The detection of ureteral injuries after hysterectomy

doi:10.1016/j.jmig.2006.04.018

Journal of Minimally Invasive Gynecology

Volume 13, Issue 5, September–October 2006, Pages 403-408

https://doi.org/10.1016/j.jmig.2006.04.018 Get rights and content

Abstract

Study objective

To identify the incidence and outcomes of ureteral injuries in patients undergoing hysterectomy, and to evaluate the effect of intraoperative cystoscopy and early postoperative ureteral jet ultrasonography.

Design

Retrospective comparative study (Canadian Task Force classification II-2).

Setting

Tertiary medical center.

Patients

Fifteen patients who experienced ureteral injuries while undergoing hysterectomy out of 4950 total patients during a 6-year period.

Interventions

All patients underwent hysterectomy, and intraoperative cystoscopy or early postoperative ureteral jet ultrasonography were used to evaluate ureteral integrity.

Measurements and main results

The incidence of ureteral injury recognized after hysterectomy was 0.32%, and all ureteral injuries occurred during laparoscopic hysterectomy. The initial detection of ureteral injury resulted from intraoperative cystoscopy in five patients, early postoperative ureteral jet ultrasonography in two patients, and signs and symptoms in eight patients. The patients whose injuries were detected by either intraoperative cystoscopy or early postoperative ureteral jet ultrasonography were diagnosed earlier (1.7 and 19.9 postoperative days, respectively; p <.01) and tended toward more conservative treatment (p = .119; OR = 10; 95% CI 0.78–128.78) than those who were diagnosed based on signs and symptoms alone.

Conclusions

Use of intraoperative cystoscopy or early postoperative ureteral jet ultrasonography leads to earlier diagnosis of posthysterectomy ureteral injury, thereby allowing for more conservative treatment.

Section snippets

Patients

A review of medical records was conducted in which ureteral injuries occurred during hysterectomies performed from January 1998 through December 2003 at Changhua Christian Hospital. Three main surgical procedures were included: total abdominal hysterectomy (TAH), laparoscopic hysterectomy (LH), and total vaginal hysterectomy (TVH). Only patients who underwent surgery for nonmalignant disease were enrolled in the study, and the diagnoses included uterine leiomyoma, adenomyosis, refractory

Results

A total of 4950 hysterectomies comprised the study population: 2836 LHs, 1844 TAHs, and 270 TVHs. The frequency of LHs increased with time (Figure 1). A total of 15 patients with ureteral injuries were identified in the study. The incidence of ureteral injury was 0.32% (15/4950) in all patients undergoing hysterectomy and 0.53% (15/2836) in patients undergoing LH. Altogether, 51 patients had intraoperative cystoscopy, and 527 patients had early postoperative ureteral jet ultrasonography, all of

Discussion

Ureteral injury remains a severe complication in gynecologic surgery. The incidence of ureteral injuries is 0.1% to 0.4% in patients undergoing TAH and zero to 0.5% in patients undergoing TVH.3, 4, 5, 6, 7, 21 In our review, no ureteral injuries occurred in patients who underwent TAH or TVH. Laparoscopic surgery has largely replaced traditional surgery for most benign gynecologic conditions. In our series, 57% of hysterectomies were performed by laparoscopy, and the trend for LH continues to

Conclusion

Intraoperative cystoscopy and early postoperative ureteral jet ultrasonography are useful tools for the early diagnosis of ureteral injuries before obvious physical signs and symptoms develop. However, there are limitations for both methods. If the postoperative signs and symptoms of flank pain, costovertebral tenderness, and fever develop, a ureteral injury should be highly suspected even if previous cystoscopy or jet ultrasonography reveals bilaterally patent ureters.

Acknowledgment

We thank Miss Yu-Jun Chang, Laboratory of Epidemiology and Biostatistics at Changhua Christian Hospital, for the statistical assistance.

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Evaluation and Management of Common Intraoperative and Postoperative Complications in Gynecologic Endoscopy
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Citation Excerpt :
If an injury is still suspected, an intraoperative IV pyelogram or retrograde cystogram may be performed.39 Early detection decreases the risk of requiring reimplantation by tenfold.49 The type of injury—kinking, ligation, crush, or thermal—and the location of the injury determine the necessary repair strategy.
Laparoscopic and laparotomic guided ureteral stenting during gynecological surgery without use of imaging: Safety and feasibility in a single institutional case series
2020, European Journal of Obstetrics and Gynecology and Reproductive Biology
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Moreover, a delayed diagnosis of ureteral injuries increases the rate of complications [5,17,18]. In gynecological surgery, when a routine intra-operative cystoscopy is practiced the detection rate of ureteral trauma is five times higher than usually reported. [19] During surgery, we currently use intraoperative cystoscopy and ureteral stenting.
Aim of this study is to refer a single center experience of laparoscopic or laparotomic assisted ureteral stenting without the use of imaging guidance.
We recruited 19 patients in the Institute for Maternal and Child Health in Trieste (Italy) who underwent ureteral stenting between June 2017 and December 2018 for suspicious ureteral injury during gynecological surgery.
Ureteral stents insertions were performed in all cases using rigid cystoscopes, hybrid guidewire with a hydrophilic coating, and double loop ureteral stents; the ureters were skeletonized during surgery and stents were used to permit better visualization of the ureteral whole and to prevent complications connected with the ureteral devascularization and minor not recognized ureteral injuries. All the procedures were performed under a laparoscopic or laparotomic guide.
No sign of acute kidney failure was reported during the post-operative kidney functions evaluation. The right position of the stents was confirmed in the first postoperative day by ultrasonographic imaging. No major complications related to the urinary tract have been detected. Ten patients stated stent related symptoms well controlled by analgesic therapies. All stents were removed by office cystoscopies one month later without reporting any complication.
Introducing fluoroscopy or ultrasonographic imaging into the operative field could be difficult and time-consuming. Instead, the laparoscopic and laparotomic guided ureteral stenting without the use of imaging currently used in the standard clinical practice of many institutions even without an official standardization in order to treat or prevent ureteral injuries after the surgery, seems to be safe and feasible.
Does Early Ureteroneocystostomy After Iatrogenic Ureteral Injury Jeopardize Outcome?
2020, Urology
To compare the outcomes of patients who underwent early repair (≤7 days) of iatrogenic ureteral injury with ureteroneocystostomy and compare them to those repaired in a delayed fashion (>7 days).
A retrospective review of billing data between 2012 and 2018 identified patients who underwent ureteroneocystostomy for a benign ureteral disease. Inclusion criteria included all ureteral injuries related to a laparoscopic, robotic, or open surgical injury. Patients with ureteral injury related to radiation, stones, or reconstructive surgery were excluded. Patients undergoing reconstruction during the initial injury or within ≤7 days were designated as having undergone early repair, while the remaining were considered delayed repair. Demographics, as well as inpatient and postdischarge data were acquired, and statistical analysis was performed comparing the 2 groups.
Sixty-seven patients met inclusion criteria. Early repair was performed on 12 patients, while 55 underwent delayed repair. No significant difference in age, gender, Charlson Comorbidity Score, laterality, stricture location, or history of pelvic/abdominal radiation was noted. Inpatient complications were significantly higher in the immediate group (58 vs 18%, P =.004). Thirty- and 90-day complications were similar. Two patients in the delayed group and none in the immediate group demonstrated stricture recurrence (P =.710). A higher rate of Boari flap ureteral reconstruction was performed in the delayed cohort (P =.001).
In this cohort, there was no detectable difference in outcomes when comparing early and delayed ureteroneocystostomy for iatrogenic ureteral injuries.
Prevention of iatrogenic ureteral injuries during robotic gynecologic surgery: A review
2016, American Journal of Obstetrics and Gynecology
Iatrogenic ureteral injuries, more than half of which occur during gynecologic surgery, may have devastating consequences for both patients and physicians. Gynecologists have employed various techniques such as cystoscopy, ureteral stents, and lighted ureteral stents to prevent ureteral injuries. The emergence and increasing prevalence of robotic surgery necessitates that we not only reevaluate the utility of these techniques, but also develop new ones specific for the robotic modality. In the robotic setting, the surgeon lacks tactile feedback and must rely primarily on visual cues. The use of intraureteral indocyanine green and subsequent visualization under near-infrared fluorescence appears to be a promising technique to primarily and secondarily prevent ureteral injuries during robotic gynecologic surgery.
Measurement of peritoneal fluid urea nitrogen and creatinine levels is useful to detect iatrogenic urinary tract leakage in colorectal surgery
2015, Journal of the Chinese Medical Association
Increased peritoneal drainage after colorectal surgery is a common problem. Measurement of peritoneal fluid urea nitrogen (UN) and creatinine (Cr) is a diagnostic tool to detect the urinary tract leakage (UTL). We evaluated its application in colorectal surgery.
We conducted a retrospective chart review study. We enrolled patients with iatrogenic UTL, and measured their UN and Cr levels in peritoneal fluid and compared them with those in blood and urine. Meanwhile, we assigned patients without UTL to a control group and compared clinical parameters of both groups.
Twenty-three patients with iatrogenic UTL were recruited. The overall incidence was 0.5%. UN level in peritoneal fluid (322 ± 56 mg/dL) was significantly higher than that in blood (18.7 ± 4.0 mg/dL, p < 0.001); Cr level in peritoneal fluid (69.7 ± 14.3 mg/dL) was also significantly higher than that in blood (1.5 ± 0.5 mg/dL, p < 0.001). UN level in peritoneal fluid was significantly higher in the iatrogenic UTL group than in the control group (322 mL/dL vs. 9.3 mL/dL, p < 0.001); Cr level in peritoneal fluid was also significantly higher (69.7 mg/dL vs. 0.98 mg/dL, p < 0.001).
When increased peritoneal drainage is found postoperatively in colorectal surgery, measurement of UN and Cr levels in peritoneal fluid can be a useful diagnostic tool to determine intraperitoneal iatrogenic UTL.
Review of the current management of upper urinary tract injuries by the EAU trauma guidelines panel
2015, European Urology
Citation Excerpt :
Early recognition facilitates immediate repair and provides better outcome. Prolonged ureteral obstruction (>2 wk) predisposes the patient to pain and risk of infection [47]; it generally results in irreversible renal damage and almost doubles the risk of hypertension [48]. Extravasation of contrast medium on CT scans or in IVP is the hallmark sign of ureteral trauma.
The most recent European Association of Urology (EAU) guidelines on urological trauma were published in 2014.
To present a summary of the 2014 version of the EAU guidelines on upper urinary tract injuries with the emphasis upon diagnosis and treatment.
The EAU trauma guidelines panel reviewed literature by a Medline search on upper urinary tract injuries; publication dates up to December 2013 were accepted. The focus was on newer publications and reviews, although older key references could be included.
A full version of the guidelines is available in print and online. Blunt trauma is the main cause of renal injuries. The preferred diagnostic modality of renal trauma is computed tomography (CT) scan. Conservative management is the best approach in stable patients. Angiography and selective embolisation are the first-line treatments. Surgical exploration is primarily for the control of haemorrhage (which may necessitate nephrectomy) and renal salvage. Urinary extravasation is managed with endourologic or percutaneous techniques. Complications may require additional imaging or interventions. Follow-up is focused on renal function and blood pressure. Penetrating trauma is the main cause of noniatrogenic ureteral injuries. The diagnosis is often made by CT scanning or at laparotomy, and the mainstay of treatment is open repair. The type of repair depends upon the severity and location of the injury.
Renal injuries are best managed conservatively or with minimally invasive techniques. Preservation of renal units is feasible in most cases. This review, performed by the EAU trauma guidelines panel, summarises the current management of upper urinary tract injuries.
Patients with trauma benefit from being accurately diagnosed and treated appropriately, according to the nature and severity of their injury.

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View full text

Original articleThe detection of ureteral injuries after hysterectomy

Abstract

Study objective

Design

Setting

Patients

Interventions

Measurements and main results

Conclusions

Section snippets

Patients

Results

Discussion

Conclusion

Acknowledgment

Litigation following ureteral injuries associated with gynecological surgery

J Soc Obstet Gynecol Can

Hysterectomy in the United States

Obstet Gynecol

Ureteral injury in gynecologic surgery: a ten-year review in a community hospital

Am J Obstet Gynecol

Urinary tract injuries after hysterectomy

Obstet Gynecol

Suture entrapment and secondary ureteral obstruction

Am J Obstet Gynecol

Diagnosis and management of serious urinary complications after major operative laparoscopy

Obstet Gynecol

Ureteral complications with operative gynecologic laparoscopy

Am J Obstet Gynecol

The value of intra-operative cystoscopy at the time of laparoscopic hysterectomy

Hum Reprod

Ureteral injuries in gynecologic surgery

J Urol

Ureteral injury in pelvic surgery

Obstet Gynecol

Lower urinary tract injury during gynecologic surgery and its detection by intraoperative cystoscopy

Obstet Gynecol

Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy

Obstet Gynecol

Ureteric jet effect: the echographic appearance of urine entering the bladder—a means of identifying the bladder trigone and assessing ureteral function

Radiology

Interpretation of submerged laminar jets: ureteric jet phenomenon

Radiology

Laminar submerged jets by color Doppler ultrasound: a model of the ureteral jet phenomenon

Invest Radiol

Original article
The detection of ureteral injuries after hysterectomy