Genitourinary Injuries

GYN Conference
10/7/2020
Case #1
45yo G3P3 with AUB undergoing
TLH/BS
PE: 14 week size uterus, mobile
PSx: none
Case 1 Questions?
Describe the path of the ureter?
Describe common diseases or conditions
that can lead to ureteral injury?
Describe the 3 most common areas of
injury of the ureter?
If you transect the ureter during surgery,
what would you see?
Path of the ureter
Most Common Gyn Causes of Ureteral
Injury
endometriosis
cervical cancer
pelvic mass-TOA
uterine procidentia
pelvic hematoma
The Mo s t Fe a re d Pre da to r o f
the Ure te r

THE GYNECOLOGIST
Causes of Ureteral Injury
Hysterectomy
◦ Vaginal, abdominal, laparoscopic, robotic
Oophorerectomy
Reconstructive surgery
Abdominally ¾, Vaginal ¼
Lower 3 cm of ureter majority of the
time
 Incidence of Ureteral Injury
Ureteral injury occurs in 0.5 to 1.5% for all
major pelvic gynecologic surgery.
It has been suggested that 75% of ureteric
injuries are due to gynecologic operations.
In one study pelvic malignancy was
associated with 44.4% of all ureteral
injuries.

Dowling RA et al. J Urol 1986;135:912–915.

Symmonds RE. . Clin Obstet Gynecol 1976;19:623–643.
Liapis A. Int Urogynecol J 2001;12:391-394
Location of injury
Location of injury

L
e t e

US
Ur
Location of injury

Ur
e
ter
Histology
Mucosa
◦ Transitional epithelium
Smooth muscle
Outer adventitia
◦ lymphatics, vessels, nerves
Preserve the adventitia
The Ureter
Blood supply
• Upper: medial
• Lower: lateral
Location
• Lower medial portion of broad
ligament
Size
• 24-28 cm long
Case #2
47 yo G2P2 undergoing TAH/BSO for 18
week size fibroid uterus.
You identify the ureter and place a clamp
on the cardinal ligament.
Before cutting, you re-check the clamp
and notice the ureter was placed inside the
clamp. It has been 60 seconds…
Case #2 Questions
What type of injury is this?
What are the various types of injuries?
What is your next step?
What is the most common complaint
postoperatively after unidentified ureteral
injury?
Mechanism of injury
Avulsion
Transection
Suture ligation
Laceration
Crush
Accidental excision
Devascularization
Perforation

Assess the condition of the ureter!

Stents
Align areas of anastomosis
Provide a mold
Prevent extravasation
Alleviate obstruction
COMPLICATIONS of STENTS
irritative flank pain
hematuria encrustation
infection stone formation
migration obstruction
fragmentation reflux
perforation
Postoperative Recognition
Most are asymptomatic
early post-op complaints
flank pain
ileus
fever
abdominal mass
urine from vagina
decreased urine output
Case #3
36 yo G3P2 undergoing TLH/BS for AUB and
pelvic pain.
PSx: CD x 2, appendectomy
PE: 12 week size uterus with minimal
mobility and uterosacral nodularity
Dx LSC demonstrates stage 4 endometriosis
with the anterior uterus scarred to the
abdominal wall. You are able to see around the
thick scar to the bladder peritoneum and
proceed with the TLH
How do you identify the ureter?
What is the incidence of ureteral injuries?
Cystoscopy demonstrates no flow on the
right. What are the next steps?
You identify an injury 4 cm above the cuff.
How do you repair?
Ureter identification
Through peritoneum along lateral pelvic
side wall
Opening the broad ligament
Locate at pelvic brim
Evaluation
Intraoperative
◦ Indigo carmine/ fluoroscein and
cystoscopy
◦ Ureteral stent
◦ Retrograde pyelogram
Postoperative
◦ Renal U/S
◦ IVP
◦ CT Urogram
Indigo Carmine
RPG
IVP
CT Urogram
CT Urogram
Management decisions

Location
Length
Mechanism of injury
Time from injury
Condition of the ureter
Condition of patient
Location & length of injury
Distal ureter
◦ Stenting, de-ligation,
ureteroneocystostomy
◦ Longer: Psoas hitch, Boari flap
Proximal or mid
◦ Stenting, de-ligation, ureteroureterostomy
◦ Longer: Boari flap, ileal ureter,
mobilization of kidney
Time from injury
Intraoperative or within 3 to 5 days
◦ Immediate repair is indicated
◦ Deligation alone
◦ Deligation and ureteroureterostomy
◦ Ureteroneocystostomy if ligated segment
is ischemic
Delayed?
◦ Inflammation, stenting, nephrostomy
Principles of Ureteral Surgery
Non-crushing instruments
Tension free
Water tight
Delayed absorbable suture
Pelvic drain to evaluate for leak
Mobilization of bladder
Spatulate to prevent stricture
Stent for stabilization/prevent stenosis
Regeneration of mucosa at 2 weeks
Peristalsis at one month
Ureteroneocystotomy

• If the injury is in the distal 2

cm
• Double J stent for 2-6 weeks
• Non-refluxing vs. refluxing
Psoas Hitch

• If the ureteral reimplant

can not be done tension
free
• Cystotomy should be
done on anterior wall
of bladder
• Avoid genitofemoral
nerve
Boari Flap

• Bladder must be
mobilized
• Graft length of 3:2
ratio
• Base must be 4 cm
wide
Ureteroureterostomy
 Ifthe injury is 3-4 cm above
the ureterovesical junction
 Resect tissue from both
ends
 Spatulate
 Leave in stent for 2-6 weeks
 Leave in drain post-op