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WJOLS

Ureteral Injury in Gynecologic Laparoscopy

of ureteric stent may increase the injury to the ureter during There are several methods to deal with ureteral injury
laparoscopic dissection. 8 after laparoscopic surgery. A small laceration, not leading
Ureteral damage is usually caused by one of the three to the transaction of the ureter, can be managed with an
ways-either by direct injury from clamping, cutting, ligating insertion of ureteric stent and 1 suture closing the defect
or kinking in an attempt to stop the hemorrhage deep in the may be placed, if an injury has been recognized
pelvis, by stripping ureter of its periurethral sheath devoiding intraoperatively. 12 Most commonly, if ureteral damage is
it from its blood supply thereby creating postoperative minimal, ureteral stenting is sufficient. Sometimes
damage, or by use of electrosurgery. 9 exploratory laparotomy with reimplantation of the ureter
One of the issues in laparoscopic surgery is a wide- into the bladder, anastomosis of the damaged ureter,
spread use of electrosurgery during dissection, during
transureteral ureterostomy, interposition of the loop of ileum
development of tissue planes, during exposure of the
between the ureter and the bladder may be required (Figs 3
pedicles and such. Good understanding of principles of 13
and 4).
electrosurgery is imperative for the safe laparoscopic
Occasionally, ureteral injury after laparoscopy presents
surgeon (Fig. 2).
late in patient’s postoperative course (3-33 days post-
Issues such as difference between monopolar and bipolar
operatively). The presenting symptoms are similar to early
energy, direct coupling, and lateral thermal spread have to
recognized ureteral injuries, such as nausea, vomiting,
be kept in mind. Blind use of electrosurgery without first
fever, flank pain and peritoneal signs-abdominal
identifying exact source of bleeding near uterine artery, for
distension, abdominal pain, ileus as well as diffuse urinary
example, can lead to ureteral injury and create other
peritonitis due to urinary ascites. Blood test shows an
complications.
increase in creatinine level. If ureteral injury remains
Routine cystoscopy during laparoscopic gynecologic
undetected until late in postoperative course, obstruction
surgery allows for detection of more urinary tract injuries
and fistula may occur. Ureteral stricture may also develop
than without use of routine cystoscopy. The rate of injury
that makes ureteral stenting very difficult. So, delayed
to the ureter increases from 7.3 per 1,000 surgeries to 14.5
recognition of ureteral injury in gynecologic laparoscopy
per 1,000 surgeries when routine intraoperative cystoscopy
10
is employed. Intraoperative cystoscopy with intravenous associated with serious complications and treatment with
ureteral stenting is not useful. Exploratory laparotomy with
indigo carmine is a simple way to detect lower urinary tract
injury, such as injury to the ureter and the bladder. It is one of the methods of repair mentioned above, usually
7
highly recommended to ensure absence of injury to the lower indicated.
urinary tract. 11 Early recognition and repair is the key to Prevention of lower urinary tract injury and particularly
successful recovery. 5 ureteral injury, during gynecologic laparoscopy can be
Manifestations of ureteral injury usually seen early after minimized by thorough knowledge of pelvic anatomy,
the surgery (48-72 hours postoperatively). Patients present identification of the course of the ureter intraoperatively
with signs and symptoms of peritonitis that is accompanied (Fig. 5), and knowledge of it’s location at all times during
by nausea, vomiting, abdominal pain, fever and the dissection, keeping in mind most common sites of
leukocytosis. Sometimes flank tenderness and hematuria are ureteral injury, understanding principles of electrosurgery
also observed. IVP is a diagnostic method of choice in as well as use of correct and safe operative techniques
patients where ureteral injury is suspected. (Fig. 6).

Fig. 2: Electrosurgical generator used in Fig. 3: Ureteral reimplantation 14 Fig. 4: Ureteral anastomosis 14
gynecologic laparoscopy 14

World Journal of Laparoscopic Surgery, January-April 2012;5(1):46-48 47