Prevention of ureteral injury

A)                    Prevalence: - Up to 1 % of abdominal hysterectomies can be complicated by ureteral injury. In women with  cervical Cancer, extensive   adhesions, endometriosis,  tubo ovarian and interligamentous leiomyomata   are risk  factors. For such injury   Any gynecologic   procedure including   laparoscopy or vaginal   hysterectomy may also result in ureteral   injury  however the majority of the injuries   are associated  with abdominal  hysterectomy.

B)                     Site of injury:-- Site 1:-The most     common location   for ureteral injury is at the cardinal ligament, where   the ureter is only 2 to 3 cm  lateral  to the cervix. The ureter is  just under   the uterine  artery ( so it is often taught as water under th bridge) . Site 2:- Other   locations of ureteral injuries include   the pelvic brim which occur during  the ligation of the ovarian vessels    and Site 3)  at the point  at  which the ureter enters the bladder   .

C) kinds of damage:- Ureteral injuries include a) suture   b) ligation c) trans section ,d) crushing with clamps e)   ischemia induced  damage from stripping the blood  supply and f) laparoscopic injury.

  Point : IV:-It the IVP shows  possible  obstruction with hydronephrosis and / or  hydroureter , the next   steps include  antibiotic administration and cystoscopy  to attempt   retrograde stent  passage. This procedure   is performed in the hope   that the ureter is kinked but not occluded. Relief  of the obstruction is paramount in preventing renal damage. The decision  for immediate ureteral repair    versus initial    percutaneous  nephrostomy  with later ureteral repair should be    individualized.

In general ,  bladder   lacerations mostly if ever occur  it happens at  dome of the bladder. Such injury   can be sutured at the time   of surgery,. By contrast ,  injury  in the trigone area may need insertion  due ureteral stent  placement  to prevent   ureteral  stricture.

There are many risk factors associated with ureteral injury  however the majority are associated  with abdominal hysterectomies . Other risk   factors  include cancer   extensive   adhesions endometriosis   tubo ovarian  abscess residual ovaries interligamentous leiomyomata and most gynecological  procedures  . also the presentation of fever  and flank tenderness after  surgery   makes the diagnosis of ureteral ligation   most likely in comparison   to the other options. When the ureter is ligated   the patient is at  an increased risk of hydronephrosis    and / or hydroureter. Antibiotic   treatment   and relief   of the obstruction should be administered prompty   to avoid the situation  in this scenario of phylonephritis.  Patients  with a bladder    perforation   injury typically present   with gross haematuria pain  or tenderness  in the Suprapubic region   and difficulty in voiding. Ureters are not   typically  dissected out during   a hysterectomy  therefore   it would be unlikely for ischemia to occur  in this situation.

Over dissection of the ureter may  lead to de vascularization injury   because  the ureter  receives  its blood supply from various  arteries along its course and flows along its adventitial sheath. Urine   is  leaked  into the abdominal cavity   and causes irritation  to the intestines and induces nausea and emesis. With a vesico vaginal fistula  urine continuously leaking   out the vagina but   not  into the abdominal cavity  . Nausea  and vomiting   are not associated  with any of the other  answer   choice   except  for bladder perforation . In bladder perforation injures patients present with pain  in the Suprapubic region.

Constant   urinary  leakage   after pelvic  surgery  is a typical history for vesico  vaginal fistula . In other   words there is  constant connection between the bladder and vagina. Any type of pelvic   surgery predisposes   to fistula  . Surgery  is necessary   to remove the fistula.

Thermal   injury   can spread  from cauterized   tissue  to surrounding  structures. As with the patient diagnosed  with a ureteral  ligation this patient   presents with fever and  flank  tenderness. The fact  that the procedure  in this scenario was performed   using bipolar  cautery the likelihood that the symptoms  deal with thermal  injury  versus  ligation  is much  higher.

Ureteral injury   should be suspected  when a patient develops flank  tenderness and fever after a hysterectomy or oophorectomy

Meticulous ureteral dissection can lead to devascularization injury to the ureter    since the vascular   channels   run along   the adventitia of the ureter.

A fistula should be  considered  when  there is constant   leakage   of drainage  from the vagina    after surgery    or radiation  therapy.

An  intravenous   pyelogram is the imaging test of  choice   to assess a postoperative    patient   with a suspected ureteral injury.