV Indigo carmine test
Pyridium/ Methylene blue test
3 swab tests with Methylene blue
Cystoscopy with passage of retrograde ureteral stent, if possible, should be done.
Comparison of pre and postoperative creatinine level.
9. Treatment depends upon
Integrity of opposite ureter.
Loss of length
Time of Dx:
recognized during surgery.
unrecognized during surgery
9.1 General guidelines for management of ureteral injuries
This depends on the type and timing of presentation, the site of injury and the patient’s condition. Immediate treatment is to relieve obstruction and stop leakage of urine. Definitive surgery for women with intraperitoneal or extraperitoneal leakage or obstruction, this should be undertaken as soon as the patient is stable and ready. Management of transaction and thermal injuries is the same as of intraoperatively diagnosed injuries. Very small fistulas may close with stenting. For large fistulas and when urine leaks despite stenting, surgery is required (Figure 7).
Mobilization should be sufficient to allow a tension-free closure. Tissue interposition is typically recommended. Common sites for ureteral injury are found beneath the uterine vessels near the cardinal ligament and beneath the infundibulopelvic ligament and the tunnel of Wertheim. Successful ureteral repair relies on careful mobilization, wide spatulation, use of fine absorbable suture (4-0, 5-0), and temporary stenting.
|Upper & middle third|
9.2.1 Injury recognized during surgery
Simple pelvic closed drainage should be done.
Intubate the ureter for 7 days by means of cystoscopy/cystotomy and retrograde catheterization of ureter with
Infant feeding tube - No.5
J-shaped stent is preferable. (Figure 6)
If ureter is discovered to be cut or if extensive damage after clamping or ligation -Injury to lower third is most common
Injury to ureter < 4-5cm of ureterovesical junction
If 3–4 cm proximal to ureterovesical junction ➔ Ureteroureterostomy is needed.
If within 2 cm of ureterovesical junction ➔ Ureteroneocystostomy is required.
If above two cannot be done without tension ➔ Vesicopsoas hitch is the procedure required.
Injury to ureter > 4-5cm of ureterovesical junction/at brim
9.2.2 Injuries unrecognized during surgery
Immediate ureteral catheterization and bypass the obstruction— should be left for 14 days or longer.
If catheterization not possible:
Diagnosed within 48-72 hours of surgery- immediate ureteral repair should be done.
If diagnosis is made late or if extensive devascularization and injury are likely to occur e.g., after extensive hysterectomy, or extensive retroperitoneal fibrosis, cellulitis and induration is expected in patients with poor medical condition -PCN (Percutaneous Nephrostomy) preferably under ultrasound is required and definitive surgery can be planned 6-8 weeks later.
Sound knowledge of ureteral anatomy is critical to the avoidance of injury. In the event that the ureter is damaged during gynecologic surgery, intraoperative diagnosis allows for immediate repair in most cases. For this reason, intraoperative confirmation of ureteral integrity should be routine, whether the surgical approach is transvaginal or transabdominal through the open, laparoscopic, or robot-assisted approach. The ureter may be assessed visually, by palpation, or cystoscopically. Identification of the mechanism of injury and its location guides immediate or delayed repair. With proper recognition and therapy, ureteral function can be restored, and renal function maintained.
I am extremely grateful to my family for always being there to support me. I want to thank my parents who always believed in me. I would especially like to thank my children for constantly motivating me to work harder and my granddaughter for constantly cheering me up.
Conflict of interest
The author declares no conflict of interest.
Thank you very much Er Sidharth Garg (M Eng Electrical and Computer) for formatting the paper and making all the necessary edits to achieve its desired structure and Dr. Muskaan Bharti MBBS Intern for editing the chapter.