Prevention of Ureteral Injury 2014 - En'wezoh
Author: Derick En'Wezoh
This presentation describes the anatomy of the ureter, risk factors for ureteral injury, and key points from the literature relating to injury of the ureters.
Published on: Mar 4, 2016
Transcripts - Prevention of Ureteral Injury 2014 - En'wezoh
INJURY TO THE
By Derick En’Wezoh
Clinical Anatomy 2014
• Precursor: Ureteric bud
• Structure: Retroperitoneal
• Blood Supply:
• Upper: Renal a.
• Middle: Common iliac a. & branches
• Lower: Internal iliac a. & others
• Innervation: nerves from T12-L2
segments of spinal cord
• Function: carries urine (AKA
pee, piddle, weewee, piss)
The Abdominal Ureter
• Travels retroperitoneal
• Begins proximally at level of
• Posterior to renal vessels
• Ureteropelvic junction at
level of 2nd lumbar vertebrae
• Continues anteriorly on
psoas major m.
• Crosses under gonad
The Pelvic Ureter
• Enters the pelvis at pelvic
• Anteriorly crosses lateral to
medial of the bifurcation of
the common iliac arteries
• Descends into pelvis with
peritoneal sheath (ureteric
• Pass under the uterine
arteries in the cardinal
Netter's Clinical Anatomy , 3E
John T. Hansen
chapter 4, 145-216
Copyright © 2014 by Saunders,
Operations Prone to Ureteral Injury
• Gynecologic Surgery
• Pelvic Surgery
• Colorectal Surgery
• Prostate Surgery
• **Orthopedic Surgery**
- Anterior retroperitoneal
approach to the lumbar
- Pelvic fractures
Surgical exposures in orthopaedics
Hoppenfeld, c2009. [4th ed.]
Risk Factors for Ureteral Injury
• Patient Risk Factors
• Prior pelvic surgery
• Urinary tract abnormalities
• History of pelvic irradiation
• Procedure Risk Factors
• Surgery for malignancy
• Advanced pelvic reconstructive surgery
• Laparoscopic hysterectomy (the literature is mixed)
UpToDate: Urinary tract injury in gynecologic surgery: Prevention, 6/2014
Examined incidence/location of
urinary tract injury during
hysterectomy in 839 patients.
• Ureteral Injury Rate of
1.8% (15/839 cases)
• Junction of ureter and
uterine artery represented
80% of ureteral injuries
• Transection and kinking
injuries most common
Obstet Gynecol. 2009;113(1):6-10.
Rates of Ureter Injury
Review of 47 studies reporting ureteral and bladder injury
in gynecologic surgery. 2-3X more ureteral injuries found
with the use of intraoperative cystoscopy.
29.5 Studies Without
17.5 Studies With
Ureteric Injury Rate
(Per 1000 Surgeries)
Lap. Hysterectomy 7.8 17.3
Obstet Gynecol. 2006;107(6):1366-72.
Evaluated incidence of urinary tract injury 2/2 hysterectomy
using cystoscopy in 471 patients. Only 12.5% of ureteral
injuries were detected before cystoscopy.
Approach Ureteral Injury
Abdominal 6/272 2.2%
Vaginal 2/142 1.4%
Laparoscopic 0/49 0.0%
Recommended routine use of cystoscopy during
hysterectomy to prevent “silent injuries which can have
devastating consequences.” Am J Obstet Gynecol. 2005;192(5):1599-604.
Reviewed several articles discussing laparoscopic ureteral
Complications of Unrecognized Ureteral Injuries:
• Urethral strictures
• Fistula formation
• Loss of renal function
• Intraoperative mortality
J Minim Invasive Gynecol. 2007;14(3):356-61.
Key Points from the Literature
• Ureteral injury during hysterectomy is common
• The most common anatomical site of injury is at
the ureter/uterine artery junction
• Without the use of cystoscopy, many ureteral
injuries go undetected
• Undetected ureteral injuries can have significant
1° Approach to Injury Prevention
• Knowledge of anatomy
• Careful surgical dissection
• Use of ureteral catheters
Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(6):689-93.
What are we looking at?
The ureter (along with the calyces, renal pelvis, bladder
and prostatic urethra) is lined by transitional epithelium
known as urothelium. Urothelial cells express specific
membrane proteins called uroplakins.
Junqueira's Basic Histology: Text & Atlas, 13e.
Kidney Int. 2009;75(11):1153-65.