1. URETERIC INJURY IN OBST ETRICS AND
GYNAECOLOGICAL SURGERY AND
URINARY DIVERSIONS
Prof. M.C. Bansal.
Founder Principal & Controller ;
Jhalawar Medical
College And Hospital Jhalawar
Ex Principal & Controller ;
Mahatma Gandhi Medical College
and Hospital Sitapura, Jaipur.

2. OUTLINE
• INTRODUCTION
• APPLIED ANATOMY
• COMMEN SITES OF INJURY OF URETERS
• TYPE OF INJURY OF URETER
• PREDISPOSITION
• IDENTIFICATION OF URETRIC INJURY
• SPECIFIC INJURY
• MANAGEMENT
• PREVENTION
• CLINICAL SCENARIOS
• CONCLUSION.

3. OBJECTIVE
• FUNCTIONAL ANATOMY.
• ISSUES SURROUNDING URETERAL INJURY.
• BASIC PRINCIPLES OF INJURY
AVOIDANCE,RECOGNITION AND
MANAGEMENT.

4. APPLIED
ANATOMY OF
PELVIC URETER

5. • The ureters are the
muscular ,thick
walled narrow
tubes(Right and Left)
• Each measures 25-30
cm in length and
extends from renal
pelvis to its entry in
the bladder.

6. PELVIC URETER
• The ureter are located
retroperitonealy and run
from the renal pelvic to
urinary bladder.
• The abdominal segment
lies on the psoas muscle
and enter the pelvis by
crossing the common iliac
vessel from lateral to
medial aspect at their
bifurcation just medial to
ovarian vessel.

7. • At the level of ischial spines
it runs in the broad
ligament and enter the
ureteric canal formed by
the cardinal ligament,
crossed by the uterine
vessels running anterior to
ureter.
• Here, It is 1.5 cm lateral to
cervix.
• The ureter runs medially
and enter the bladder close
to the anterior vaginal wall .
On left side it even can
cross the vaginal angle .
Ureters while running at
base of broad ligament ,are
also very close to utero
sacral ligament.

12. • The ureter is supplied
by : Renal
, Gonadal, Common
iliac , Internal
iliac, vescical Uterine
arteries and the
Abdominal aorta.
• The venous drainage
generally follows the
arterial supply.
BLOOD
SUPPLY

13. LYMPHATIC DRAINAGE
• Lymph drains into sub mucosal ,intramuscular
and adventitial plexuses ,which all
communicates.
INNERVATION
• The ureter is supplied from the lower three
thoracic , first lumber and second to fourth
sacral segment of spinal cord by branches
from the renal and aortic plexuses and the
superior and inferior hypogastric plexuses.

15. INCIDENCE
• 75% ureteric injuries take place during
gynaecological procedures.
• Abdominal Hysterectomy is the most
common procedure.
• 30% chance of injury during
gynaec-oncosurgery.
• 0.5-1% ―Abdominal Hysterectomy.
• 0.1 % —Vaginal Hysterectomy.
• 9-10%-Wertheim's Hysterectomy

16. Common sites of ureteric injury
• At the pelvic brim during clamping of infundibulopelvic
ligament.
• At the bifurcation of common iliac artery during internal
iliac artery ligation.
• Lateral pelvic wall above the uterosacral ligament.
• Base of broad ligament , ureter passes under the uterine
artery.
• Ureteric canal-During Wertheim hysterectomy.
• Intramural portion near the insertion into the trigon when
base of bladder is injured or repaired.
• Upper vagina during clamping of vaginal angle.

19. RISK FACTORS FOR
URETERIC INJURIES
1. ANATOMICAL RISK FACTORS.
2. PATHOLOGICAL RISK FACTORS.
3. TECHNICAL RISK FACTORS

20. 1.ANATOMICAL RISK FACTORS:
A)THE URETER:
• Has close attachment to the peritoneum.
• Closely related to female genital tract.
• Has variable course.
• Not easily seen or palpated.

21. 2.PATHOLOGICAL RISK
FACTORS:
1. Congenital anomalies of ureter or Kidney.
2. Ureteric displacement by:
Uterine size ≥12 weeks.
Prolapse.
Tumour{ovarian neoplasm}.
Cervical fibroid/Ca.
broad ligament swellings(fibroids , incarcirated
ovarian tumours or hematomas)
3.Adhesions:
Previous pelvic surgery.
Endometriosis.
PID.
Extention of carcinomatous indurations in broad
ligaments , post irradiation.
4.Distorted pelvic anatomy.

22. 3.TECHNICAL RISK FACTORS
• Massive intraoperative haemorrhage.
• Coexistent bladder injury.
• Technical difficulties.
• Inexperienced surgeon.

23. TYPES{CAUSES}OF INJURY
INTRAOPERATIVE
• Crushing from misapplication
of a clamp.
• Ligation with a suture.
• Transection{partial or
complete}
• Angulation of the ureter with
secondary obstruction.
• Ischemia from ureteral
stripping , LASER or
electrocoagulation.
• Resection of a segment of
ureter.
• Any combination of these
injuries may also occur.
POSTOPERATIVE
• Avascular necrosis
following werthiem.
• Kinking-peritonisation of
vaginal stump after
hysterectomy.
• Subsequent obstruction
over:
-Haematoma or
-Lymphocele

24. In ½ OF THE cases
URETERIC INJURy is not
identified at the time of
primary injury during
surgery

25. ABDOMINAL
• Hysterectomy.
• Wertheim’s hysterectomy.
• Oophorectomy.
• Uterine suspension.
• Burch colposuspension.
• Vesicovaginal fistula repair.
LAPROSCOPIC
• Division of adhesions.
• Electrocoagulative injury
while uterine arteries are
coagulated or ligated.
• Transection of uterosacral
ligament.
• Colposuspension
• Treatment of
endometriosis.
• Sterilisation
(electrocoagulation)
PROCEDURE ASSOCIATED WITH
URETERIC INJURIES
VAGINAL
• Hysterectomy.
• Anterior colporrhaphy
• Cervical biopsy.
• Vesicovaginal fistula
repair.
• Culdoplasty

26. Prevention strategies to
reduce the risk of ureteric
injuries
• General preventive strategies:
Preoperative
Intraoperative
• Specific Preventive strategies:

27. GENERAL PREVENTIVE
STRATEGIES
A .Preoperative measure:
• Intravenous urogram(IVU).
• Ultrasound scan.
• Previous investigations ,can identify ureteric
dilatation and disclose anatomical variations.
• Preoperative stenting in conditions of
anatomical distortion.

28. INTRAOPERATIVE PREVENTION
• Surgeon is to constantly and equivocally know
where ureter is all times.
• Appropriate operative approach.
• Adequate exposure.
• Avoid blind clamping and ligature of blood
vessels.
• Mobilise bladder away from operative site
• Stay outside vascular sheath .
• Limit the zone of coagulation to avoid thermal
injury.
• Ureteric dissection and direct visualisation.

29. IDENTIFICATION OF URETER
• The peritoneal reflection anterior to the
uterus is incised and the bladder is pushed
down with blunt or sharp dissection.
• Pelvic ureter is identified on the medial
aspect of the broad ligament during the
opening of perivescical and perirectal
spaces while performing extended
hysterectomy or removing broad ligament
tumors.

32. IMAGING
• No proof that
preoperative IVU or
CE-CT reduces risk of
injury.
• Endometriosis , PID
uterovaginal prolapse
and previous intra -
abdominal surgery are
associated with
increased prevalence of
abnormal IVU finding.

33. SPECIFIC PREVENTIVE STRATEGIES
A}During Abdominal
hysterectomy:-
Clamp infundibulopelvic ligament
after lifting up the ligament
dissection and palpation ,clamp
near to the ovary.
-Always clamp{cardinal
, Uterosacral} ligaments close to
the uterus.
-Never to open vagina unless
urinary bladder is dissected down
properly and sufficiently.
-Use of intrafacial technique.

34. SPECIFIC PREVENTIVE
STRATEGIES
B}During Vaginal surgery :
1. Prevention of ureteric injuries can be achieved by adequate
development of vescico-uterine space , by:
-Downward traction on the cervix.
-Counter traction upward by Sim’s speculum below the bladder.
2. All clamp:-Small bites.
-Close to the uterus.
3. Avoid double clamping of uterosacral ligament.
4. Vaginal Oophorectomy should be avoided or done cautiously.
5. During anterior colporrhaphy:
-Avoid too lateral dissection .
-Avoid deep suture :as the distance between needle and ureter
in upper vagina ≤0.9 cm.

35. • C)During laparoscopy:can be achieved by:
• -Moving the fallopian tubes away from pelvic
side walls before coagulation.
• -The bleeding points at uterosacral ligaments
should be secured with sutures or clips
instead of electrocoagulation.
• -In LAVH place stapler or suture across uterine
vessels and cardinal ligaments instead of
electrocoagulation.

36. GOOD SURGICAL
SKILL

59. MANAGEMENT

60. AIM OF MANAGEMENT
• Preservation of function.
• Anatomical continuity.
• Decision depends on-
Time of detection
Extent of injury
Site of injury
General condition of patient

69. Upper ureteric injuries
• Primary
ureteroureterostomy
• If there is extensive loss
of the
ureter, autotransplantat
ion of the kidney can be
done as well as bowel
replacement of the
ureter.

73. STENTING
 Insert a silicone internal stent
through the anastomosis
before closure.
Advantages :
1. Maintenance of a straight
ureter with a constant caliber
during early healing,
2. The presence of a conduit for
urine during healing,
3. Prevention of urinary
extravasation,
4. Maintenance of urinary
diversion,
5. Easy removal

78. Ureteric Injury Repair
• Depends on cause, location, and extent
– Minor trauma (ligature or crush) may be managed with
stent and drainage
– Partial transection corrected with suture repair or
resection
• Lower third
– Primary ureteroureterostomy (ligation)
– Bladder tube flap (Boari flap)
– Transureteroureterostomy (extensive urinoma or pelvic
infection
– Procedure of choice: Psoas Hitch

79. Psoas Hitch Procedure

81. Upper, Middle, Lower Segments

83. Laboratory findings
 Retrograde Urethrogram
 Rule out urethral injury
▪ Insert catheter
▪ Inflate balloon
▪ Inject dye (20 ml, water
soluble)
▪ Visualize (X-ray)

84. Laboratory findings
 Catheterization
 Hematuria
 Culture initial
catheterization
▪ Infection
 Contra indication
▪ bloody urethral discharge

85. Laboratory findings CT Scan /
Cystogram
 Check bladder
integrity
▪ Catheterize
▪ Inject dye
▪ Radiograph
imaging
▪ X-ray
▪ CTS
▪ Drainage Film

86. 86
Urinary diversion
• to divert urine from the bladder to a new
exit site.
• Usually through a surgically created
opening (stoma) in the skin.

87. Introduction
• Diversion of urinary pathway from its natural
path
• Types:
–Temporary
–Permanent

88. Indications of permanent
urinary diversion
• When the bladder has to be removed
• When the sphincters of the bladder & the detrusor
muscle have been damaged or have lost their
normal neurological control
• When there is irremovable obstruction in the bladder
& distal to that
• Ectopic vescicae
• Incurable vescico- vagina fistula

89. 89
Indications
• Tumour necessitating removal of entire bladder
• Pelvic malignancy
• Birth defects
• Strictures
• Trauma to ureters and urethra
• Neurogenic bladder
• Chronic infection causing severe uretral and renal damage
• Intractable interstitial cystitis and
• Incontinence

90. Temporary urinary diversion
• Suprapubic cystostomy
• Pyelostomy or nephrostomy or
urethrostomy (with indwelling catheters)

91. Illustration of suprapubic tube placed to aid bladder drainage
Suprapubic Cystostomy

92. A nephrostomy is a
surgical procedure by
which a tube, stent, or
catheter is inserted
through the skin and into
the kidney.

93. Permanent urinary
diversion
• Uretero - sigmoidostomy
• Ileal conduit
• Colon conduit
• Ileocaecaecal segment
• Lowsley’s operation

94. 94
Types of urinary
diversions
Cutaneous urinary
diversions
•Ileal conduit (ileal loop)
•A 12 cm loop of ileum led out
through abdominal wall
•Stents used
•The space at cystectomy site
drained by a drainage system
•After surgery a skin barrier
and a transparent disposable
urinary drainage bag
•Constantly drains

96. 96
Complications of ileal conduit
• Wound infection
• Wound dehiscence
• Urinary leakage
• Ureteric obstruction
• Small bowel obstruction
• Ileus
• Stomal gangrene
• Narrowing of the stoma
• Pyelonephritis
• Renal calculi

97. 97
Cutaneous
Ureterostomy…

98. 98
Vescicostomy

99. 99
Nephrostomy…

100. Uretero- sigmoidostomy
• Complications:
– Reflux of urine
– Hyperchloraemic acidosis
– Renal infection
– Stricture formation

101. 101
Continent Urinary Diversions
• Continent Ileal Urinary Reservoir
Indiana Pouch
• Most common continent urinary diversion
• Periodically catheterized
Koch Pouch
Charleston Pouch
Ureterosigmoidostomy
• Voiding occurs from rectum

102. 102

103. 103

104. 104
Koch
Pouch II

105. 105
ureterosigmoi
dostomy

106. 106
Potential complications
• Peritonitis due to disruption of anastomosis
• Stomal ischaemia and necrosis due to
compromised blood supply to stoma
• Stoma retraction and separation of
mucocutaneous border due to tension or
trauma

108. Bladder reconstruction

109. Recto sigmoid pouch

110. 110
Nursing process : The patient undergoing urinary diversion surgery
Preoperative assessment :
• Cardiopulmonary assessment
• Nutritional assessment
• Learning capacity assessment
Preoperative nursing diagnosis
• Anxiety
• Knowledge deficit
Preoperative planning and goals
• Relief of anxiety
• Ensuring adequate nutrition
• Explaining surgery and its effects

111. 111
Nursing Management
• In the immediate postoperative period urine volumes are
monitored hourly
• An output below 30 ml/h dehydration or obstruction
• Promote urine output – a catheter may be inserted through
urinary conduit
• Provide stoma and skin care – consult with enterostomal
therapist
• Skin care specialist consulted
• Stoma looked for color – dark purplish –blood supply
compromised
• Skin inspected for irritation
• Bleeding
• Wound infections

112. 112
Postoperative nursing interventions
• Monitor urinary function
• Prevent complications
infection, sepsis, respiratory, complications, fluid and
electrolyte imbalances, fistula formation.
• Ryle’s tube aspiration
• Ambulate quickly
• Maintain peristomal integrity
• Relieve pain
• Improve body image
• Exploring sexuality issues
• Treat peritonitis
• Look for stomal ischaemia and necrosis
• Look for stomal retraction and separation

113. 113
• Neomycin, kanamycin
• Immediately after operation – catheter in rectum – to prevent
reflux into ureters and infection of the newly formed ureteric
opening into the intestines
• Monitoring fluid and electrolytes : intestinal mucosa absorb
urine water and electrolytes; diarrhoea due to potassium and
magnesium; maintain the balance. Pt advised to empty the
rectum every 2 hours to ↓ build up of pressure and thereby the
absorption of urinary salts
• Retrain the rectum – special sphincteric exercises – learn the
differentiate between the need to defaecate and the need to
urinate

114. 114
• Promoting dietary measures – avoid chewing
gum, smoking.
• Salt intake restricted to prevent hyperchloremic
acidosis. Potassium increased to make up for
potassium lost in acidosis
• Monitoring and managing potential complications : -
pyelonephritis due to reflux of bacteria from rectum
– long term antibiotics – late complication due to
irritation - adenocarcinoma

115. 115
Managing ostomy
appliance
• Empty the pouch when 1/3 full to prevent weight pulling
down
• A small amount of urine is left to prevent collapse of the
bag against itself
• The collecting bottle and tubing is rinsed with cold water
daily and once in a week with a 3:1 solution of water and
white vinegar
• Continuing care – look for metastases

116. 116
• Look for leakage of urine from the appliance
• Urine pH is kept below 6.5 by administration of ascorbic acid
• Appliance to be fitted properly to prevent skin from getting
irritated by urine
• If the urine is foul smelling C&S done
• Ileal conduit – mucosa – mucus produced – urine gets mixed
with mucus – patient encouraged to take lot of fluid to wash
out the mucus.
• Appliances : reusable or disposable
• Skin barrier used to protect skin from urine

117. 117
Promoting home and
community care
• Teach patients self care
• Control odour : food that gives odour to urine avoided e.g.
Cheese, eggs
• Deodorizers or dilute white vinegar introduced into the drainage
bag
• Ascorbic – acidifies – suppresses odour
• Aspirin introduced into bag to deodorize may cause ulceration of
the stoma

118. 118
• Home and community care
• Teaching self care
• Continuing care

119. Future aspects
1. More than 40 variants of continent
diversion, no single best technique
2. Which bowel segment ?
3. Which continent technique ?
4. Which anti-reflux technique ?
Only long term follow up can answer these
questions