DOI: 10.14260/jemds/2015/1436

ORIGINAL ARTICLE

OUTCOME OF URETERIC INJURIES IN ABDOMINAL AND VAGINAL HYSTERECTOMIES

Sankareswari R1, Ghurunaath T. R2

HOWTOCITETHISARTICLE:

Sankareswari R, Ghurunaath T. R.“Outcome of Ureteric Injuries in Abdominal and Vaginal Hysterectomies”.JournalofEvolutionofMedicalandDentalSciences2015;Vol.4,Issue57,July 16;Page:9924-9930,

DOI:10.14260/jemds/2015/1436

ABSTRACT: BACKGROUND:Uretericinjuryisoneofthemostseriouscomplicationsinabdominalandvaginalhysterectomies.Itleadstosignificantmorbidityduetoureterovaginalfistulasandpotentiallossofkidneyfunction.Aimofthisstudyistoevaluatehowandwhyuretericinjuriesoccurduringhysterectomyandtohighlighttheoutcomewithappropriatesurgicaltreatment.METHODSANDMATERIALS:ThisprospectiveandobservationalstudywascarriedoutattheDepartmentofObstetricsGynaecologyandUrology,fromMarch2014toMay2015.Totalnumbersofhysterectomiesdonewere246thatinclude144totalabdominalhysterectomies,61vaginalhysterectomiesand41laparoscopeassistedvaginalhysterectomy(LAVH).Alluretericinjurypatientswereanalysedforincidence,location,typeofinjury,recognitiontimeandmanagement.RESULTS:Incidenceofuretericinjuryinourstudyis0.8%.Typesofuretericinjurieswereureterictransection,sutureligation,uretero-vaginalfistulaandthermalinjuryduetosurgicaldiathermy.Intervalbetweensurgeryanddiagnosisofinjuryvariesbetweenimmediateduringsurgeryand2daysto4weeksofpostoperativeperiod.Allthepatientshadloweruretericinjuries.Bilateralureteralinvolvementwasseeninonepatientand8patientshadunilateralureterinvolvement.LeftureterwasinvolvedinallthecasesofLAVH.ContrastenhancedCTscanweredoneforconfirmationofuretericinjuries.Psoashitchwithureteroneocystostomydonein7patients,forapatientwithuretericstricture,DoubleJStentingfollowedbyureteralreimplantationwithpsoashitchwasdoneafteroneyear.Bivalveingofbladder,Boariflapwithureteralreimplantationandpsoashitchwascarriedoutinonepatientwhohadassociatedvesico-vaginalfistula(VVF)withuretericinjury.Allthepatientsweresymptomfreeandwithnoevidenceofobstruction.CONCLUSION:Iatrogenicuretericinjuriesarepreventable.Timelyrecognitionandinterventionhasgoodoutcome.

KEYWORDS:Hysterectomy,Uretericinjuries,LAVH.

INTRODUCTION: BACKGROUND:Hysterectomyisthemostcommonlyperformedgynaecologicalsurgery.Uretericinjuryisoneofthemostseriouscomplicationsinhysterectomy.Itisoftenassociatedwithsignificantmorbidityduetoureterovaginalfistulasandpotentiallossofkidneyfunction,especiallywhenrecognizedwithdelayorpostoperatively.Forthesereasons,injuriestotheurinarytract,particularlytheureter,isthemostcommoncauseforlegalproblemsagainstgynaecologicsurgeons.Uretericinjuriesmaybeaniatrogenic(75%)orfromblunttrauma(18%)orfrompenetratingtrauma(7%).1Iatrogenicuretericinjuriesoccurringinopenorlaparoscopichysterectomyisoftennotrecognizedintraoperativelyandresultinseveresequelae.2Whenaureteralinjurydoesoccur,quickrecognitionoftheproblemandaworkingknowledgeofitslocationandtreatmentareessentialinprovidingpatientswithoptimalmedicalcare.3

Thepurposeofthisstudyistoevaluatehowandwhyuretericinjuriesoccurduringhysterectomyandtohighlighttheoutcomewithappropriatesurgicaltreatment.

METHODSANDMATERIALS:ThisprospectiveandobservationalstudywascarriedoutatthedepartmentsofObstetricsGynaecologyandUrologyofSriVenkateswaraMedicalCollegeHospitalResearchCentre,Ariyur,Pondicherry,duringtheperiodfromMarch2014toMay2015.Informedconsentwasobtainedfromallpatients.Thetotalnumbersofhysterectomiesdonewere246fromMarch2014toMay2015.Inthis,thenumberoftotalabdominalhysterectomieswere144,vaginalhysterectomieswere61andlaparoscopeassistedvaginalhysterectomy(LAVH)were41.Outofthese,ninepatientswerefoundtohaveuretericinjury,inwhichtwopatientswerefromtheinstitutionandtheremainingwerereferredpatients.Theagegroupofpatients,presentingfeatures,causeofuretericinjury,associatedvesico-vaginalfistula(VVF),timefrominjurytothediagnosis,typeofuretericinjury,investigationsdone,treatmentofuretericinjuryandoutcomeoftreatmentwereanalyzed.

Thestudyincludedthecasesofuretericinjuriesduetohysterectomy.Thestudyexcludedothergynecologicalsurgeriesandpatientswithinjuriesduetoaccidentaltrauma.Therecognitiontimeofinjurywasarbitrarilydividedinto:Intra-operative,early(<1Week)andlate(>1week)post-operative.Thosecasesidentifiedintra-operativelyweremanagedper-operatively,whilethosecasesidentifiedpost-operatively,underwentvariousnecessaryimagingandfunctionalstudiesbeforeplannedintervention,suchasclinicalexamination,ultrasonographyofabdomenandcontrastenhancedCTscan,whenindicated.CystoscopyperformedinallcasestoruleoutassociatedVVF.Retrogradeuretericcatheterizationwasdoneinonepatientwhopresentedwithstricture.Follow-uprangedfrom1to6months,followingdefinitivecorrectionofuretericinjury.Follow-upincludedroutineclinicalassessment,ultrasonographyandcontrastenhancedCTscaninneededcases.Successwasdefinedassymptomfreewithnoevidenceofobstruction.

RESULTS:Inthisstudy,ninepatientswerefoundtohaveiatrogenicuretericinjuriesafterhysterectomy.TheageofthepatientsvaryBetween27to43.Thesignsandsymptoms(Table1)werecontinuousdribblingofurine(78%),vaginalpooling(22%),abdominaldistention(11%),oliguria(11%),Intra-operativeurineleak(11%).Somepatientshadmorethanonesymptomandsign.TheprevioussurgeriesdonewereopenabdominalhysterectomyintwocasesandLAVHinsevencases.Nopredisposingfactorswerefoundinanyofthepatients.Alltheuretericinjurieswerefoundinthelowerureter.Typesofuretericinjury(Table2)wereureteraltransactioninonecase,sutureligationinonecase,ureterovaginalfistulain5cases.Unilateraluretericinjurywasin8casesandbilateraluretericinjurywasinonecase.Thecauseofuretericinjurieswasmonoploarcauterythermalinjuryin4cases,bipolarcauterythermalinjuryin3cases.

Timeofrecognitionofurologicalinjuries(Table3)variesbetweenimmediateduringsurgeryand2daysto4weeksofpostoperativeperiod;Per-operative1(11%),lessthanoneweek4(44.5%),morethanoneweek4(44.5%).AssociatedVVFinthesupratrigonalregionof1cminsize,inonecasewaspresent.LeftureterwasinvolvedinallthecasesofLAVH.Ultrasonogramrevealedlefthydroureteronephrosiswithpelviccollectionin7casesandgrossabdominalfluidinonecase.Intravenousurogramrevealedlefturetericfistulainonecase.ThefindingsinCTwereleftureterovaginalfistula,pelviccollectionandgrossfluidinabdominalcavityandhydroure-teronephrosis.Psoashitchwithureteroneocystostomy(UNC)doneinsixpatients,psoashitchwithUNCureterolysisdoneinonepatient,foronepatientwithuretericstricture,DoubleJStentingfollowedbyureteralreimplantationwithpsoashitchwasdoneafteroneyear.

Bivalveingofbladder,Boariflapwithureteralreimplantationandpsoashitch(Figure1)wascarriedoutinonepatientwhohadassociatedVVFwithuretericinjury.Followupcarriedupat1month,3monthsand6months.

DISCUSSION:Asignificanturetericinjuryisdefinedasanyrecognizedorunrecognizediatrogenictraumatotheureterthatpreventsitfromfunctioningproperlyoreffectively.3Theinjurymayleadtoacuteorchronicureteralobstruction(e.g.,aureterthatisinadvertentlyligated,crushinjuryorischemia)ordiscontinuity(i.e.inadvertentureteralresection)orTheformationoffistulas.3

Themostcommonsitesofuretericinjuryarelateraltotheuterinevessels,inthetunnelofthecardinalligament,onthelateralpelvicwalljustabovetheuterosacralligamentandbaseoftheinfundibulo-pelvicligament,astheureterscrossthepelvicbrimattheovarianfossa.Thisistheloweronethirdcourseoftheureter.Here,ureterliesanatomicallyveryclosetotheuterineandovarianvessels,henceitisoftenincludedintheligatureofthesevessels.4Hurdetal.(2001)showedthattheureterrunswithin0.5cmofthecervixin12%ofwomen.5Hence,intimateknowledgeoftheureterallocationismandatorytoavoiduretericinjuries,especiallyingynaecologicsurgeries.4Thus,surgeon’sexperienceisalsoanimportantaspect.675%ofuretericinjuriesareiatrogenic.1Themostcommonsiteofinjuryisthelowerthird(74%).1,6,7Inourstudyalltheuretericinjurieswereattheloweronethirdoftheureter.Predisposingfactorsincludeuterussizelargerthan12weeks’gestation,ovariancysts4cmsorlarger,radiationtherapy,advancedstageofmalignancyandanatomicalanomaliesoftheurinarytract.Inthisstudy,noriskfactorwasidentified.Nevertheless,thereisaminimalriskofuretericinjuryevenwithoutriskfactors.2,5Inthisstudy,allcaseswereunintendeduretericinjuryduringhysterectomy.

Itoccursinopenorlaparoscopicproceduresandisoftennotrecognisedintra-operativelyandmayresultinseveresequelae.8Gynaecologicsurgicalproceduresarethemostcommoncauseofuretericinjuries(Table 4)withahigherpercentageoccurringduringabdominalhysterectomyandlaparoscopeassistedvaginalhysterectomy.2,8InalargeretrospectivestudybyDobrowolskiet.al.,(2002)outof340iatrogenicinjuriestotheureter,73%weregynaecological,14%weregeneralsurgicaland14%wereurologicalinorigin.9Inonestudy,abdominalhysterectomywasresponsiblefor54%ofalluretericinjuries,colorectalsurgery14%,pelvicsurgery8%andabdominalvascularsurgeryfor6%casesofuretericinjury.6In2002,CarleyMEet.al.,reportedtheincidenceofbladderandureterinjuriesrespectivelyas0.58%and0.36%inabdominalhysterectomy,1.86%and0%invaginalhysterectomyand5.13%and1.71%inobstetrichysterectomy.10Uretericinjuryhasanincidenceof0.2-1%duringabdominalandpelvicsurgerywithahigherpercentageofinjuriesoccurringduringabdominalhysterectomiesandpartialvaginectomies.7Obstetricandgynaecologicalsurgeriesaccountforapproximately50%ofuretericinjuries.7

Inourstudytheincidenceofuretericinjuryinhysterectomysurgeriesis0.8%.Thetypesofuretericinjuryare,crushingfrommisapplicationofaclamp,ligationwithasuture,transsection(Partialorcomplete),angulationoftheureterwithsecondaryobstruction,ischemiafromureteralstrippingorelectrocoagulationandresectionofasegmentofureteroranycombinationoftheseinjuries.2,4Post-operativeinjurytotheurinarytractcanoccurduetoavascularnecrosisandbythekinkingandsubsequentobstructionoverahematomaorlymphocele.In2002,BerkmanFet.al.,reportedtheincidenceofuretericinjury,intheformofcompletetransectionwas61%,excision29%,ligation7%andpartialtransection3%.11Inourstudythetypesofuretericinjurieswereureteraltransaction11%,sutureligation11%,ureterovaginalfistula55.5%.Unilateraluretericinjury89%andbilateraluretericinjury11%.Uretericinjurieswithmonopolar cauterythermalinjury44.5%,bipolarcauterythermalinjury33%(Table3).Thepathophysiologyofuretericinjurydependsonthetypeofinjuryandwhentheinjuryisidentified.3Injuryseverityscalefortheureterisgiveninthetable5.1,4

In1998,Harkki-SirenPet.al.,reportedtheriskofuretericinjuryishigherafterlaparoscopichysterectomy.12Inlaparoscopicsurgery,especiallyduringhysterectomysurgery,injuriesmainlyoccurintheareaoftheuterosacralligaments(Graingeret.al.,1990).13Becauseoftheinflammatoryadhesions,visualizationoftheuretermightbedifficult,withahigherriskofinjury.Inlaparoscopicsurgery,specialattentionmustbepaidtoureteralinjuriesbecause,incontrasttoopensurgerywhereapproximatelyonethirdofureteraldamageisrecognizedduringthefirstprocedure,therateofrecognitionislowerinlaparoscopy.13Inthisstudy,theuretericinjuryinthesevenpatientsofLAVHwerenotrecognizedintra-operatively.

Managementofuretericinjurydependsonthefollowingfactors.Timeofdetectionwhetherintraoperativeorpostoperative,typeandseverityofinjury,anatomicallevel,mobilityoftheureterandbladder,pathologyleadingtouretericinjuryandpatient’sgeneralcondition.Treatmentmodalitiesavailableareimmediateremovalofsuture,ureteralstenting,conservativemanagementwithpercutaneousnephrostomy(PCN),uretero-ureterostomy,ureteroilealinterposition,uretroneocystostomywithpsoashitchandBoariflapwithureteralreimplantation.14Endo-urologictreatmentofsmallurtericfistulaeandstricturesaresafeandeffectiveinselectedcases.Inthisstudy,67%underwentpsoashitchandureteroneocystostomy,11%neededpsoashitchwithureteroneocystostomyandleftureterolysis,11%underwentBoariflapwithureteralreimplantationandpsoashitchand11%neededDJStentingforstricturefollowedbyureteralreimplantationwithpsoashitchthatwasdoneafteroneyear.

Inourstudy,psoashitchwithureteroneocystostomywasdoneinsixcases,whichwereeasilyfeasible,becausethebladderswerewelldistendedandwouldbeeasilymobilysedandfixedtothepsoas.BoariflapwasdoneinonecasewhichhadassociatedVVFanditwasdoneonlyforthepurposeofbivalveingthebladder.Boariflapingeneralwasnotneededinotherpatients.Since,thesuccessfulDJStentingwouldbedifficultandasthecontrastenhancedCTclearlyshoweduretericfistula,retrogradepyelography(RGP)followedbyDJStentingwasnotroutinelyfollowedinallthecases.Noneofoururetericinjurywastreatedonconservativemanagementwithorwithoutpercutaneousnephrostomy(PCN),astherewereevidencesofseverehighgradeuretericinjuryinallthepatients.Earlyrepairisassociatedwithshorterhospitalstaywhencomparedtothedelayedrepair.Inthisstudytherewerenocomplicationslikestricture,infection,uretericobstructionandrefluxofurineandallthecasesweresymptomfreewithnoevidenceofobstruction.

Preventionofiatrogenicureterictraumaisbasedonvisualidentificationoftheuretersandcautiousintra-operativedissection.Adequateexposureofpelvicorganisamust.Inadequateincisionleadstoinadequateexposureanddissection.Thismayleadtoblindclampingorsuturing.Meticulouscareduringdissectioni.e.nottodamagethesheathofureter,sothatlongitudinalvesselsshouldnotbedestroyed.Duringhysterectomyforbenigncondition,blindclampingofbloodvesselsshouldbeavoided.Liftingtheuteruswellabove,beforeapplyingclampscanavoidtheureter.Byapplyingsingleclampandworkingveryclosetotheuteruswillhelptoavoidureter.

CONCLUSION:Iatrogenicuretericinjuryisaseriouscomplication.Everyeffortshouldbemadetopreventuretericinjuries.Surgeonmusthaveadequateknowledgeofabdominalandpelvicanatomy,especiallyduetothecloserelationofureterwithadjacentstructures.Urologistmustbeinvolvedearlywheniatrogenicuretericinjuryissuspected.Timelyrecognitionandinterventiongivesgoodoutcome.

REFERENCES:

  1. N. Djakovic, Th. Lynch, L. Martínez-Piñeiro, Y. Mor, E. Plas, E. Serafetinides, L. Turkeri, R.A. Santucci, M. Hohenfellner. Guidelines onurological trauma.Eur Urol. 2005; 47(1):1-15(Text update March 2009).
  2. Duncan J. Summerton, Noam D. Kitrey, Nicolaas Lumen, Efraim Serafetinidis,Nenad Djakovic, EAU Guidelines on Iatrogenic Trauma.European Urology 62 (2 01 2) 6 2 8 – 6 3.
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  4. J.Pfitzenmaier, CH.Gilfrich, A.Haferkamp, M.Hohenfellner. Trauma of the Ureter. In: Markus Hohenfellner, Richard A.Santucci, eds. Emergencies in Urology. Chapter 15.5, 233-245, SBN 978-3-540-48603-9 Springer-Verlag, Berlin Heidelberg New York Library of Congress, Control Number: 2006938751, Springer-Verlag Berlin Heidelberg 2007.
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Presenting Features / Number / Percentage
PervaginalUrineleak / 7 / 78%
VaginalPooling / 2 / 22%
Anuria/Oliguria / 1 / 11%
AbdominalDistension / 1 / 11%
Intraoperativeurineleak / 1 / 11%
Table 1: Presenting features of ureteric injuries
Types of Ureteric Injury / Number / Percentage
Sutureligation / 1 / 11%
Ureterictransection / 1 / 11%
Ureterovaginalfistula / 5 / 55.5%
Unilateraluretericinjury / 8 / 89%
Bilateraluretericinjury / 1 / 11%
Monopolarcautery(thermal) / 4 / 44.5%
Bipolarcautery(thermal) / 3 / 33%
Table 2: Types of ureteric injuries
Type of Injury / Intra-oprative / Early < 1 week / Late > 1 week
Ureteraltransection / 1 / 1 / 0
UnilateralLigation / 0 / 1 / 0
Monopolarcautery / 0 / 2 / 2
Bipolarcautery / 0 / 1 / 2
Table 3: Time of recognition and number of urological injuries
Procedure / Percentage
Gynaecologic
Vaginal Hysterectomy / 0.02 - 0.5
Abdominal Hysterectomy / 0.03 - 2
Laparoscopy assisted vaginal hysterectomy / 0.2 - 6
Urogynaecologic / 1.7- 3
Colorectal / 0.3-10
Ureteroscopy
Mucosal abrasion / 0.3-4.1
Ureteric perforation / 0.2-2
Intussusception/avulsion / 0-0.3
Table 4:Incidence of ureteral injury in various procedures
GradeDescription
  1. Haematoma only

  1. Laceration < 50% of circumference

  1. Laceration > 50% of circumference

  1. Complete tear < 2 cm of devascularisation

  1. Complete tear > 2 cm of devascularisation

*AdaptedfromtheAAST.
Table5:Injuryseverityscalefortheureter*1,4

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