Ureteral Injury after Hysterectomy Case File
Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD
CASE 32
A 45-year-old woman underwent a total laparoscopic hysterectomy for symptomatic endometriosis 2 days ago. Today, she complains of new onset right flank tenderness. On examination, her temperature is 102°F (38.8°C), heart rate (HR) is 100 beats per minute, and blood pressure (BP) is 130/90 mm Hg. Her heart and lung examinations are normal. The abdomen is slightly tender diffusely with normal bowel sounds. The small incisions appear within normal limits. Exquisite right costovertebral angle tenderness is noted.
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ANSWER TO CASE 32:
Ureteral Injury after Hysterectomy
Summary: A 45-year-old woman who underwent a total laparoscopic hysterectomy for symptomatic endometriosis 2 days previously has right flank tenderness, fever of 102°F (38.8°C), and exquisite costovertebral angle tenderness. The small incisions appear normal.
- Next step: Intravenous pyelogram (IVP) or computed tomography (CT) scan of the abdomen with intravenous contrast.
- Most likely diagnosis: Right ureteral obstruction or injury.
ANALYSIS
Objectives
- Understand that the urinary tract is sometimes injured in pelvic surgery.
- Know the common presentations of ureteral and bladder injuries after gynecologic surgery.
- Know some of the conditions that predispose patients to urinary tract injury.
Considerations
This patient has a clinical picture identical to pyelonephritis; however, because she has recently undergone a hysterectomy, injury to or obstruction of the ureter is of paramount concern. Endometriosis tends to obliterate tissue planes, making ureteral injury more likely. Either an intravenous pyelogram (IVP) or a CT scan of the abdomen and pelvis with intravenous contrast would also be diagnostic. In the past, IVP would have been the preferred imaging study, but more recently, CT imaging has emerged as the examination of choice due to its availability and ease of performance. If the same clinical picture were present without the recent surgery, then the most likely diagnosis would be pyelonephritis and the next step would be intravenous antibiotics and urine culture. Finally, the wound incisions are normal, which argues against a wound infection causing the postoperative fever. Laparoscopic hysterectomies can cause injury to the ureter by mechanical ligation, for instance, if a stapling device were used. Thermal injury can also cause ureteral injury either directly to the ureter, or thermal spread. Thermal spread injury occurs when the ureter is not directly in contact with the electrocautery device but close enough so that the injury evolves over time. Typically, it is a delayed presentation such as 7 to 10 days following surgery. At this time, the tissue becomes devitalized and the injury presents clinically.
APPROACH TO:
Ureteral Injuries
DEFINITIONS
CARDINAL LIGAMENT: The attachments of the uterine cervix to the pelvic side walls through which the uterine arteries traverse.
CYSTOSCOPY: A procedure in which a scope is introduced through the urethra to examine the bladder lumen and its ureteral orifices. Various procedures, such as placement of stents into the ureters, can be performed.
INTRAVENOUS PYELOGRAM: Radiologic study in which intravenous dye is injected and radiographs are taken of the kidneys, ureters, and bladder.
HYDRONEPHROSIS: Dilation of the renal collecting system, which gives evidence of urinary obstruction.
PERCUTANEOUS NEPHROSTOMY: Placement of a stent into the renal pelvis through the skin under radiologic guidance to relieve a urinary obstruction.
CLINICAL APPROACH
Rates for ureteral injury for total laparoscopic hysterectomies are 17 per 1000 procedures. Cancer, extensive adhesions, endometriosis, tubo-ovarian abscess, residual ovaries, and interligamentous leiomyomata are risk factors. Any gynecologic procedure, including laparoscopy or vaginal hysterectomy, may result in ureteral injury; however, the majority of the injuries are associated with abdominal hysterectomy. 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, “water under the bridge” (Figure 32– 1). Other locations of ureteral injuries include the pelvic brim, at which injury occurs during the ligation of the ovarian vessels (infundibular pelvic ligament), and at the uterovesicular junction, the point at which the ureter enters the bladder (anterior to the vagina, when the vaginal cuff is ligated at the end of the hysterectomy). Ureteral injuries include suture ligation, trans-section, crushing with clamps, ischemia-induced damage from stripping the blood supply, and laparoscopic injury.
Figure 32–1. Location of ureters during hysterectomy. The ureters are within 2- to 3-cm lateral to the
internal cervical os and can be injured upon clamping of the uterine arteries.
If the IVP shows possible obstruction with hydronephrosis and/ or hydroureter (Figure 32– 2), 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 critically important in preventing renal damage. The decision for immediate ureteral repair versus initial percutaneous nephrostomy with later ureteral repair should be individualized.
Figure 32–2. Intravenous pyelogram. Right hydronephrosis is reflected by dilation of the renal collecting system and hydroureter, whereas the left collecting system is normal (A). Delayed film of the
same patient shows the right hydroureter more prominently (B). (Courtesy of Dr John E. Bertini.)
In general, bladder lacerations on the dome (top) of the bladder can be sutured at the time of surgery; however, injury in the trigone area (lower) may need ureteral stent placement to prevent ureteral stricture.
Ureteral injury is not a common cause of postoperative fever but must be considered after hysterectomy. Table 32– 1 shows more common etiologies (5W’s) of postoperative fever.
Prevention of Complications
The most important intervention in preventing surgical site infections after hysterectomy is the use of preoperative antibiotics, typically a first generation cephalosporin agent 15 to 60 minutes prior to incision time (see Case 33). Another important complication is venous thromboembolism prevention. Table 32– 2 shows how to grade VTE risk and the prophylactic measures recommended.
NOTE: Table 32–1 was 31–1 in 4e.
COMPREHENSION QUESTIONS
Match the following processes (A-E) to the most likely clinical situations (32.1-32.4).
A. Vesicovaginal fistulaB. Ureteral ligationC. Ureteral ischemia leading to injuryD. Ureteral thermal injuryE. Bladder perforation injury
32.1 A 55-year-old woman undergoes a total laparoscopic hysterectomy and develops fever and flank tenderness.
32.2 A 33-year-old woman undergoes pelvic lymphadenectomy for cervical cancer. During the procedure, the right ureter is meticulously and cleanly dissected free and a Penrose drain is placed around it to ensure its safety. She is asymptomatic until postoperative day 9, when she develops profuse nausea and vomiting, and is noted to have ascites on ultrasound.
32.3 A 55-year-old woman, who underwent a vaginal hysterectomy for thirddegree vaginal prolapse 1 month ago, complains of constant leakage of fluid per vagina of 7 days duration.
32.4 A 44-year-old woman undergoes a right salpingo-oophorectomy laparoscopically. Bipolar cautery is used to ligate the infundibular pelvic ligament. The next day, she complains of fever and flank tenderness.
ANSWERS
32.1 B. There are many risk factors associated with ureteral injury; however, the majority are associated with laparoscopic 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 promptly to avoid the situation in this scenario of pyelonephritis. Patients with a bladder perforation injury typically present with gross hematuria, 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.
32.2 C. Over dissection of the ureter may lead to devascularization 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 vesicovaginal fistula, urine is continuously leaking out the vagina, but not into the abdominal cavity. Nausea and vomiting are not associated with any of the other answer choices except for bladder perforation. In bladder perforation injuries, patients present with pain in the suprapubic region.
32.3 A. Constant urinary leakage after pelvic surgery is a typical history for vesicovaginal fistula (see Case 34—Urinary Incontinence). In other words, there is a constant connection between the bladder and vagina. Any type of pelvic surgery predisposes to fistula formation. Surgery is necessary to remove the fistula.
32.4 D. 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.
CLINICAL PEARLS
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» 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 or drainage from the vagina after surgery or radiation therapy. » An intravenous pyelogram (IVP) is the imaging test of choice to assess a postoperative patient with a suspected ureteral injury. |
REFERENCES
American College of Obstetricians and Gynecologists. The role of cystourethroscopy in the generalist obstetrician– gynecologist practice. ACOG Committee Opinion 372. Washington, DC; 2007. Gambone JC. Gynecologic procedures. In: Hacker NF,
Gambone JC, Hobel CJ, eds. Essentials of Obstetrics and Gynecology. 5th ed. Philadelphia, PA: Saunders; 2009:332-344.
Underwood P. Operative injuries to the ureter: prevention, recognition, and management. In: Rock JA, Jones III HW, eds. TeLinde’s Operative Gynecology. 10th ed. Philadelphia, PA: Lippincott; 2008: 960-971.
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