URETERIC INJURY IN GYNAECOLOGY

SUBMITTED BY: ANKITA GOSWAMI

ROLL NO.: 12
BATCH:2017
SUBMITTED TO: OBSTETRICS &
GYNAECOLOGY DEPT.
 CONTENTS
• INTRODUCTION
• SITES OF URETERIC INJURY
• TYPES OF URETERIC INJURY
• DIAGNOSIS
• MANAGEMENT
 INTRODUCTION
• Ureteric injury is defined as any recognized/unrecognized
trauma to the ureter that prevents it from functioning
properly and effectively & may lead to obstruction/
discontinuity & ureterovaginal fistula.

• Causes of ureteric injury:

A. CONGENITAL CAUSES: Congenital malformations such as,
 Duplex ureter
 Aberrant ureter opening into vagina, uterus, or into, urethra
• ACQUIRED CAUSES:
 Pelvic hematoma following trauma during pelvic surgery.
 Cervical fibroid.
 Broad ligament fibroid.
 Pelvic endometriosis.
 Gynecological malignancy.
 Tubo-ovarian mass, pelvic adhesions.
 Reapplication of clamp to uterine artery pedicle.
 Abdominal hysterectomy/ Radical hysterectomy.
 Laproscopically assisted vaginal hysterectomy.
 Colposuspension.
 SITES OF URETERIC INJURY
1. At the level of infundibulopelvic ligament, where
ureter runs parallel to ovarian vessels.
2. Below the level of ischial spine, where ureter lies
lateral to the uterosacral ligament.
3. At the level of internal cervical os, where uterine
artery crosses ureter from above.
4. Tunnel of Wertheim, the ureteric tunnel of cardinal
ligament.
5. Where it traverses through musculature of
bladder, (intravesical part).
6. Duplex ureter.
 TYPES OF URETERIC INJURY
• Kinking/angulation
• Ischemic injury
• Ligature incorporation
• Crushing injury
• Transection : Partial or complete
• Segmental resection either accidental or planned
• Thermal injury
• Injury by staplers
 DIAGNOSIS
• Symptoms: Fever, flank pain, hematuria, abdominal
distension, urine leakage (vaginally), peritonitis, ileus and
retroperitoneal urinoma.
• Escape of urine through vagina.
• Three swab test.
• Intravenous indigo carmine test : if the urine turns blue after
the injection of indigo carmine, there is presence of
ureterovaginal fistula.
• Cystoscopy, excretory urography, renal ultrasound & CT scan
helps to determine the side & site of ureterovaginal fistula.
 MANAGEMENT
• PREVENTIVE MEASURES:
A. Preoperative intravenous urography.
B. Placement of ureteral catheters (preoperative or
intraoperative).
C. Direct visualisation / palpation of ureters.
D. Uriglow
E. Adequate exposure of pelvic organs, to avoid blind
clamping of blood vessels.
• OPERATIVE PROCEDURES:
Depend upon the time of detection of injury:
1. INTRAOPERATIVE INJURY:
 Minor injuries like,
a. Ureteral sheath denudation, requires no intervention.
b. Ureteral kinking, due to closely placed sutures, immediate
removal of sutures.
c. Ureteral ligation, requires deliagtion immediately.
d. Ureteral crushing (clamp injury), requires removal of clamp
and ureteral stent placement via cystoscopy & follow up
IVU after 6 weeks.
 Major injuries like ureteral transection, treatment
depends on type and level of transection.
 Partial transection:
1. Upper one-third: Ureteral stent repair
2. Middle one-third: Ureteroureterostomy (end to
end anastomsis over ureteral stent) , ureteroileal
interposition.
3. Lower one-third: Ureteroneocystostomy
 Complete transcetion: Ureteroneocystostomy with
psoas hitch, Bladder flap procedure (Boari flap),
ureteroileoneocystostomy.
• POSTOPERATIVE REPAIR COMPLICATIONS:
Stricture, infection, ureteric obstruction, urine
reflux, stent or boari flap complications.