A Review of Laparoscopic Ureteral Injury in Pelvic Surgery

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A Review of Laparoscopic Ureteral Injury in
Pelvic Surgery

• Obstetrical and Gynecological survey
• Volume 58, Number 12

2004? 4? 29? ? ? ?
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Abstract

• Objective of this study
• laparoscopic surgeries? ureteral injury? ??? ???
  review
• Determine
• Reported rates of ureteral injury
• Initial laparoscopic surgeries during which
  ureteral injury occurred
• Time of injury recognition (intra- versus
  postoperative)
• Type
• Location
• Mode of injury repair
• Surgical laparoscopic instruments involved in
  ureteral injury.

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• ??? medical subject heading(MSH) terms ?? ? ??
• Medline computerized database ? the online ACOG
  database ??
• 1966 2003? ??? ??? ????? ? ??? ????? ?? ??
  literature ??

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• A total of 70 reported instances in 2491 reported
  cases
• Incidences of injury lt1 to 2
• 2491 cases
• case reports, small series of studies, as well as
  longer, consecutive studies.
• Total 70 case?
• The type of laparoscopic surgery
• Not described or specified 18(25.7) cases
• LAVH 14 (20.0)
• Ureteral injury identification
• Intraoperatively 6(8.6) cases
• Postoperatively 49(70.0) cases
• Not specified 15(21.4) cases
• Type of injury
• not specified or described 36(51.4)
• Transection most common, 14 (20.0)

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• Location of ureteral injury
• Not specified 46(65.7) cases
• At or above the pelvic brim 10(14.3) cases
• Surgical laparoscopic instrument
• Electrocautery 17(24.3) cases
• Not reported 34(48.6) cases
• Repair the ureteral injury
• Laparotomy - 43(61.4) cases
• LAVH the leading procedure in which injury
  occurred
• Electrocoagulation ???? injury? ??

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Target Audience

• Obstericians Gynecologists, Family physicians

Learning Objectives

• After completion of this article, the reader
  should be able to
• Summarize the reported rates of ureteral injury
• Identify the location of the more common
  laparoscopic ureteral injury
• List the various types of laparoscopic ureteral
  injuries

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Materials and Methods

• Laparoscopic surgeries? ??? ureteral injury? ??
  ??? ?? (1966-2003)
• Appropriate MSH terms? ??? medline database ?
  online ACOG database? ??
• Bibliographies? manual? ??
• Key terms Laparoscopic complication and
  ureter

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Results

• Medline computerized database 3344 articles
• ACOG database 3690 articles
• Manual search of bibliographies
• 30 articles discussed ureteral injury during
  laparoscopic surgery
• 70 individual cases contained

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Rate of Injury and Initial Procedure

• Incidence rates lt1 to 2
• Initial laparoscopic procedure
• Not described 18(25.7) cases
• LAVH 14(20.0) cases
• Oophorectomy 8 (11.4)
• Laparoscopic pelvic lymphadenectomy 7 (10.0)
• Laparoscopic sterilization 5 (7.1)
• Excision of endometriosis 5 (7.1),
• Endometriosis ablation 4 (5.7)
• Drainage of lymphoceles, electrocoagulation, and
  laparoscopic adhesiolysis ?? 3 (4.3)

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Time of Injury Recognition

• Intraoperatively 6 cases (8.6)
• Postoperatively 49 (70.0) cases
• Not specified 15 (21.4) cases

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Type of Injury

• Not described 36 of the 70 (51.4) cases
• Transection 14 cases (20.0)
• Laceration, obstruction, and stenosis ?? 4
  cases (5.71)
• Fistula formation, necrosis, and ligation ?? 2
  cases (2.9)
• Resection and burn injury ?? 1 case (1.4)

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Location of Injury

• Not specified 46 cases (65.7)
• At or above the pelvic brim 10 of the 70 cases
  (14.3)
• At or above the uterine artery 8 cases (11.4)
• At or above the bladder 6 cases (8.6)

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Mode of Approach to Injury Treatment

• Laparotomy 43 cases (61.4)
• Not described 15 cases (21.4)
• Repair through laparoscopy 8 cases (11.4)
• Conservative, nonsurgical management 4 cases
  (5.7).

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Instrumentation Involved in the Injury

• Not specified 34 (48.6)
• Electrocautery 17 (24.3)
• Endoscopic stapling 12 (17.1)
• CO2 laser 4 (5.7)
• Forceps 2 (2.9)
• Aspirating needle 1 (1.4).

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Discussion

• Incidence of major complications in laparoscopic
  hysterectomy
• 3.5
• Incidence of ureteral injuries
• Between 0.3 and 2
• Rate of laparoscopic ureteral injury
• Not comprehensively described and documented in
  the literature

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• ?? Laparoscopic hysterectomies ? retroperitoneal
  laparoscopic procedures ? ??? ?? Ureteral injury
  ?? ?? ??
• Härkki-Sirén et al.
• Ureters particularly vulnerable to injury
  during major operative laparoscopy

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• Intraoperative diagnoses of ureteral injury
• only 6(8.6) cases
• Papers on classic (nonlaparoscopic) gynecologic
• procedures
• Injury diagnosis ????? ureteral injury?
  detection?? method? ?? ??
• Hurt et al. 5 methods
• 1) retrograde ureteral dye injection
• 2) intravenous dye injection
• 3) intraoperative ureteral catheterization
• 4) intravenous excretory urography
• 5) dissection of the ureter
• 15(21.4) cases? diagnosis time? ?? ?? ??

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• Ureteral injury repair? approach ??
• Laparotomy 43(61.4) cases
• 15(21.4)cases did not report
•  Gordon and Lewis
• Focal ureteral injuries
• Double J-shaped catheter? ????, urine leakage? ??
  ureter? ???? spontaneous healing? ???? ?? ??
• More extensive damage
• end-to-end anastomosis ? ureteral implantation?
  ??
• laparotomy? ??

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• Preferred technique of ureteral injury repair
• Dependent on the time of injury diagnosis
• 59 cases
• both time of ureteral injury diagnosis and mode
  of treatment were reported
• Diagnosed postoperatively
• Laparotomy ?? ??? 49 case? 38 cases (77.6)
• 5 cases of ureteral injury not treated using
  laparotomy
• 4 cases conservative treatment
• 1 case laparoscopic approach
• most often repaired using laparotomy
• Diagnosed intraoperatively
• laparoscopic repair ??
• 6 cases
• 2 cases laparotomy
• 4 cases laparoscopy.

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• The type and location of ureteral injuries
• Type not specifically described in 51.4
• Location specified in even fewer cases
• Potential locations for ureteral injury
• Hurt et al. classic, nonlaparoscopic pelvic
  surgeries
• at the pelvic brim
• Ureter? uterine arteries ???? cervix ???? ???? ??
• Ureters? bladder? ???? vaginal fornix? ?? ??
• Gordon and Lewis laparoscopic surgeries
• at the infundibulopelvic ligament
• where the ureter passes deep to the ovarian fossa
• at the ureteral canal
• Our review
• at or above the pelvic brim the most common
  site

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• Instruments involved in ureteral injuries
• 34 cases (48.6) not defined or specified
• LAVH and electrocautery
• Identified as leading causes of laparoscopic
  ureteral injury
• (when data was available for analysis and
  review)
• In more than 50 of the cases
• Location and type of injury were also not
  specified
• In this review (most common findings)
• Electrocautery instrumentation
• Transection injuries
• At or above the pelvic brim

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• Decrease the risk of this complication
• Ostrzenski
• laparoscopic suturing and tying method
• Laparoscopic suturing technique and the tying of
  an intracorporeal or extracorporeal
• staplers or electrocautery?? ?? ??? method
• Improved training in laparoscopic technique
• Recognition of intra- and retroperitoneal gross
  and functional anatomy
• Lower urinary tract? integrity? ???? ??
  intraoperative protocols ??
• ???? urology consultation? ??
• Decrease the delay in recognition of ureteral
  injury
• Increase of their intraoperative repair.

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• laparoscopic surgeries? ureter injury? ?? Data
  and discussion
• Lacking in both breadth and depth
• Much of the reviewed literature on existing
  information
• Cursory and incomplete.