Video Clips on DVD
Retrograde Ureteral Stent Placement
Ureteral Reimplantation with Psoas Hitch
Ureterotomy with Stent Placement
Hysterectomy is the second leading surgery performed in the United States (second only to cesarean section) with an estimated 600,000 procedures performed annually. Injuries to the lower urinary tract have been estimated at less than 10 per 1000 hysterectomies. Nevertheless, given the large number of hysterectomies performed annually, these injuries result in significant morbidity and economic cost to the patient and to the health care system. This chapter focuses on the epidemiology of ureteral injury, ways to prevent injury, and how to best detect and repair them when they occur.
Seventy-five percent of injuries to the bladder and ureters occur following gynecologic procedures. Although this proportion is decreasing with the increasing prevalence of urologic endoscopic procedures and their associated complications, hysterectomy remains the most common procedure associated with injury to the lower urinary tract (LUT). Although the risk of injury to the LUT increases with increasing difficulty of primary operation (e.g., large uterus, excessive bleeding, prolapse procedures, malignancy, and endometriosis), more than 50% of injuries occur during uncomplicated procedures. Furthermore, in the absence of cystoscopy, the majority of the injuries are undetected during the primary operation, leading to increased morbidity and costs associated with diagnostic procedures, prolonged hospital stay, reoperations, return visits, and delay in diagnosis (e.g., ileus, urosepsis, and fistula formation).
The incidence of ureteral injury following gynecologic surgery ranges from 0.2% to 11%, depending of the type of study (historical or prospective) and definition of injury (e.g., kinking from suspension or transection/crush injury). Using a Finnish database of all hysterectomies performed between 1993 and 1995, Harkki-Siren and colleagues found an overall rate of ureteral injuries to be 1 per 1000 hysterectomies. The incidence of injuries was lower after vaginal, supracervical, and abdominal hysterectomy (0.2, 0.3, and 0.4 per 1000, respectively) compared with laparoscopic hysterectomy (13.9 per 1000; P < 0.00001). Others have also reported increased risk of ureteral injuries during laparoscopic surgery, regardless of whether or not the procedure was performed by an endoscopic specialist.
Several risk factors are associated with injury to the LUT. Laparoscopic approach and combined pelvic reconstruction increase the risk of injury sixfold and 2.4-fold, respectively, compared with abdominal hysterectomy and 39- and 15.5-fold, respectively, compared with vaginal hysterectomy. In addition, studies without routine intraoperative cystoscopy underestimated the risk of injury by approximately twofold. Ureteral obstruction occurs frequently following uterosacral vault suspension (5.9%; 95% CI, 3.9, 8.9), McCall culdoplasty (4.4%; 95% CI, 4.4, 8.2), and colpocleisis (4.2%; 95% CI, 1.2, 1.4). These injuries are also observed following anterior colporrhaphy (0.4; 95% CI, 0.1, 1.3). Even though routine cystoscopy in uncomplicated hysterectomies remains controversial and may not be cost effective, its use during prolapse repairs has 99.5% specificity for excluding injury to the ureter during the index procedure. Given the relatively high rate of ureteral injuries during reconstructive procedures and the high negative predictive value of cystoscopy with indigo carmine to rule out these injuries, we recommend that cystoscopy be performed routinely during prolapse repairs.
LUT injuries occurred commonly in the setting of technical difficulties arising during the primary operation. Technical difficulties were reported in 76% of abdominal and 51% of laparoscopic hysterectomies and included heavy bleeding, endometriosis, enlarged uterus, obesity, and bladder adhesions. In fact, cases with concomitant injury were rated more difficult by the primary surgeon compared with cases in which no injury occurred (using a 10-point ordinal scale, with 10 being most difficult; 7.0 vs. 4.9; P = .001). More alarming, up to 100% of ureteral injuries were undetected during the primary procedure in reports in which routine cystoscopy was not used. When cystoscopy is routinely used, only 12.5% of ureteral injuries were detected before cystoscopy. Unrecognized injuries lead to diagnostic delays, predispose to litigation, and lead to increased overall morbidity and highlight the need for testing (with intravenous indigo carmine/cystoscopy, intravenous pyelogram, or ureterolysis) whenever the possibility of injury is considered or technical difficulties arise during a procedure, regardless of route of hysterectomy.
View DVD: Videos 6-1 and 6-2
6-1: This 42-year-old patient is undergoing repair of vesicovaginal fistula after abdominal hysterectomy elsewhere. Because the fistula is close to the trigone, bilateral ureteral stents are placed.
6-2: This 39-year-old patient is undergoing a radical hysterectomy for cervical cancer. Complete bilateral uterolysis is shown.
If during a laparotomy the ureter or ureteral sheath is injured, the ureter(s) may be stented ( Fig. 6-1 ). The most effective way to achieve this is to perform an intentional cystotomy in the dome of the bladder. The bladder is mobilized from its anterior peritoneal attachments and a bladder dome cystotomy is made with electrocautery. A double-J ureteral stent (6 Fr × 26 cm) is placed under direct vision with the proximal end of the stent in the renal pelvis and distal end in the bladder ( Fig. 6-2 ). The cystostomy is closed in two layers with a 2.0 chromic suture and the bladder drained for 7 to 10 days. The stent is removed in 6 weeks and the integrity of the urinary tract evaluated with a CT urogram or equivalent study.
View DVD: Video 6-3
This 58-year-old female had an uncomplicated total vaginal hysterectomy with anterior colporrhaphy and posterior colpoperineorrhaphy. Intraoperative cystoscopy revealed bilateral spill of indigo carmine, although the right was less robust than the left ureteral jet. Routine serum creatinine the day following surgery was elevated from 0.8 to 1.2 mg/dL. The patient’s condition was hemodynamically stable and she had a mild drop in hemoglobin. Fractional excretion of sodium and urinalysis showed no evidence of prerenal (fractional excretion of sodium ([FeNa] < 1%) or cytotoxic causes of renal insufficiency (no cast or eosinophilia, suggesting nephrotoxic injury to the kidney). Renal ultrasound was inconclusive (no hydroureter or hydronephrosis) and follow-up computed tomography urogram revealed a right distal ureteral obstruction. A nephrostomy tube was placed and attempted antegrade stenting of the right ureter was not successful. As a result, the patient was returned to the operating room to undergo a ureteral reimplantation procedure (ureteroneocystostomy).
The abdomen is entered via a midline incision and the bowel packed in the upper abdomen. The retroperitoneum is entered and the right ureter identified and mobilized caudally to the level of the obstruction. During the dissection, care is taken to minimize trauma to the longitudinal blood supply and to facilitate identification and ligation of the uterine artery as it crosses over the ureter. The injured segment is resected and the distal end is further dissected until it enters the bladder. The ureter is then ligated distally with a permanent suture and the excess ureter is excised. The proximal end is spatulated (approximately 0.5 cm) and secured with a 4.0 absorbable suture. A 4- to 5-cm cystotomy is made at the bladder dome, and with a finger in the bladder, a suitable site for the ureteroneocystostomy is chosen on the extraperitoneal posterolateral wall of the bladder ( Fig. 6-3A ). A curved forceps is placed in the bladder and a small (approximately 1 cm) full-thickness incision made at the chosen site. The tagged proximal ureter is brought into the bladder (see Fig. 6-3B ) and secured to the detrusor with four to six fine (3.0 or 4.0) interrupted absorbable sutures in a circumferential fashion (see Fig. 6-3C ). The approximation includes a full-thickness bite of the ureter and near full-thickness bite of the detrusor and overlying bladder mucosa to form a mucosa-to-mucosa anastomosis (see Fig. 6-3E ). The ureter is further stabilized with two 2.0 delayed absorbable sutures to the serosal side of the bladder (see Figs. 6-3D-F ). A double-J ureteral stent is placed and the cystotomy incision reapproximated in two layers with a delayed absorbable suture. Continuous bladder drainage is continued for 7 to 14 days postoperatively (either via a suprapubic or transurethral catheter) to allow for healing of the cystotomy and the ureteral stent is removed at the 6-week follow-up visit. Following removal of the stent, the integrity of the urinary tract is evaluated with a CT urogram or equivalent radiographic evaluation.
Psoas Hitch and Boari Flap
View DVD: Video 6-4
This 21-year-old para gravid 2 woman sustained a right ureteral transection during an abdominal hysterectomy with resection of the ureterosacral ligaments for chronic pelvic pain. A ureteroureterostomy was performed; however, she was later found to have a distal ureteral stricture. Given the significant loss of distal ureteral length, she was scheduled for exploratory laparotomy, ureteroneocystostomy, and psoas hitch 4 months after the index procedure.
If the ureteral anastomosis is under tension (e.g., because of large ureteral defects as in the case described here), additional ureteral length can be obtained by performing a psoas hitch. In this procedure, the bladder is freed anteriorly by entering the retropubic space as if performing a retropubic urethropexy. The lateral parietal peritoneal attachments are freed, with care taken not to injure the bladder. The psoas muscle tendon and genitofemoral nerve are identified and two to three delayed absorbable sutures are placed in the muscle and tendon, avoiding the genitofemoral nerve. The sutures are tagged and later used to secure the bladder to the psoas muscle and remove tension from the anastomosis. The ureteroneocystostomy is performed as described earlier. Before closing the bladder dome, the previously tagged sutures are brought through the bladder wall and tied ( Fig. 6-4 ). A double-J ureteral stent is placed and the cystotomy incision reapproximated in two layers with a delayed absorbable suture. Continuous bladder drainage is continued for 7 to 14 days postoperatively (either via a suprapubic or transurethral catheter) to allow for healing of the cystotomy, and the ureteral stent is removed in 3 to 6 weeks. Following removal of the stent, the integrity of the urinary tract is evaluated with a CT urogram or equivalent radiographic evaluation.