Upload
raina-chawla-bhatia
View
214
Download
2
Embed Size (px)
Citation preview
OPERATIVE INJURIES TO THE URETER
Dr Raina
“ The venial sin is injury to the ureter, but the mortal sin is failure of recognition”
Ureteric Injuries
Incidence:
0.2-1.0% during any abdominal or pelvic surgery
Obstetric or gynecological surgery accounts for approximately 50% of all these injuries
Ref: Jha S, Coomaraswamy A, Chan KK. Ureteric injury in obstetric and
gynecological surgery. The obstetrician and gynecologist 2004;6:203-208, RCOG
Risk of ureteric injury in obstetric and gynecological procedures
Obstetric Gynecological cesarean section hysterectomy(abdominal) cesarean hysterectomy vaginal hysterectomy forceps subtotal hysterectomy others Wertheims hysterectomy
Urogynecological Burch colposuspension Transvaginal tape
Laparoscopy Adnexectomy LAVH Adhesiolysis Ablation of endometriotic deposits
Anatomy of the Ureter
2 major components abdominal pelvic
25-30cm in length
Course of ureter
Course of the ureter
The distance between the uterine isthmus and the ureter is not always the same on each side
Blood supply to the ureter
Ovarian artery
Renal artery
Internal iliac
Sup vesicalInf vesical
Risk Factors
Certain factors have been found to increase the
risk of ureteric injury during surgery: An enlarged uterus Previous pelvic surgery Ovarian neoplasm Endometriosis Pelvic adhesions Distorted pelvic anatomy Massive intraoperative hemorrhage
However it is notable that more than half of all injuries have no identifiable predisposing factor
Types of Ureteral Injuries
CrushingLigation with a sutureTransectionAngulation with secondary obstructionIschemiaResection of a segment of ureter Laparoscopic
Anatomical Locations of Ureteric Injuries
Injury occurs most frequently in the lower third of the ureter
The most common sites of injury:• Lateral to the uterine vessels• The area of the ureterovesical junction• Base of the infundibulopelvic ligament as the ureters
cross the pelvic brim• At the level of the uterosacral ligaments
In the obstetric patient, ureteral injury can occur when suturing an extended uterine incision in an effort to control bleeding within the broad ligament or during a cesarean hysterectomy
Sequelae of Ureteral Injury
Spontaneous resolution and healing Posthydronephrotic renal atrophy with or without sepsis Ureteral necrosis, extravasation and fistula formation Secondary stenosis of the ureteral lumen/ stenosis of the fistula tract Uremia (b/l ureteral injury)
Ureterovaginal fistula formation
1. Ureteral necrosis and occlusion following injury
2. Loss of ureteral wall with urinoma formation
3. - Ureterovaginal fistula - Ascending periureteral
infection - Perinephric abscess
Prevention of ureteric injury
Pre operatively: • Careful evaluation of the patients gynecologic
disease and recognition of the risk to the ureter with the surgical procedure planned
• Preoperative IVU: no role in preventing ureteric injuries in routine procedures
• Prophylactic ureteric catheterization: not shown to reduce the risk of ureteric injury in routine cases
Prevention of ureteric injury…
Intra operative (general)
• Appropriate operative approach• Adequate exposure• Avoid blind clamping of vessels• Ureteric dissection and direct visualization• Mobilize bladder away from operative site• Short diathermy applications
Prevention of ureteric injury…
Specific: Abdominal Hysterectomy -If the ovary is to be removed, the infundibulopelvic ligament
should be clamped with the first clamp being the lowest and most lateral clamp
-During clamping of uterine vessels, after skeletonization, place the lowest clamp first place it at right angles to the uterus place it at the level of the internal cervical os
- Intrafascial technique of removing the cervix (to avoid injury between the uterine vessels and the bladder base)
- adequate mobilization of the bladder downward and outward
- direct visualization of the ureters
Prevention of ureteric injury…
Vaginal surgery:• Adequate vesicouterine space • Downward traction on the cervix and counter traction upward beneath the bladder• Small bits of parametrial and paracervical tissue
clamped, cut and ligated
Anterior colporrhaphy:• Avoid starting too laterally or inserting sutures
too deeply while plicating the bladder to prevent needle injury to the ureter
Symptoms and signs of ureteric injury
FeverFlank painHematuriaAbdominal distensionAbscess formation/sepsisUrinary leakageRetroperitoneal urinoma
Radiographic investigations for ureteric injuries
Intravenous urogramAbdominal and pelvic CT scan with intravenous contrastRetrograde ureterogramRenal ultrasoundCystoscopy
Management
Case presentation
Mrs A37 yrs with DUB for 10 yrs, failed medical managementTAH with rt salpingo oophorectomy on 18/5/07 Presented on 2/6/07 (16th POD) with c/o
fever – 1 day
spotting PV – 1 day
watery discharge PV – 2 days
Case presentation…
O/E: Febrile (103 F) vital signs stable systemic examination: NAD P/A: - soft - tenderness on deep palpation; left side - no mass palpable - pfannensteil scar-healed by primary intention - bluish ecchymosed patches around wound site
Case presentation…
P/S: vault healthy
minimal watery discharge; clear
no purulent/blood stained discharge
no obvious fistulous site seen
P/V: no obvious mass felt
Case presentation…
Initial Investigations: CBP: WNL
Urine R & M: Pus cells: 8 - 10
RFT: serum creatinine: 1.2 ( )
blood urea – Normal
USG: complex mass seen
Initial management:• Patient was catheterized; started on T pyridium and broad
spectrum antibiotic coverage• Urine was discolored suggesting the diagnosis of urogenital
fistula• Patient transferred to KMC Manipal for further management
Case presentation…
Further investigations & management
• Cystourethroscopy: ? Vesico vaginal & lower ureteric fistula+
• IVP: confirmed the presence of vesicovaginal & ureterovaginal fistula; ureteral stenting attempted; not successful
• Percutaneous nephrostomy done; stenting re attempted; not succesful
• Follow up and surgery after 3 months
Case presentation…
Why urogenital fistula??
• Risk factors: intra operative hemorrhage; blind
clamping of vessels• Ureter not identified during surgery• Badder not mobilized away from operative
site
References
Te Linde RW, Thompson JD, Rock JA. Te Linde’s operative gynecology. Philadelphia: Lippincott-Raven; 1997
Jha S, Coomaraswamy A, Chan KK. Ureteric injury in obstetric and gynecological surgery. The obstetrician and gynecologist 2004;6:203-208, RCOG press
Chan JK, Morrow J, Manetta A. Prevention of ureteral injuries in gynecologic surgery. Am J Obstet Gynaecol 2003;188:1273-1277
Thank you