Download Urinary tract injuries in laparoscopic gynaecological surgery

DOI: 10.1111/tog.12073
2014;16:19–28
Review
The Obstetrician & Gynaecologist
http://onlinetog.org
Urinary tract injuries in laparoscopic gynaecological
surgery; prevention, recognition and management
Vasileios Minas PhD MRCOG,a,* Nahid Gul
Rowlands FRCOGb
b
FRCOG,
Thomas Aust
MD MRCOG,
b
Mark Doyle
b
FRCOG,
David
a
Fellow in Advanced Laparoscopic Surgery, ST7 Obstetrics and Gynaecology, Minimal Access Centre, Department of Obstetrics & Gynaecology,
Wirral University Teaching Hospital, Arrowe Park Road, Wirral, Merseyside CH49 5PE, UK
b
Consultant Obstetrician and Gynaecologist, Minimal Access Centre, Department of Obstetrics & Gynaecology, Wirral University Teaching
Hospital, Arrowe Park Road, Wirral, Merseyside CH49 5PE, UK
*Correspondence: Vasileios Minas. Email: [email protected]
Accepted on 24 September 2013
Key content
Injury of the urinary tract is the most common major complication
of gynaecological laparoscopic surgery.
Injury to either bladder or ureter results in significant morbidity
for the patient and may lead to litigation.
Knowledge of pelvic anatomy, training and meticulous technique
are of paramount importance in reducing the incidence of urinary
tract injury.
Ideally an injury should be identified and repaired during the
primary operation, but vigilance in the immediate postoperative
period may result in early recognition and intervention.
Learning objectives
To learn strategies to prevent injury where possible.
To learn strategies for intraoperative and postoperative recognition
and repair of such injuries.
To understand the significance of multi-disciplinary management
of such injuries.
Ethical issues
Limited evidence shows that laparoscopic hysterectomy may carry
a higher risk of urinary tract injury compared with abdominal
hysterectomy. Should patients be counselled accordingly?
Keywords: bladder injury / laparoscopy / major complications /
pelvic surgery / ureteric injury
To understand the common risk factors of urinary tract injury
at laparoscopy.
Please cite this paper as: Minas V, Gul N, Aust T, Doyle M, Rowlands D. Urinary tract injuries in laparoscopic gynaecological surgery; prevention, recognition and
management. The Obstetrician & Gynaecologist 2014;16:19–28.
Introduction
Since its introduction in the 1970s, operative laparoscopy has
shown itself to be one of the most significant developments in
surgery.1 The benefits of shorter hospital stay, quicker recovery,
superior exposure and enhanced visualisation of the pelvic
organs, make minimal access surgery attractive to patients,
hospitals and surgeons. Yet the development of the technique
has not reduced the incidence of visceral injuries; instead it has
introduced some new ways by which these may occur. Urinary
tract injuries, when pooled together, represent the most
common type of major complication of laparoscopic pelvic
surgery. A Canadian study reported that women who have
sustained a urinary tract injury in benign gynaecologic surgery
are 91 times more likely to resort to litigation compared with
those who have had another complication or problem
following the same kind of surgery.2 Collecting and reporting
ª 2014 Royal College of Obstetricians and Gynaecologists
the knowledge and experience accumulated over years by
clinicians who have dealt with such problems is invaluable. In
this article, we review the evidence on the incidence,
prevention, recognition, and management of urinary tract
injuries that occur during laparoscopic gynaecological surgery.
Methods
The following electronic databases were used to perform a
literature search for material published between 1980 and
2013: PubMed, Embase, and the Cochrane Database of
Systematic Reviews. Search items included: laparoscopy,
urinary tract injury, bladder injury, ureteric injury,
gynaecological surgery and laparoscopic complications. The
search retrieved a total of 482 references. After exclusion of
duplicate and irrelevant studies, 49 studies published in
English were identified and used to write this review.
19
Urinary tract injuries in gynaecological laparoscopy
Urinary bladder injury
Incidence and risk factors
The urinary bladder is at risk of injury during laparoscopic
gynaecological surgery, either due to the entry process (for
example during suprapubic port insertion) or due to its
close association with the operating field (for example
during hysterectomy). In complex cases the bladder can also
be at risk because of its direct involvement in the disease
process (utero-vesical endometriotic nodule). The reported
incidence varies greatly. Injury rates range from 0.02%
to 8.3%3 placing bladder injury at the top of the list of
visceral damage complications related to laparoscopic
pelvic surgery.4,5
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.6 Less often the bladder
can be put at risk during insertion of the Veress needle
or a trocar. Surgical experience, the type and complexity
of the operation, and operating on normal or distorted
pelvic anatomy are all factors accounting for different
levels of risk and are likely to explain the wide differences
in reported incidence. Indeed, Altgassen et al. found that
experienced surgeons had almost half the complication
rate compared with their less experienced colleagues.7
Certain types of procedures, such as laparoscopic-assisted
vaginal hysterectomy (LAVH), appear to be associated
with a higher frequency of bladder injury compared
with others.8,9 Factors that distort pelvic anatomy may
increase the risk of bladder damage (Box 1). These should
be taken into account when planning a laparoscopic
procedure and patients must be counselled and consented
accordingly.10–12 Still, in a large number of cases bladder
injuries occur in women without any identifiable
risk factors.
Box 1. Risk factors for urinary tract injury due to distorted pelvic
anatomy
Endometriosis
Cancer
Adhesions (previous surgery/infection/inflammatory
radiation)
Severe genital organ prolapse
Obesity
Pregnant uterus
disease/
Prevention
Knowledge of the anatomy, thorough understanding of
electrosurgery and meticulous technique are prerequisites for
a safe laparoscopic surgeon. A review of the literature
revealed a number of strategies aimed at preventing bladder
injury at laparoscopy.
20
The Royal College of Obstetricians and Gynaecologists
advises that suprapubic insertion of the Veress needle should
be avoided as it puts the dome of the bladder at risk of injury,
and carries a high failure rate.13 Similarly, insertion of
secondary trocars should be performed under direct view.
Although not evidence-based, bladder catheterisation prior
to peritoneal insufflation and insertion of trocars is
recommended to avoid injury to a bladder distended by
urine.14 Kyung et al.14 also advise insertion of an indwelling
catheter in long procedures. Keeping the bladder empty
during surgery will protect it not only because its decreased
size will keep it out of the surgeon’s operating field, but also
because an empty bladder cannot be penetrated as easily as a
distended one.14,15
Laparoscopy offers a magnified view of the pelvic organs.
Surgeons should use this feature to their advantage to identify
the boundaries of the bladder during surgery. Maheshwari
et al. suggest filling the bladder with saline while keeping it
under direct vision to better define its borders in cases where
this is proving difficult.16 Alternatively, 200–300 mL of
dye-stained Ringers lactate may delineate both the bladder
edges during difficult dissection and help recognise an injury
if it occurs.17 Cystosufflation with carbon dioxide can be used
for the same purpose.18 The bladder, however, should be
decompressed before lateral and inferior dissection to
decrease the chance of injury.
Specific attention is drawn to the risk associated with LAVH,
and particularly to those cases where the bladder is dissected
laparoscopically and the cuff is then closed vaginally. Kadar
and Lemmerling19 suggest that the caudal direction of the
laparoscopic dissection places the bladder in close proximity to
the vaginal cuff and thus at increased risk during distal cuff
closure performed vaginally. Contrarily, vaginal dissection of
the anterior peritoneum displaces the bladder cephalad and
then closure of the cuff vaginally may be safer. These authors
therefore recommend laparoscopic closure if the majority of
the dissection is done laparoscopically (i.e. performing a total
laparoscopic hysterectomy) and vaginal closure if the majority
of the dissection is done vaginally.19 When a total laparoscopic
hysterectomy is performed, the bladder should be dissected
adequately off the upper part of the vagina to avoid injury
during closure.
Finally, it is important to be aware of and adhere to the
rules of safe electrosurgery.20 There are four causes of
inadvertent laparoscopic electrosurgical injuries, namely
inadvertent tissue contact, insulation failure, direct
coupling and capacitive coupling. The above apply to all
visceral injuries that may occur during laparoscopic surgery.
Such injuries may be difficult to identify, as they can occur at
a site distant to the surgeon’s view, and/or present as delayed
tissue breakdown several days following the primary insult.
Safety measures to prevent such complications are listed
in Box 2.21
ª 2014 Royal College of Obstetricians and Gynaecologists
Minas et al.
Box 2. Safety measures to prevent laparoscopic electrosurgical
complications
(a)
Inspect insulation carefully before use
Use the lowest possible effective power setting
Use available technology; newer tissue response generators and
active electrode monitoring technology eliminate concerns about
insulation failure and capacitive coupling
Use a low-voltage waveform for monopolar diathermy (cut).
Use bipolar electrosurgery when appropriate
Use brief intermittent activation
Do not activate in close proximity or direct contact with another
instrument
Ensure that both the heel and the tips of the bipolar forceps are kept
under direct view when activating
(b)
Recognition (intraoperatively)
When a visceral injury is suspected or identified, a
multidisciplinary team of specialists will usually need to be
involved to provide appropriate care to the patient. In some
cases the operating surgeon may have the skills to
conclusively diagnose and manage an injury of the urinary
tract. In any other case a urologist should be consulted. A
radiologist may also offer valuable assistance in terms of
both diagnosis and management (this is covered in more
detail later in the article). Intraoperative recognition and
repair of a bladder injury will reduce morbidity and is less
likely to lead to litigation.22,23 It is thought that
approximately half of bladder injuries remain unrecognised
during the primary operation.20
A bladder injury may be directly recognised during
laparoscopy because of an obvious cystotomy or
visualisation of urine leakage. A suspicion of a not so
obvious injury may be raised by noting haematuria or a
distended catheter bag because of gas leaking through the
defect into the bag. Therefore, it is always worth inspecting
the catheter and its bag, near the end of a complex
laparoscopic pelvic operation and before closure.
Intraoperative cystoscopy and/or instillation of 200–
300 mls of coloured saline (such as methylene blue or
indigo carmine) into the bladder will identify the site and
extent of the injury.17
Care is advised when instillating coloured saline to look for
an injury, as this may not be seen leaking intra-abdominally
in cases where the bladder injury opens to the retro-pubic
space (space of Retzius) (Figure 1). Such an injury may occur
for example during a difficult suprapubic trocar insertion
(previous suprapubic incision) which is accomplished by
repeated attempts. In such a case, an initial unsuccessful
attempt to insert the trocar may injure the bladder dome in a
retro-peritoneal fashion. A second successful intraperitoneal
entry achieved by repositioning the trocar may ‘miss’ the
bladder dome and thus enter the peritoneal cavity in a
misleadingly uneventful manner. The result will be a bladder
ª 2014 Royal College of Obstetricians and Gynaecologists
(c)
Figure 1. A retro-pubic bladder injury at the bladder dome, which
occurred during the insertion of a 10 mm supra-pubic trocar in a woman
with one previous transverse incision. (a) Cystoscopic image of the injury;
(b) computed tomography with intravenous contrast. The contrast was
still at the portal phase when this image was taken; as a result it has not
yet been excreted to the bladder and the injury is clearly visible; (c)
magnification of the same image. The upper white arrow points towards
the direction of the path of the suprapubic trocar starting from the
anterior abdominal wall and leading to the injury at the bladder dome.
The middle black arrow points at the level of the injured bladder dome.
The injured tissues produce a higher attenuation signal due to the fresh
haemorrhage and appear whiter than their surrounding healthy tissues.
The lower black arrow is pointing to a blood clot within the bladder.
injury that will communicate with the space of Retzius and
might go unnoticed, as opposed to a more commonly
expected laparoscopic injury that communicates with the
21
Urinary tract injuries in gynaecological laparoscopy
intraperitoneal cavity. Therefore, an intraoperative
cystoscopy is advised in all cases where a bladder injury
is suspected.
In fact, routine cystoscopy after major gynaecologic
surgery has been suggested by some authors24,25 but not
supported by others.26,27 An injury involving or occurring
near the trigone carries a risk of potential ureteric injury. This
can be assessed cystoscopically, but it is also useful to
remember that the bladder mucosa can be accessed and
inspected laparoscopically by inserting the laparoscope
through the bladder injury. If the injury is not large
enough for a 10 mm scope, then a 5 mm can be used and a
30-degree angled lens will allow inspection of the trigone and
ureteral orifices.17
Recognition (postoperatively)
Recovery following laparoscopic surgery is usually rapid.
Any patient who is not recovering as expected should raise
the suspicion of a visceral injury. Often, in cases where a
bladder injury is suspected postoperatively, assessment
for possible ureteric injury will also be required (see
next section).
Clinical evidence of a bladder injury includes suprapubic
pain, haematuria, leakage of urine per vagina and oliguria.
Sterile urine does irritate the peritoneum, causing a form of
chemical peritonitis (uroperitoneum). Symptoms and signs
are misleading and subtle compared to peritonitis caused by
contaminated material such as bowel content or infected
urine. Uroperitoneum can present with diffuse abdominal
pain, distension and ileus. Characteristically, tenderness may
be absent.28 The above symptoms and signs usually appear
within the first 48 postoperative hours unless a thermal injury
has occurred. Thermal injuries may present after 10–14 days
with uroperitoneum or vesico-genital fistula. Biochemistry
investigations aid the diagnosis as serum creatinine levels will
be abnormally elevated due to reabsorption of urine
creatinine through the peritoneal membrane.29 A computed
tomography (CT) scan with contrast may confirm the
presence of uroperitoneum and/or show direct evidence of
an injury. Retrograde cystography will confirm the diagnosis
and cystoscopy will assess the injury and help decide whether
conservative management is appropriate, depending on the
extent of the damage (Figure 1). In cases of late presentations
where a fistula is suspected the diagnosis will be supported by
filling the bladder with dye (such as methylene blue) and
demonstrating vaginal leakage. Magnetic resonance imaging
(MRI) provides good tissue contrast and can be diagnostic
for a vesico-vaginal fistula.
skills, thereby avoiding the additional morbidity of a
laparotomy.17 Conversion to laparotomy should be reserved
for cases where the injury or the surgeon’s experience is such
that does not allow repair by laparoscopy.
Most bladder injuries can be sutured in one or two layers
using a 2-0 or 3-0 absorbable suture (such as polyglactin).30–32
A running non-locked repair with the sutures placed 0.5 to
1 cm apart and 0.5 to 1 cm lateral to the cystotomy angles is
suggested.33 Alternatively, if extra-corporeal knotting is
preferred, interrupted sutures can be used at 0.5 cm
intervals, whereas a ‘figure of 8’ suture may be enough to
close a small defect.34 Injuries involving the trigone require
additional attention. Repair should aim to avoid obstructing
the ureters or the urethra and in most cases should be
performed by a urologist. In such cases ureteral stents must
be inserted and the patency of the urethra and ureters
confirmed following repair.35 A thermal injury to the
bladder will require debridement before repair, whereas an
injury that pierces the bladder through the space of Retzius
alone may be managed conservatively by an indwelling
catheter for 2 weeks.
Ideally, bladder repairs should be watertight and leakage
from the suture line should be tested (for example with
methylene blue or indigo carmine). A bladder catheter must
be inserted and continuous postoperative bladder drainage
should be allowed for 2 weeks. The above two measures
(watertight closure and indwelling catheter) will improve
healing and reduce the risk of subsequent vesico-vaginal
fistula formation.33 Prior to catheter removal, complete
repair without leakage should be confirmed by retrograde
cystography (Figure 2). If contrast escape is noted then the
catheter should be left in situ and the test repeated in 1 week.
Despite these measures, a fistula can still form with an
approximate incidence of 5% (of the cases where an injury
occurred).3,34 Even though management of these late
presentations will usually be by open or vaginal route,
several cases of successful laparoscopic repair of vesicovaginal
fistulas have been reported to date.36
When a bladder injury is diagnosed postoperatively,
conservative management may be appropriate, provided
that the wound is not extensive. Cystoscopic examination can
assist in the decision. Antibiotics should be administered for
5–7 days and an indwelling catheter kept for 2 weeks. In cases
where surgical repair is required, the principles are similar to
those described above.
Ureteric injury
Incidence and risk factors
Management
In the majority of cases where a bladder injury occurs during
laparoscopic surgery, repair can be achieved by either a
gynaecologist or a urologist with advanced laparoscopic
22
Just like the bladder, the ureter’s proximity to the female
genital tract puts it at risk of injury during pelvic surgery.
Most published studies quote a range of ureteric injury rates
at laparoscopic gynaecological surgery from <1% to 2%.5
ª 2014 Royal College of Obstetricians and Gynaecologists
Minas et al.
(a)
(b)
(c)
(d)
Figure 2. Retrograde cystography 2 weeks following conservative management of the case shown in Figure 1. (a–d) The contrast fills the bladder
gradually as shown in the x-ray series. The balloon of the Foley catheter can be seen. Healing is confirmed by absence of leakage.
Rates as low as 0.06% (large series of laparoscopic subtotal
hysterectomies),37 and as high as 21% (deep infiltrating
endometriosis associated with hydronephrosis)38 have been
reported. A Cochrane review39 reported a higher incidence of
ureteric injuries associated with laparoscopic hysterectomies
compared to abdominal and possibly vaginal hysterectomies.
These observations were largely based on the eVALuate study
which involved two parallel randomised trials comparing
laparoscopic with abdominal and laparoscopic with vaginal
hysterectomies. The study found a 9.8–11.1% incidence of
major complications in the laparoscopic hysterectomy
groups.40 However these conclusions have been criticised
by other authors on the grounds of bias. Donnez et al.
suggested that the unusually high complication rates reported
by the eVALuate study were probably due to the relative
inexperience of the surgeons in laparoscopic hysterectomy
than to the technique itself.41–43 In the absence of further
well-designed sufficiently-powered trials this debate remains
unresolved to date.
The most common sites of ureteric injury in laparoscopic
surgery are at the pelvic brim (where the ureter comes into
ª 2014 Royal College of Obstetricians and Gynaecologists
close proximity with the infundibulo-pelvic ligament which
contains the ovarian vessels)5 and lateral to the cervix
(during division or coagulation of the uterine artery or the
uterosacral and cardinal uterine ligaments).44 Less often,
injuries may occur at the ovarian fossa, for example during
resection of endometriosis or ovarian remnants. Risk
factors due to distorted anatomy are essentially the same
as those described above for bladder injuries (Box 1).
Electrocautery may be involved in up to one quarter of
ureteric injuries.5 Interestingly, video analysis of
laparoscopic procedures where a ureteric injury occurred
in a patient with severe endometriosis concluded that
unconscious acceleration of surgery, possibly caused by
fatigue, contributed to a judgement error that led to the
injury.45 Hurd et al.46 showed that the ureter passes lateral
to the cervix with an average distance of 2.30.8 cm.
Analysis of CT images of 52 women with apparently
normal pelvic anatomy, showed that in 12% of the patients
the distance was less than 0.5 cm. In addition, the higher
the body mass index the closer the ureter was found to be
to the cervix.46
23
Urinary tract injuries in gynaecological laparoscopy
Prevention
The principles of bladder injury prevention (knowledge of
the anatomy, safe electrosurgery and meticulous technique)
apply here as well. Instruments such as virtual reality
models of pelvic anatomy are now at the disposal of
modern surgeons and complement traditional textbooks
and learning anatomy ‘on the job’.47 Preoperatively, an
MRI with or without an intravenous urogram (IVU)
may help the surgeon plan a complex procedure, for
example, in cases of endometriosis with suspected ureteric
involvement;48 however, this investigation offers no benefit
in routine cases. Intraoperatively, the detailed vision offered
by the magnified laparoscopic view should be used to
identify ureteric peristalsis and thus localise and follow the
course of the ureter. Patience is needed to keep the
laparoscope still until peristalsis is seen. This process may
be repeated as many times as necessary during the course of
a complex procedure. On occasion it may be easier to
identify the ureter if one starts looking for it at the
pelvic brim where it crosses the bifurcation of the
common iliacs.
In complex cases which carry increased risk of ureteric
injury (for example extensive pelvic endometriosis, large
ovarian cysts, pelvic adhesions, cervical fibroids) it is useful
and often mandatory to dissect and expose the ureter
(ureterolysis) (Video S1). Mobilisation of the ureter should
be performed through a peritoneal incision using a medial to
lateral blunt sweeping technique.49 The ureter is an organ
that carries its own blood supply system within a layer of
adventitia that surrounds it. Provided that this vascular
plexus is preserved, the ureter can be mobilised over a length
of 15 cm (approximately half its total length) without
compromising viability. It follows that electrosurgery
should be used with caution and, if possible, avoided in
close proximity to the ureter. Ureterolysis performed
through dense surrounding pathology, such as severe
endometriosis, is an advanced laparoscopic skill and
should normally only be performed in centres with the
appropriate expertise.
Ureteric stenting (including lighted stents) is useful only in
very select cases, where the pelvic anatomy is severely
distorted and/or usual methods of ureter identification
have failed.50 De Cicco et al.38 suggest that in cases of
severe endometriosis associated with ureteric obstruction and
hydronephrosis, preoperative stenting is mandatory. This
practice is not evidence-based and care must be taken when
mobilising a rigid stented ureter. In such cases, where the
ureter travels through dense disease, an alternative trick is to
identify it laparoscopically while illuminating by
ureteroscopy. To achieve this, the surgeon has to keep the
laparoscope still in a position close to where the ureter is
expected to be seen. The laparoscopic lighting is then turned
down and the ureteroscope is advanced inside the ureteric
24
lumen. When transillumination is seen laparoscopically, the
position of the ureter may be identified.
Finally, adequate reflection of the bladder off the uterus
and the cervix during total laparoscopic hysterectomy will
move not only the bladder, but also the ureters away from the
uterine vessels and the cervix, thus reducing the risk
of injury.51
Recognition (intraoperatively)
There are seven types of ureteric injury (Box 3), with
transection the most commonly reported at laparoscopy.41
Only a third of such injuries are recognised intraoperatively5,41
therefore any uncertainty about the integrity of the ureter
should prompt intraoperative investigation and involvement
of a urologist. Cystoscopy allows visualisation of the ureteric
orifices and urine jets which rules out obstruction, but does
not exclude other types of injuries. Presence of blood or air
suggests injury. Intravenous administration of indigo carmine
colours the urine blue within 5 to 10 minutes and will assist a
cystoscopic assessment as well as potentially allow the surgeon
to identify a urine leak laparoscopically. Stents inserted
without resistance, under direct laparoscopic visualisation to
ensure they do not exit through a possible injury, can also rule
out obstruction. Occasionally, insertion of a stent alone can be
therapeutic if the problem was angulation (kinking) of the
ureter. Ureteroscopy may locate the approximate height and
extent of injury. Retrograde, antegrade and/or intravenous
uretero-pyelography can confirm or refute the diagnosis and
determine the location of an injury.
Box 3. Types of ureteric injury
Angulation
Crush
Ligation
Thermal
Laceration
Transection
Resection
Recognition (postoperatively)
The principles of recognising a ureteric injury postoperatively
are similar to those described earlier for bladder injuries. Any
failure to recover as anticipated following major laparoscopic
pelvic surgery must raise the suspicion of a ureteric injury.
Flank pain and flank tenderness, haematuria, oliguria or
watery vaginal loss may be present within the first 48 hours
of an acute injury. Uroperitoneum will present clinically with
the often misleading features discussed above. In a recent case
report, van Ooijen et al.52 observed extensive cellulitis as an
unusual first symptom of ureter lesion after laparoscopic
hysterectomy. A urinoma may develop as a result of
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Minas et al.
retroperitoneal leakage of urine which leads to encapsulation
by reactive fibrous tissue, such that a cyst containing urine is
formed. This may develop into an abscess and present with
sepsis and electrolyte imbalance.53 Like all visceral injuries, a
thermal injury to the ureter may result to delayed necrosis
and/or fistula formation that will often present clinically
between 10 and 14 days postoperatively. Ultrasound and/or
CT scans can evaluate hydronephrosis, urinomas and
abscesses, whereas a CT intravenous urogram (CT IVU)
will locate the injury.
The consequences of an unrecognised injury can vary from
spontaneous healing to fistula and/or stricture formation
with associated deterioration of the function of the affected
kidney. This may occasionally require nephrectomy. Up to
25% of unrecognised ureteral injuries result in eventual loss
of the ipsilateral kidney.54
Management
Traditionally ureteric injuries have been managed by
laparotomy. There is now a growing body of evidence
suggesting that both acute injuries,38,53–58 as well as late
sequelae such as uretero-vaginal59 and uretero-uterine
fistulas60 can be repaired successfully by laparoscopy.
There are a number of options when repairing a ureteric
injury. Review of the literature suggests a general consensus
that certain surgical principles must be respected41,55,61,62
(Box 4) and that the type of repair should be selected
according to the site and type of injury.
Minor crush or needle injuries may be managed
conservatively provided that the ureter’s integrity and
viability have not been compromised, i.e. there is peristalsis
and adequate perfusion present with no urine leak. Most
authors agree that obstruction (more significant crush
or ligature injuries) is best managed with ureteral stenting.
However, the recommended amount of time for which
the ureter should be stented in such cases, varies in the
literature between 2 to 6 weeks.55,62 Similarly, limited areas
of thermal injury may require stenting to prevent stenosis
and urine leakage during healing.20 Caution is required
when more extensive deep thermal injury has occurred, in
which case, excision of the affected part and ureteral
re-anastomosis or re-implantation (as discussed below)
might be needed. Ureteric lacerations appear to heal better
when managed with suturing and stent rather than
stent alone.41
In cases of major ureteric injuries (transection, resection)
the suggested techniques are site-specific.54 At the upper
third of the ureter an end-to-end re-anastomosis of the
ureter (uretero-ureterostomy) should be performed. At
the middle third either a uretero-ureterostomy or a
trans-uretero-ureterostomy
(end-to-side
anastomosis
of the injured ureter with the contra-lateral healthy
Healthy
ureter
Injured
ureter
Box 4. Surgical principles of ureteric repair
Adequate but careful debridement to avoid shortening the ureter
(debridement may be needed to enable the use of the healthy ureter
for re-anastomosis)
Adequate but careful dissection to avoid devascularisation
(dissection/mobilisation may be needed to lengthen the ureter for
anastomosis)
Anastomosis must be:
– water-tight
– tension-free
– spatulated or fish-mouth
Use absorbable and intermittent sutures
Avoid using too many sutures
Use drainage (ureteral stents, bladder catheter, retro-peritoneal
anastomotic site drain)
Consider omental flap to cover the repair site and increase
vascularity
When possible, repair by laparoscopy
ª 2014 Royal College of Obstetricians and Gynaecologists
Figure 3. Trans-uretero-ureterostomy. End-to-side anastomosis of
the injured ureter with the contra-lateral healthy ureter. This
technique is appropriate for the management of injuries occurring at
the middle-third of the ureter.
25
Urinary tract injuries in gynaecological laparoscopy
ureter) can be performed (Figure 3). It follows that
trans-uretero-ureterostomy involves intentional injury and
therefore risk to the contra-lateral healthy ureter and should
not be used as a first-line option. At the lower third
uretero-neocystostomy (re-implantation of the ureter into
the bladder) should be preferred. If a tension-free anastomosis
cannot be achieved by simple re-implantation (due to a
shortened ureter, for example), then a psoas hitch or a Boari
flap can be performed.62 In these two techniques the bladder is
mobilised and used to bridge the gap. A psoas hitch involves
fixing the bladder to the iliopsoas muscle tendon (Figure 4). To
create a Boari, an oblique flap from the dome of the bladder is
cut and the cystotomy is closed vertically extending the flap to
the ureter (Figure 5). The Boari flap technique can provide up
to 12–15 cm of additional length.
Urinomas can often be managed by involving a specialist
radiologist. A combination of percutaneous drainage of the
urinoma, percutaneous nephrostomy, ureteral stents and
bladder drainage may help avoid re-operation.53 When late
presentation is associated with a septic unstable patient
(a)
(b)
and/or abscess formation, conservative initial management
similar to that described for urinomas plus aggressive
antibiotic treatment is required. The patient should
ideally be stabilised before considering a laparoscopic or
open approach.
At the end of the healing period, an intravenous or
retrograde urogram must be performed to confirm ureteral
patency and integrity.
Conclusion
It has been quoted that to avoid all injuries to the urinary
tract, one would have to stop operating near it – an
unrealistic prospect for gynaecologists. Injuries will occur
even in the best hands. Hence, it is important to be familiar
with strategies that reduce the incidence of such
complications and limit the resulting morbidity when they
happen. The present review has brought together a number
of recommendations on how to prevent, recognise and
manage urinary tract injuries that complicate laparoscopic
(c)
Injured
ureter
Psoas
muscle
Bladder incision
Figure 4. Psoas hitch. (a) The bladder is incised transversely and mobilised to reach the shortened ureter to achieve a tension-free anastomosis; (b)
the bladder is fixed to the psoas muscle; (c) the incision repaired in a vertical manner which allows “elongation” of the bladder.
(a)
(b)
(c)
Injured
ureter
Bladder incision
Figure 5. Boari flap. (a) A wide-based flap is developed by an anterior bladder wall incision; (b) the flap is brought towards the ureter to achieve a
tension-free anastomosis; (c) the bladder incision is closed in a tubular manner to allow up to 12–15 cm of additional length.
26
ª 2014 Royal College of Obstetricians and Gynaecologists
Minas et al.
pelvic surgery. Various confounding factors, including the
relatively low incidence of these complications, make it
particularly difficult to produce data from randomised trials.
In the absence of such well-designed studies, evidence on
the efficacy of the described techniques either originates
from case series and cohort studies, or represents anecdotal
clinical experience.
To conclude, it should be emphasised that laparoscopy
offers us the unique ability to review our practice by
recording our own operations. Through such a method
Schonman et al were able to perform an accident analysis to
determine factors that were associated with a ureteric
injury.45 This process brings to mind the analysis
performed in aviation using the aeroplanes’ flight data
recorders, the ‘black box’. When adverse events occur in
medicine, we reflect on our practice using our memory and
medical notes. This process is considered an integral part of a
clinician’s learning and continuous development.
Laparoscopy gives the surgeon the opportunity to reflect by
physically playing back and reviewing every single
intraoperative decision and action. Perhaps this tool will
prove valuable in the future in gradually gaining the
experience and knowledge that a surgeon needs to maintain
a low complication rate.
Contribution to authorship
VM performed the literature review and wrote the article. NG
and DR conceived the subject of the article. NG, TA, MD,
and DR critically revised the article and contributed to the
written material. All authors approved the final version of the
submitted article.
Disclosure of interests
The authors of this article have no conflict of interest
to disclose.
Acknowledgements
We thank Dr Lilia Khafizova (Foundation Trainee, Aintree
University Hospital), for her excellent contribution of
artwork. We thank Drs Alexandra Williams and Tolulola
Odetoyinbo (Consultants Radiologists, Wirral University
Teaching Hospital) for their help in selecting and describing
the computed tomography and cystographic images.
Supporting information
The following supplementary information is available for this
article online:
Video S1. Video demonstrating ureterolysis in a case of
overlying pelvic sidewall peritoneal endometriosis. The ureter
is identified by observing peristalsis. An incision is made to
the peritoneum above the level of the ureter and the ureter is
mobilised by medial to lateral blunt sweeping movements.
ª 2014 Royal College of Obstetricians and Gynaecologists
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