1. PELVIC URETER
&
PREVENTION OF
URETERIC INJURIES

2. Retropritoneal spaces
The retroperitoneal space of pelvic side walls
contains:
• Pelvic ureter
• Internal iliac vessels
• Pelvic lymph nodes
• Obturator nerve

3. The pelvic ureter
• Total length of ureter is 25-30 cm
• Abdominal & pelvic portions are almost equal
in length.

4. Abdominal & pelvic
portions are almost
equal in length,
12-15 cm

5. Course & Relations

11. Structure
From outside inwards
1. Fibres derived from the visceral layer of the
pelvic fascia
2. Muscle coat: Outer: longitudinal
Intermediate: circular
Inner : longitudinal
3. Mucous layer : lined by Transitional epithelium

12. Ureter is comparatively constricted at
1. Where it crosses the pelvic brim
2. Where it is crossed by the uterine vessels
3. In the intravesical part

13. Blood supply
• Segmental blood supply from nearly all the
visceral branches of the anterior division of
the internal iliac artery.
• Venous drainage corresponds to the arteries.

14. Lymphatics
• The lymphatics from the lower part drain into
the external & internal iliac lymph nodes.
• The upper part into the lumbar lymph nodes.

15. Nerve supply
Sypathetic supply from:
Hypogastric & Pelvic plexus
Parasympathetic supply from:
Sacral plexus

16. Development
Ureter is developed as an ureteric bud which
arises from caudal end of mesonephric duct.

17. Ureteric injuries
• Overall incidence is 0.5 – 1 % of all pelvic
operations
• Incidence varies from 0.4 – 2.5 % for benign
conditions as reported in different
studies, but it can be as high as 30% in
operations for malignancies

18. • About 75 % of ureteric injuries occur during an
abdominal gynaecological surgeries with
incidence 0.5 – 1 % for abdominal
hysterectomy, compared to 0.1 % for vaginal
hysterectomy.

19. Sites vulnerable to injury
1. At the pelvic brim during ligation of
Infundibulo-pelvic ligaments.
2. At the base of the broad ligament, where it
passes beneath the uterine arteries.
3. As it passes through it’s tunnel in the cardinal
ligaments.
4. Along the course on lateral pelvic wall just
above the uterosacral ligaments.
5. At the anterior fornix of vagina as it enters the
bladder.

20. 6. Where it traverses through the musculature of
bladder (Intra vesical part).
7. Lateral pelvic side wall over the iliac vessels
during lymph node dissection.
8. Any congenital malformation eg. Duplex
ureter makes it more vulnerable to injury at
any of these sites.

21. Nature of ureteral injury
1. Simple kinking or angulation; obstruction
2. Ischaemic injury resulting from trauma to
ureteric shaeth endangering its blood supply.
3. Ligation with suture.
4. Crushing injury by clamps.
5. Transection - partial or complete
6. Segmental resection - Accidental or planned.
7. Thermal injury, during laparoscopic surgeries.
8. Injury by staplers.

22. Gynaecological procedures associated
with ureteric injuries
Abdominal
• Hysterectomy
• Wertheim’s hysterectomy
• Oophorectomy
• Uterine suspension
• Vesicovaginal fistula repair

23. Vaginal
• Hysterectomy
• Anterior colporrhaphy
• Vesicovaginal fistula repair
• Cervical biopsy
Laparoscopic
• Hysterectomy
• Colposuspension
• Treatment of endometriosis
• Sterilisation (especially electrocoaguation)

24. • Goodno JA, Powers TW, Harris VD. Ureteral
injury in Gynaecologic surgery: a ten year
review in a community hospital. Am J Obstet
Gynecol 1995; 172: 1817-1822
• Liapis A, Bakas P, Giannopoulos V, Creatsas G.
Ureteral injuries during gynaecological
surgery. Int Urogynecol J 2001; 12: 391-394

25. Significantly pelvic malignancies were present
in 44 %.
a/w dense adhesions, large masses displacing
the ureter & anotomical changes distorting
the course of the ureter.

26. However it should be noted that half of all the
ureteric injuries had no identifiable risk factors &
occur in so called ‘simple hysterectomy’

27. Distortion of pelvic anatomy
1. Cervical fibroid or low corporeal fibroid
2. Broad ligament tumours/ fibroids
3. Pelvic endometriosis
4. Large ovarian masses
5. PID
6. Gynaecological malignancies

28. 7. Prev. pelvic surgery
8. Pelvic haematoma
9. H/o pelvic irradiation
10.Ovarian remnant (when needs removal)
11.Congenital abnormalities like ureteric
duplication, mega-ureter, ectopic ureter or
kidney.

29. Prevention of ureteric injuries
Preventive measures:
• Pre operative intravenous urography
• Placement of ureteric catheters.
• Uriglow – ureteric catheters with incorporated
light source.

30. Abdomino pelvic surgery
• Adequate exposure
• Most important axiom of surgery:
Any imp structure at risk of inadvertent injury
must be carefully dissected & adequately
exposed.
• To avoid blind clamping of blood vessels.
• To not damage the shaeth of ureter; longitudinal
vessels
• Recognised by Pale glistening
appearance, longitudinal vessels on
surface, peristalsis.

31. 1. Divide the round ligament near the lateral pelvic
side wall, then open the lateral peritoneum 10-15
cm in a cephalad direction.
2. Place an index finger on the external iliac artery,
3. By moving the finger upward (cephalad), the first
structure to be exposed, crossing & in contact
with the iliac artery, will be the ureter.
4. As the index finger is placed on the ureter, the
infundibulopelvic lig. should be behind the
middle phalanx, can be safely clamped with the
ureter clearly visible.
5. Followed towards the cardinal lig. where it passes
under the uterine artery; Push laterally &
downward moving it away from cervix.

36. Vaginal surgery
• To develop an adequate vesico-uterine space
• To clamp, cut & ligate only small bites of
paracervical & parametrial tissue
• In post. culdoplasty ligation of uterosacrals to
support vaginal apex after the uterus is
removed can kink or obstruct the ureters if not
done carefully.
• Ant. colporrhaphy: Not to start too laterally or
to insert deep sutures;
distance between needle & ureter in upper
third of vagina is only 0.9 cm (Hofmeister’s
fluroscopic findings)

37. Laparoscopic surgery
• Retroperitoneal dissection to locate ureters
• Electrocoagulation of bleeding points around
the uterosacral ligaments is risky, might better
done with clips, sutures.
• Sometimes width & length of the stapler
makes safe application difficult;
uterines,cardinals pedicles are better ligated
vaginally.

38. Medicolegal considerations
• The first step in risk management & prevention
of litigation is at the initial consultaion for
operation.
• The necessity & risks associated with the
procedure to be performed should be discussed
in detail with the patient & properly
documented In case notes.

39. KEY POINTS FOR CLINICAL PRACTICE
• Thorough knowledge of the anatomy of the
ureter is must & to be aware of the sites where
it is liable to be injured.
• Preop intravenous urography or stent
placement has not been shown to decrease the
incidence of ureteric injuries.
• A high index of suspician & early investigations
are necessary for diagnosis.
• Early diagnosis & management will reduce
postoperative morbidity & save renal loss.
• Timings of repair should be individualised,as no
difference in outcome in early & late repair.