Ureteric Injury in Gynecologic Laparoscopy: Prevention & Management – Dr. Lalit Shah

Gynecologic laparoscopy has revolutionized the field of minimally invasive surgery, offering numerous advantages such as reduced hospital stays, quicker recovery, and minimal postoperative complications. However, it is not without risks, and one of the most significant complications is ureteric injury. Although rare, ureteric injury can lead to severe morbidity if not promptly recognized and managed.

Understanding Ureteric Injury in Gynecologic Laparoscopy

The ureter, a vital structure responsible for transporting urine from the kidney to the bladder, runs in close proximity to many pelvic organs. During gynecologic laparoscopic procedures, particularly in complex surgeries such as hysterectomies, myomectomies, endometriosis excisions, and pelvic organ prolapse repairs, the ureter is at risk of being injured due to its anatomical course near the uterus, cervix, and adnexa.

Incidence and Causes

The reported incidence of ureteric injury during gynecologic laparoscopy varies between 0.1% and 2.5%. Common causes include:

1. Thermal Injury: Use of electrocautery, laser, or ultrasonic energy devices can inadvertently damage the ureter.
2. Direct Trauma: Accidental suturing, clamping, or transection during dissection.
3. Ischemic Injury: Disruption of the ureter’s blood supply during extensive adhesiolysis.
4. Kinking or Compression: Due to excessive suturing or placement of hemostatic devices.

Prevention Strategies

Preventing ureteric injury is a key aspect of safe gynecologic laparoscopy. The following strategies can significantly reduce the risk:

1. Preoperative Assessment & Planning

• Identify high-risk cases, such as severe endometriosis, previous pelvic surgeries, or large fibroids.
• Preoperative imaging (CT Urography or IVU) in suspected distorted pelvic anatomy.
• Ureteric stenting in high-risk cases to facilitate intraoperative identification.

2. Surgical Techniques to Minimize Risk

• Adequate Ureteric Identification: The ureter should be visualized before and during dissection in high-risk areas such as the pelvic brim, cardinal ligament, and uterosacral ligament.
• Use of Energy Devices with Caution: Avoiding excessive coagulation and choosing the appropriate settings for electrosurgical instruments.
• Meticulous Dissection: Gentle handling of tissues and avoidance of unnecessary traction on the ureter.
• Laparoscopic Magnification: Enhanced visualization using laparoscopic cameras can help in precise identification of anatomical structures.

3. Intraoperative Techniques for Ureter Protection

• Performing ureterolysis in cases of suspected adhesions or deep infiltrating endometriosis.
• Ensuring the ureter remains lateralized and away from the area of active dissection.
• Frequent reassessment of ureteral peristalsis to confirm its integrity.

Diagnosis of Ureteric Injury

Early diagnosis of ureteric injury is crucial for optimal patient outcomes. Signs of ureteric injury include:

• Intraoperative visualization of ureteric damage.
• Absence of peristalsis or devascularization.
• Postoperative symptoms such as flank pain, hematuria, fever, and anuria.
• Persistent postoperative urinary leakage.
• Elevated serum creatinine in unilateral injuries.

Diagnostic Tools:

• Cystoscopy with intravenous indigo carmine to assess ureteral patency.
• Intraoperative Ureteric Catheterization if injury is suspected.
• Postoperative Imaging, including CT Urography or retrograde pyelography, for delayed diagnosis.

Management of Ureteric Injury

The management of ureteric injury depends on the timing of recognition and severity of the injury.

Intraoperative Management

• Minor Thermal or Contusion Injury: Observation and potential stenting.
• Partial Transection: Ureteric repair with primary suturing or stenting.
• Complete Transection: Reanastomosis (ureteroureterostomy) or ureteroneocystostomy.
• Severe Injury or Late Detection: Psoas hitch or Boari flap procedures may be needed for distal injuries.

Postoperative Management

• Ureteral Stenting: Essential for mild injuries to promote healing.
• Percutaneous Nephrostomy: In cases where immediate repair is not feasible.
• Delayed Ureteric Reconstruction: If the injury is identified late, reconstructive surgery may be needed.

Conclusion

Ureteric injury in gynecologic laparoscopy is a serious but preventable complication. Proper surgical planning, meticulous technique, and early recognition are crucial in minimizing risks and ensuring optimal patient outcomes. Surgeons should remain vigilant, employ preventive strategies, and be prepared for timely management to reduce the long-term morbidity associated with ureteric injuries.

Dr. Lalit Shah emphasizes that continuous training in advanced laparoscopic techniques, knowledge of ureteric anatomy, and utilization of technological advancements such as fluorescence imaging and robotic-assisted surgery can further enhance the safety and efficacy of gynecologic laparoscopic procedures.