Unexpected encounters with ureters

Published Date: 23rd December 2016

Publication Authors: Thomas A

Ureteric injuries are as common as 0.5-3% and are frequently missed.Delayed diagnosis can occur in upto 15% patients and can lead to serious morbidity such as fistula formation, peritonitis, loss of renal function and is a frequent cause of medico legal litigation.

The common sites of ureteric injury are at infundibulopelvic ligament, ovarian fossa, uterine vessels, uterosacral ligament and anterior vaginal fornix. Mechanisms of injury include transection, ligation or necrosis from energy damage or ischaemia. Detailed knowledge of pelvic anatomy, meticulous dissection skills, use of the avascular surgical spaces and good haemostatic principles will keep the pelvic surgeon safe around the ureter.Ureteric injury can be avoided by acquiring the ability to identify its course from the pelvic brim to the bladder, dissecting ureter away preserving the adventitia. Pre operative stenting may be useful in recurrent endometriosis, oncological surgery and when hydroureter is present on imaging.

Three surgical scenarios are presented in the video where the ureter required careful dissection at 1.IP ligament, 2.uterine artery and 3.pelvic sidewall with a duplex ureter. First scenario shows the inherent danger of assuming ureteric safety by lifting the IP ligament and transection and the requirement for careful dissection along its pelvic course when anatomy is altered in the presence of fibrosis. Second scenario demonstates the close relationship of ureter to the uterine artery near the cervix when myomas are present and safe dissection with lateral ligation of uterine artery. Third scenario shows the unexpected recognition of duplex ureter in a patient with recurrent endometriosis.

 George, S; Thomas, A.. (2016).Unexpected encounters with ureters. Gynecological Surgery 13 (3), 215-280.

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