URINARY TRACT INJURIES

Dr. Sonam Panday

2nd year resident
10thDecember, 2023
 Objectives

 To understand the common risk factors of urinary tract injury

at laparoscopy and laparotomy procedure
 To learn strategies to prevent injury where possible
 To learn strategies for intraoperative and postoperative
recognition and repair of such injuries
 Incidence

 The overall rate of urinary tract injury associated with pelvic surgery
in women ranges from 0.3 to 4 percent

 In a study of a large health care database including over 223,000

patients between 2007 and 2011, 81 percent of whom underwent
hysterectomy for benign indications, ureteral injury occurred in less
than 1 percent of patients 0.78 %
Blackwell RH, Kirshenbaum EJ, Shah AS, Kuo PC, Gupta GN, Turk TMT. Complications of Recognized and Unrecognized Iatrogenic
Ureteral Injury at Time of Hysterectomy: A Population Based Analysis. J Urol. 2018 Jun;199(6):1540-1545
 Ureteric injury rates at laparoscopic gynaecological surgery
ranges from <1% to 2%

 Rates ranges from 0.06% (during laparoscopic

hysterectomy) and as high as 21%(deep infiltrating
endometriosis)
 Bladder injury is approximately three times more common
than ureteral injury and up to 2.4 % of patients may require
concomitant urologic intervention after hysterectomy-related
injury to the urinary tract

Teeluckdharry B, Gilmour D, Flowerdew G. Urinary Tract Injury at Benign Gynecologic Surgery and the
Role of Cystoscopy: A Systematic Review and Meta-analysis. Obstet Gynecol. 2015 Dec;126(6):1161-
1169
Introduction

• The ureter is generally

divided into two parts
– Abdominal and pelvic

• Each part is about the

same length 12- 15 cm
 The abdominal part of ureter extends from the renal pelvis
to the bifurcation of the common iliac artery

 The pelvic part of the ureter extends from the pelvic brim
(at the level of bifurcation of the common iliac artery) to
the base of the urinary bladder
 Course of ureter: abdominal part

 The ureter begins as a downward continuation of a funnel

shaped renal pelvis at the medial margin of the lower end
of kidney
 The ureter passes downward and slight medially on the
psoas major, which separates it from the transverse
processes of the lumbar vertebrae
 Enters the pelvic cavity by crossing in front of bifurcation of
the common iliac artery at pelvic brim
Course of ureter in pelvis
 The ureters descend into the posterior lateral pelvis lateral to
the sacrum and immediately ventral to internal iliac
(hypogastric) artery

 The ureters then deviate medially and course medial to the

internal iliac artery and its anterior branches.

 The ureters subsequently pass beneath the uterine artery

(often referred to as water under the bridge).
 The ureter passes through this paracervical tissue often
referred to as “the tunnel” of the cardinal ligament/anterior
bladder pillar (also referred to as the web or the tunnel of
Wertheim)
 Once through this tunnel, the ureter travels medially and
anteriorly over the vaginal fornix to enter the trigone of the
bladder.
 Relations of abdominal part
Anterior relations Posterior relations
Right ureter -second part of the duodenum -right psoas major
-right colic vessels -bifurcation of right
-ileocolic vessels common iliac artery
-right testicular or ovarian
vessels
-root of mesentry

Left ureter -left colic vessels -left psoas major

-sigmoid vessels -bifurcation of left common
-left testicular or ovarian iliac artery
vessels
-sigmoid mesocolon
Posterior relation of ureter
 Relations of pelvic part

 The pelvic part of the ureter crosses in front of all the

nerves and vessels on the lateral pelvic wall except vas
deferens, which crosses in front of it

 Near the uterine cervix, the uterine artery lies above and in
front
Sites of anatomical narrowing/constrictions

 At the pelviureteric junction where

the renal pelvis joins the upper
end of ureter.
 At the pelvic brim where it crosses
the common iliac artery
 At the uretero-vesical junction
(i.e. where ureter enters into the
bladder)
 Arterial supply

 The ureter derives its arterial supply from the branches of all the arteries
related to it. The important arteries supplying ureter from above
downward are
1. Renal

2. Testicular or ovarian

3. Direct branches from aorta

4. Internal iliac

5. Superior and inferior vesical

6. Middle rectal

7. Uterine
 Venous drainage
 The venous blood from the ureter is drained into the
veins corresponding to the arteries
 Lymphatic drainage
 The lymph from the ureter is drained into lateral aortic
and iliac nodes
 Nerve supply
 Sympathetic supply derived from T12 to L1
 Parasympathetic supply derived from S2 to S4
 Histology

 Ureter is divided into 3 distinct layers

mucosa
muscularis layer
adventitia
 Ureteric injuries

 Overall incidence is 0.5 – 1 % of all pelvic operations

 Incidence varies from 0.4 – 2.5 % for benign conditions as

reported in different studies, but it can be as high as 30% in
operations for malignancies
 About 75 % of ureteric injuries occur during an abdominal
gynaecological surgeries with incidence 0.5 – 1 % for
abdominal hysterectomy, compared to 0.1 % for vaginal
hysterectomy
Types of Ureteric Injury

 Angulation
 Crush
 Ligation
 Thermal
 Laceration
 Transection
 Resection
 Most common
 Most common site: Pelvic brim near the infundibulopelvic
ligament
 Most common type of injury: obstruction
 Most common “activity” leading to injury: Attempts to obtain
hemostasis
 Most common time of diagnosis: None: 50-50 split between
intraoperative and postoperative
Common site of ureteric injury during
Abdominal procedures

 At the pelvic brim during clamping of infundibulopelvic

ligament
 At the bifurcation of common iliac artery during internal iliac
artery ligation
 Lateral pelvic wall above the uterosacral ligament

 Base of broad ligament, ureter passes under the uterine

artery
 Ureteric canal – During Wertheim hysterectomy
Common site of ureteric injury during
laproscopic

 Most common site – at pelvic brim where the ureter comes

in close proximity with infundibulopelvic ligament which
contain ovarian vessels followed by lateral to cervix

 Ureter passes lateral to cervix with an average disctance of

2.3 +/- 0.8cm
 Electrocautery may be involved in 1/4th of ureteric injuries
 Common site of ureteric injury

1. At the pelvic brim during clamping of infundibulopelvic

ligament
 Common site of Ureteric injury contd..
2. At the bifurcation of common iliac artery during internal
iliac artery ligation
 Common site of Ureteric injury contd..

3. Lateral pelvic wall above the uterosacral ligament

 Common site of Ureteric injury contd..

4. Base of broad ligament, ureter passes under the uterine

artery
 Common site of Ureteric injury contd..

5. Ureteric canal – During Wertheim hysterectomy

 Common site of Ureteric injury contd..

6. Upper vagina during clamping of vaginal angle

 Risk factors for uterine injuries

1. Anatomical risk factors

2. Pathological risk factors
3. Technical risk factors
 Anatomical risk factors

1. Has close attachment to the peritoneum

2. Closely related to female genital tract
3. Has variable course
4. Not easily seen or palpated
 Pathological risk factors

 Congenital anomalies of ureter

 Ureteric displacement by
 Uterine size >12 weeks
 Prolapse
 Tumor (ovarian neoplasm)
 Cervical fibroid/carcinoma
 Broad ligament swelling (fibroids, incarcirated ovarian
tumours or hematomas
 Pathological risk factors contd…

 Adhesions:
 Previous pelvic surgery
 Endometriosis
 PID
 Extention of carcinomatous indurations in broad
ligaments, post irradiation
 Distorted pelvic anatomy
 Technical risk factors

 Massive intraoperative haemorrhage

 Coexistent bladder injury
 Technical difficulties
 Inexperienced surgeon
 How injuries can happen intraoperatively?

 Crushing from misapplication of a clamp

 Ligation with a suture
 Transection (partial or complete)
 Angulation of the ureter with secondary obstruction
 Ischemia from ureteral stripping, laser or
electrocoagulation
 Resection of a segment of ureter
 How injuries can occur postoperatively ?

 Avascular necrosis following werthiem

 Kinking-peritonisation of vaginal stump after hysterectomy
 Subsequent obstruction over
 Hematoma or
 Lymphocele
 Procedures asso. with ureteric injuries

 Abdominal
1. Hysterectomy
2. Werthiem’s hysterectomy
3. Oopherectomy
4. Uterine suspension
5. Burch colposuspension
6. Vesicovaginal fistula repair
Procedures asso. with ureteric injuries contd

 Vaginal
1.Hysterectomy
2.Anterior colporrhaphy
3.Vesicovaginal fistula repair
4.Culdoplasty
Procedures asso. with ureteric injuries contd

 Laparoscopic
1. Division of adhesions
2. Transection of uteroscral ligaments
3. Colposuspension
4. Treatment of endometriosis
5. Sterilisation(especially with electrocoagulation)
 Grading of ureteric injury

 Grade I – hematoma; contusion or hematoma without

devascularization.
 Grade II – laceration; less than 50% transection.
 Grade III – laceration; 50% or greater transection

• Grade IV – laceration; complete transection with less than 2 cm

of devascularization
• Grade V – laceration; avulsion with greater than 2 cm of
devascularization
 Preventive strategies

 General preventive strategies

1.Preoperative
2.Intraoperative

 Specific preventive strategies

 General preventive strategies

 Preoperative measures
1.Intravenous urogram
2.Ultrasound scan
Identify ureteric dilatation and disclose anatomic variations
3.Preop stenting in case of anatomic distortion
 General preventive strategies contd…

 Intraoperative measures
1. Appropriate operative approach
2. Adequate exposure
3. Avoid blind clamping of blood vessels
4. Mobilize bladder away from the operative site
5. Stay outside the vascular sheath
6. Zone of thermal injury
7. Dissection should preferably be done under direct visualization
Ureteric stenting: No reduction in risk. May aid in intraoperative
detection of ureteric injury.
 Specific preventive measures

 During laparoscopy: can be achieved by:

• Moving the fallopian tubes away from pelvic side walls
before coagulation.
• The bleeding points at uterosacral ligaments should be
secured with sutures or clips instead of electrocoagulation.
• In LAVH place stapler or suture across uterine vessels and
cardinal ligaments instead of electrocoagulation.
During Abdominal hysterectomy:-

Clamp infundibulopelvic ligament

after lifting up the ligament dissection
and palpation ,clamp
near to the ovary.

-Always clamp{cardinal ,
Uterosacral} ligaments close to
the uterus.

-Never to open vagina unless

urinary bladder is dissected down
properly and sufficiently.
 During Vaginal surgery
1. Prevention of ureteric injuries can be achieved by adequate
development of vescico-uterine space , by:
-Downward traction on the cervix.
-Counter traction upward by Sim’s speculum
below the bladder.
2. All clamp:- Small bites - Close to the uterus.
3. Avoid double clamping of uterosacral ligament.
 During Vaginal surgery contd…

4. During anterior colporrhaphy:

-Avoid too lateral dissection
-Avoid deep suture : as the distance between needle
and ureter in upper vagina ≤0.9 cm.
 Diagnosis of ureteral injury

 Intraoperative
 Postoperative
 Postoperative

 Symptoms:

Loin or flank pain 0-21 days

Fever 0-21 days
Adynamic ileus / peritonitis 0-7 days
Fistulas 0-30 days
Lower abdominal / Pelvic mass 20-40 days
Anuria (if bilateral) <24 days
Asymptomatic Incidental
Frank discharge of urine from drain, vagina or abdominal wound.
 Investigation

 WBC count
 Urea and electrolytes
 Intravenous pyelogram (IVP)
 Ultrasound of abdomen and pelvis
 CT scanning
 Cystoscopy
 Fluid analysis from drains, ascitic collection
 Intravenous urography

 Gold standard of post-

operative diagnosis
 Non visulatisation
 Dilatation
 Delayed dye spillage
 Peritoneal extravasation
 Urinoma
 Sequelae

1. Spontaneous resolution and healing

2. Hydronephrosis and gradual loss of renal function
3. Urinoma / Urinary Ascites, infection in transection or
necrosis with urinary extavasation
4. Fistula formation: uretrovaginal / uretero-uretrine or
uretero-cutaneous
5. Stenosis with insidious loss of renal function
 Aim of management

 Preservation of renal function

 Anatomical continuity
 Decision depends upon:-

1.Time of detection
2.Extent of injury
3.Site of injury
4.General condition of the patient
 Conservative?

 Obstruction without intraperitoneal or retroperitoneal

leakage
 No major degree of obstruction
 Obstruction is not the result of a permanent agent
 Small ureteral leak in the setting of prior pelvic radiation
 When to operate?

 If diagnosed immediate post op:-reoperation within 24 to

48 hrs
 If diagnosed later:-delayed repair
 General guidelines for the Mx of ureteral
injuries identified at the time of surgery
 Ureteral ligation:-

Deligation
assessment of the viability and then stent placement

 Partial transection:-

Primary repair over a ureteric stent

 Total transection:-
 Uncomplicated upper third and middle third:-

Ureteroureterostomy over ureteral stent

 Complicated upper third and middle third:-

Ureteroileal interposition
 Lower third:-

Ureteroneocystostomy over ureteral stent

(psoas hitch technique or boari flap technique)
 Thermal injury:-

Resection with management as per a transection

 Ureteroileoneocystomy—Restoration of the continuity of the
urinary tract by anastomosis of the upper segment of a partially
destroyed ureter to a segment of ileum, the lower end of which is
then implanted into the bladder

 Ureteroureterostomy—Establishment of an anastomosis between

the two ureters or between two segments of the same ureter

 Ureteroneocystotomy—An operation whereby a ureter is

implanted into the bladder
Psoas hitch
Boari flap technique
Bladder injury
 Most injuries occur during dissection of the bladder from the
cervix and therefore the most common site is in the midline,
above the inter-ureteric bar

 Less often the bladder can be put at risk during insertion of

the Veress needle or a trocar
 Bladder injury during primary Caesarean is about 0.2% and
during repeat Caesarean is about 0.6%
 Injuries rates ranges from 0.02% to 8.3% during laparoscopic
pelvic surgery
 Most of the bladder injuries which occur during Caesarean are
intraperitoneal injuries to the dome of the bladder, 6-10cm
away from the trigone

 Intraperitoneal injuries are generally more significant and

involve a higher risk of complications than extraperitoneal
injuries.
 Factors that distort pelvic anatomy may increase the risk of
bladder damage
 Endometriosis
 Cancer
 Adhesions (previous surgery/infection/inflammatory
disease/radiation)
 Severe genital organ prolapse
 Obesity
 Pregnant uterus
Risk factors for intraoperative bladder injury include

 Prolonged or obstructed labour with bladder distension

 Pregnancy with scarred uterus
 Suspected intra-abdominal adhesions
 Distorted local anatomy – cervical/lower segment fibroid,
congenital urogenital system anomaly
 Caesarean birth in advanced labour
 Placenta accreta spectrum
 Caesarean hysterectomy
 >3 previous Caesarean births, unplanned Caesarean birth and
Caesarean birth in labour are associated with a significantly
higher chance of intraoperative bladder injury
Bladder injury can be classified as follows

 Grade 1: contusion, intramural hematoma or partial thickness

laceration
 Grade 2: extraperitoneal bladder wall laceration <2 cm
 Grade 3: extraperitoneal >2 cm or intraperitoneal <2 cm
laceration
 Grade 4: intraperitoneal bladder wall laceration >2 cm
 Grade 5: intra- or extraperitoneal bladder wall laceration
involving the trigone or bladder neck
 Recognition of an intraoperative bladder injury

Signs suggestive of a bladder injury include

 Urine visualised in the operative field

 Transurethral Foley's catheter bulb visualised in the operative field

 Haematuria

 Test done by:-

dye test

cystoscopy
 Recognition of an post-operative bladder injury

 Clinical evidences of bladder injury includes:-

- usually appear within 48hrs of operation

- suprapubic pain, hematuria, leaking of urine per vaginum(10-14 days), oliguria

- features of chemical peritonitis

 Test done by

- serum creatinine level (raised)

- CT scan with contrast confirmatory

- retrograde cystography

- methylene blue test

- MRI (for vesico vaginal fistula)

 Preventive stratigies

 Suprapubic insertion of veress needle should be avoided

 Insertion of secondary trocars should be performed under
direct vision
 Keeping bladder empty during surgery
 General guidelines for the Mx of Bladder
injuries identified at the time of surgery
 Grade 1, limited to the serosa, and Grade 2 injuries should be
managed conservatively with prolonged drainage with indwelling
transurethral catheter for at least 10 to 14 days

 Bladder injuries of Grade ≥3 require surgical management

 Bladder injuries of Grade 4 and 5 must be repaired by

urogynaecologist or urologist
 Post-operative

 An indwelling transurethral catheter should be used for at least

10 to 14 days

 An additional abdominal drain is used to identify urinary leakage

in the pelvis this can be removed within 48–72 hours if the output
remains minimal

 If there is high volume output consider sending a sample of the

fluid for assessment of creatinine to compare to plasma levels
and/or radiological imaging of the urinary tract
 References

 Howard w. jones III. John A. ,Textbook for TeLinde's

Operative Gynecology 13th edition
 Jonathan S. Berek, Deborah L. Berek, Berek and Novak’s
Gynecology, 16th edition.
 Hoffman, Schorge, Halvorson. William’s Gynecology. 2nd ed.
India. Mac. Graw. Hill; 2020