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    Preventing ureteral injury at hysterectomy: Expert approach

    Dr. Magrina is the Barbara Woodward Lipps Professor of Obstetrics and Gynecology, Department of Gynecologic Surgery, Mayo Clinic Arizona.

    He has no conflicts of interest to report with respect to the content of this article.

     

    Ureteral injury can occur during many gynecologic operations, and particularly hysterectomy, regardless of the surgical approach. The pelvic ureter is the segment most commonly injured during gynecologic operations (91%), compared with 2% and 7% incidence of injuries to the upper and middle ureteral thirds, respectively.1

    In most patients, the pelvic ureter can be easily identified in the upper pelvis at the level of the pelvic brim and also along the lateral pelvic peritoneum. The segment that is difficult to identify is the portion of the ureter between the intersection with the uterine artery and the bladder.

    This article reviews how I identify and manage the course of the parametrial (paracervical) segment of the pelvic ureter in order to prevent injury to it during endoscopic, laparoscopic, or robotic hysterectomy.

    Grasper is shown clipping the uterine artery as it crosses over the left ureter. This allows for moving the ureter out of harm's way while working in the area around the cervical neck. The ghosted instruments show subsequent steps in ligation: blunt dissection and gentle manipulation of the ovary with consequent drop of the ureter.

    Incidence of injury

    Before addressing the incidence of ureteral injuries, it is important to understand that unless otherwise indicated, reports of these complications reflect postoperative detection. That incidence is always lower than for injuries detected intraoperatively as reviewed below. The rates of ureteral injury discussed in this article are postoperative, unless otherwise noted.

    The risk of ureteral injury at vaginal hysterectomy is higher (0.6%) than with an open abdominal approach (0.07%), and almost all such injuries occur when the surgery is done for prolapse.2 The main reason is the inability to see and sometimes palpate the ureter during vaginal surgery as compared to an open procedure. The introduction of laparoscopy and later robotics resulted in an increased number of urinary injuries of any type, including ureteral injuries. In time, the risk of ureteral injury with laparoscopy and robotics decreased surgeons’ awareness of the problem grew, instrumentation improved, and experience with endoscopic procedures increased.

    A collective review of 236,392 patients who underwent gynecologic operations between 1994 and 2000 reported a risk of laparoscopic injury ranging from 0.02% to 1.7%, depending on the complexity of the operation.3 The risk of ureteral injury ranged from <1% to 2% in 2491 patients who underwent laparoscopic gynecologic surgery, based on data collected from several reports.4 In some reports, the most common injuries were due to electrocoagulation; laparoscopic-assisted vaginal hysterectomy (LAVH) was the procedure with the highest rate of ureteral injury.4

    However, other reports have indicated that ureteral pelvic injuries can occur with the use of any mechanical or electrocoagulation devices, laser beams, loop suturing, trocars, or staple devices.5

    Javier F. Magrina, MD
    Dr. Magrina is the Barbara Woodward Lipps Professor of Obstetrics and Gynecology, Department of Gynecologic Surgery, Mayo Clinic Arizona.

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