Ureteric Injury (RCOG)

Question 1

Incidence of ureteric injury during abdominal or pelvic surgery?

Answer 1

0.2-1%
O+G accounts for 50% of these injuries
Risk higher in GONC, BUT benign gynae accounts for most cases.

Question 2

Anatomical features increasing risk of ureteric injury?

Answer 2

enlarged uterus
previous pelvic surgery
ovarian neonplasms
endometriosis
pelvic adhesions
disorted pelvic anatomy
coexistent bladder injury
massive intraoperative haemorrhage

Question 3

Most common site of ureteric injury

Answer 3

• lower third 51%
• upper third 30%
• middle third 19%

Lateral to uterine vessels, close to cardinal ligaments

base of infundibulopelvic ligament as the ureters cross the pelvic brim at the ovarian fossa

at the level of the uterosacral ligaments (most frequent during laparoscopic procedures)

Question 4

How are ureteric injuries classified?

Answer 4

grade 1 = haematoma
grade 2 = laceration <50% transected
grade 3 = laceration >50% transected
grade 4 = complete transection with <2cm devascularisation
grade 5 = complete transection, laceration or avulsion with >2cm of devascularisation.

Question 5

Measures to reduce risk of ureteric injury?

Answer 5

Preoperative IVU
Intraoperative 
- ureteric stents
- optimise exposure
- appropriate approach
- urological assistance where appropriate

Other

• mobilise bladder down + out moves ureters away from uterine.
• direct visualisation of ureters
• dissection of ureteric course (reduction of injury from 0.7–>0.2%
• short diathermy applications

Question 6

Most common action leading to ureteric injury?

Answer 6

Blind clamping of blood vessels.

Question 7

intraoperative tests to check for ureteric transection?

Answer 7

If unsure about ureteric injury, IV administration of mehtylthionium chloride or indigo carmine 5mL can demonstrate patency or leak

Cystoscopy
Pick up rate of injuries:
- urogynaecology: diagnoses injury in 2.6-8%
- benign gynaecological procedures: 0.4%

Question 8

Postoperative symptoms or signs of ureteric injury?

Answer 8

flank pain
fever
haematuria
retroperitoneal urinoma
peritonitis/ileus
anuria
hypertension with obstructive uropathy

Question 9

Imaging for ureteric injury?

Answer 9

Intravenous urogram (transection, delayed function)
CTU- ureteric transection
retrograde ureterogram (if CT/IVU findings inconclusive, identifies site of obstruction)
renal USS (hydronephrosis, urinoma)
cystoscopy +/- contrast dye

Question 10

biochemical serum findings of ureteric injury?

Answer 10

hyponatraemia