Ureteral Injury During Gynecologic Surgery- Risk Factors, Types, Management, and Prevention

What Are the Ureteral Injuries During Gynecologic Surgery?

Ureteral injuries are significantly responsible for postoperative morbidity and mortality in women. Sometimes gynecological surgeries may result in lower urinary tract, bladder, or ureteral injuries. These injuries can be recognized or not recognized during the procedure. The ureter and pelvic organs are closely related anatomically, so a deep knowledge of these structures plays a vital role in preventing such injuries.

The gynecologic surgical procedures which can cause ureteral injuries are-

• Hysterectomy- It can be abdominal, vaginal, or radical.

• Laparoscopic pelvic surgery.

• Repair of pelvic or uterine prolapse.

• Abdominal oophorectomy (removal of ovaries).

• Fallopian tube removal.

• Cesarean section delivery.

• Adnexectomy (the procedure of removing one of the uterine tubes and an ovary).

• Pelvic lymphadenectomy (lymph node removal).

• Direct or indirect thermal injuries are due to various energy sources like radiofrequency or ultrasonic radiation.

Ureteral injuries are difficult to identify immediately during surgery, but the postoperative symptoms play an important role. Delayed diagnosis of ureteral injuries can result in life-threatening complications like fistula formation, permanent kidney damage, sepsis, or even death.

How to Prevent and Identify Ureteral Injuries During Gynecologic Surgery?

The surgeon must identify ureters before commencing the surgical procedure. Preoperative radiographs, CT scans, or ultrasounds for patients with a history of pelvic surgery, irradiation, or infection. Placement of preoperative stents in ureters can be done if required. Use of Intraoperative cystoscopy (a type of fiber-optic endoscope). Intraoperative identification and repair of the injury.

What Are the Risk Factors for Ureteral Injuries During Gynecologic Surgery?

Risk factors include:

• Urinary tract abnormalities.

• Obesity.

• History of pelvis surgeries or pelvic irradiation.

• Endometriosis (endometrial tissue grows outside the uterus).

• The large size of the uterus or pelvic mass.

• Fibroids.

• Pelvic adhesions.

• Large adnexal masses.

• Hemorrhage (intraoperative bleeding).

What Are Various Types of Ureteral Injuries During Gynecologic Surgery?

The common types of ureteral injuries caused during gynecological surgeries are as follows:

• Partial laceration.

• Division.

• Ligation or kinking by suture.

• Thermal damage from electrosurgery.

• Crushing of tissues due to clamps.

• Devascularization or denervation.

What Are Signs and Symptoms of Ureteral Injuries During Gynecologic Surgery?

The recognized ureteral injuries can be identified and repaired during the operation. The unrecognized or missed ureteral injury is challenging to diagnose as the symptoms are nonspecific.

Postoperatively following signs and symptoms can be present suggestive of ureteral injury-

• Flank pain.

• Prolonged ileus (blockage in intestines).

• Persistent abdominal distention.

• Unexplained fever.

• Vaginal Discharge- watery discharge from the vagina.

• Elevated serum creatinine levels (Oliguria).

• Unexplained hematuria (blood in urine).

• Presence of abdominal mass.

• Hydronephrosis- Swelling in one or both kidneys due to urine retention. It can occur due to blockage in the pathway of urine drainage. The situation can worsen if the infection increases to cause pyonephrosis (pus accumulation in kidneys).

• Urinary Extravasation- Occurs due to unrecognized ligation of ureters. It leads to urinary leakage in periureteral areas, further forming urinary ascites or peritonitis. If urine leakage occurs in the retroperitoneum or retropubic space, it might develop into a urinoma.

• Ureteral Stricture may occur due to electrocoagulation or stripping of the ureter's outer layer. It may lead to obstruction and hydronephrosis.

• Uremia- Due to obstruction in urine drainage, anuria (kidneys fail to produce and filter urine) is present, leading to kidney damage and uremia (kidneys stop filtering toxins through urine).

What Is the Management of Ureteral Injuries During Gynecologic Surgery?

The best time to repair a ureteral injury is- when it occurs during the operation. At that time, the tissues are in their best condition, and the success rate after the repair is very high, with fewer complications. But unfortunately, most ureteral injuries due to gynecological surgery are discovered postoperatively on the appearance of signs and symptoms. Such cases require multiple procedures and complex repairs. The chances of developing complications are high if the treatment is delayed.

Ureteral injury repair and management depend on the following factors:

• Time of diagnosis (during surgery, postoperative, or delayed).

• Length and location of the injury.

• Type of injury.

• Patient's health condition.

A few ureteral injuries during gynecological surgery and their management are mentioned below:

1. Laparoscopic Injury- The endoscope can place ureteral stents for four to six weeks. A lacerated ureter can be sutured laparoscopically.

2. Fistulas- They close themselves spontaneously after establishing proper drainage and ureteral stents. No open repair surgery is needed.

3. Strictures- Early Ureteral strictures can be treated by balloon dilatation, endoscopic incision, or stent placement for about six weeks. But, the ureteral strictures that are diagnosed late require open segmental removal and repair surgery.

4. Bladder Injuries- Mostly, bladder injuries accompany ureteral injuries. Bladder repair is done to prevent fistula formation. A Foley catheter is employed for a few days, and placement of a suction drain is done. This condition resolves in a few weeks.

5. Hysterectomy- Abdominal hysterectomy is managed by a two or three-layer closure of the bladder with absorbable sutures, and a foley catheter is placed on established drainage. During a vaginal hysterectomy, cystoscopy is used to identify the exact location of the injury.

6. Delayed Ureteral Complications- In delayed cases, urine leakage can cause an abscess, scarring of the ureter, obstruction, and formation of abnormal passages. Kidney removal is done in severe, delayed, and complicated cases.

Conclusion:

Gynecological surgeries are intense procedures with high chances of damage to the ureteral complex. These mishaps can be prevented by preoperative evaluation of the patient and attention to the location of the ureter during the procedure by surgeons. In recognized cases of injury during surgery, quick identification of damage and restoration is made to avoid complications in the future. In non-recognized cases, treatment should be planned the earliest after the appearance of the first symptoms. Although ureteral injuries due to gynecological surgery can sometimes be unavoidable due to the comparative anatomy of structures, meticulous management can save the patient's life with excellent outcomes.