Management of Ureteral Injuries
Jun 2012 – by L. Copeland, MD
A 35-year-old patient presents with the complaint of new onset left flank pain on postoperative day #6 following a difficult hysterectomy and bilateral adnexectomy for severe endometriosis, related to a didelphic uterus. You are asked to assess and manage the problem.
Postoperative urinary tract injuries are one of the many risk factors associated with pelvic surgery. It is estimated that the risk of injury to the urinary tract is about 1% and many of these injuries are occult at the time of surgery. Obviously, any recognized injury at the time of surgery should be repaired at that time. Occult injuries of either the bladder or ureters may subsequently cause an obstructive uropathy or leakage of urine outside of the urinary collection system. In the postoperative interval the complaint of new onset flank pain should raise the question of possible obstruction and diagnostic interventions should evaluate the patient for hydronephrosis and hydroureter. Ureteral injury resulting in extravasation of urine from the collecting system will often present with an ileus and possible low grade fever. The serum creatinine may or may not be minimally elevated.
While ureteral injuries may occur in an anatomically normal surgical field, the most common risk factor associated with ureteral injuries is the presence of anatomic distortion. The etiology of the anatomic distortion can be varied and multiple. Common causes of anatomical variances include embryologic anomalies (e.g. double ureters), prior surgery (e.g. C-sections, renal transplants), tumors, (both benign - e.g. fibroids; and especially infiltrative malignant tumors), severe endometriosis, and severe acute or chronic inflammatory disease (including fibrosis from prior surgery or radiation).
Preventive strategies are worthy of consideration. Preoperative imaging may help define unsuspected anatomical distortion. During the surgical procedure, optimal exposure of adjacent anatomical structures should be maximized. The ureter is most reliably identified at the pelvic brim. The most common steps to identify the ureter at this location are as follows: enter the retroperitoneum lateral to the infundibulopelvic ligament; identify the iliopsoas muscle; identify the external iliac artery medial to the muscle; move superior along the artery to the level of the common iliac bifurcation; the ureter should cross the bifurcation of the common iliac artery and then run along the lateral edge of the medial leaf of the broad ligament. The placement of ureteral stents preoperatively may be of help for some surgeons, however it has also been suggested that they may increase the risk of injury to the ureter. In general, ureteral stents are not required to aid in the identification of normal anatomy. If possible, the direct visualization of the urinary tract structures throughout the surgical procedure is the best method to avoid a urinary tract fistula.
In the patient presenting above, one should review the history, including the details of the surgery and perform a focused pelvic examination. Imaging, including an intravenous pyelogram or CT scan, pelvic or renal ultrasound, may help identify the nature of problem. Also a well-performed retrograde pyelogram can provide information regarding the status of the ureters. The retrograde pyleogram carries less risk of damage to the kidneys compared to the use of intravenous contrast. Cystoscopy or cystograms may also be useful to evaluate for bladder injuries.
If either a ureteral blockage or a ureteral defect is found, the first consideration is to place a ureteral stent is using the retrograde approach. If this fails, then placement of a percutaneous nephrostomy, with subsequent antegrade stent placement is advised. Of course, if conservative management is neither possible nor successful, then surgical intervention may be necessary to resolve the defect.
Ureteral defects may require reimplantation of the ureter (ureteroneocystotomy), segmental resection and anastomosis and in rare occasions the use of a segment of small bowel in the performance of an ureteroileoneocystotomy.
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