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Intraoperative injuries of the urinary tract

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Intraoperative injuries
of the urinary tract
SEAN L. FRANCIS, M.D.1, JAVIER F. MAGRINA, M.D.1,
DONALD E. NOVICKI, M.D.2, JEFFREY L.
CORNELLA, M.D. 1
Department of Gynecologic Surgery1, Department of Urology2,
Mayo Clinic Foundation, Scottsdale, Arizona
ABSTRACT
ABSTRACT Morbidity related to injuries of the urinary tract
during gynecologic surgeries has remained relatively low
despite decades of operating in close proximity to the bladder,
ureters, and urethra. This is a result of gynecologic surgeons
having a constant awareness of the anatomy with which they
work and maintaining the knowledge and skills required to
quickly repair such injuries. As a result of experience and
excellent training, the surgeon is often able to avoid such
mishaps. However, with time, types of surgery performed,
methods of repair of complications and standards for timing of
repairs can change resulting in a necessity to occasionally
review such topics and anatomy. Most recently, a surge in min-
imally invasive surgery has introduced with its many benefits,
new complications. This publication provides a detailed review
of the anatomy of the urinary tract, preventive measures, risk
factors and types of injuries that occur to the urinary tract dur-
ing gynecological surgery. In addition, the authors discuss new
gynecologic surgeries, complications resulting from them and
methods for repair. Finally, the publication reviews recent
trends in repair of the better-known injuries.
Key words iatrogenic injury, urinary tract injury, intraopera-
tive injuries, ureter injury, bladder injury, urethra injury,
gynecology complications, pelvic surgery complications
INTRODUCTION
INTRODUCTION Benign and oncologic gynecologists frequently
operate in immediate proximity to the urinary tract. Conse-
quently, complications to the urinary tract occur more often
in our specialty and all pelvic surgeons should be well versed
Address correspondence to:
Sean L. Francis, M.D.
Gynecologic Surgery
Mayo Clinic Scottsdale
13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
Phone (1 480) 301 6884 Fax (1 480) 301 8414
E-mail francis.sean@mayo.edu
CME Journal of Gynecologic Oncology 2002; 7:65–77
in avoiding, diagnosing and/or treating such complications.
As might be expected the rate of urinary tract injuries in
oncologic surgery is slightly higher at 1.1 to 5.5% when com-
pared to benign pelvic surgery (0.3%) (1-5). In several large
studies with an average of 2,139 patients undergoing major
gynecologic procedures the incidence of ureteral injury was
0.5-1.5% (6). The incidence of ureteral injuries during radical
hysterectomies is 2.2% (6). As a result, in most practices the
oncologist, urogynecologist or urologist is more adept at deal-
ing with such injuries than the average gynecologist and con-
sequently will be counted upon when such problems arise. It
is however essential for anyone performing pelvic surgery to
be familiar with the anatomy, potential risks and at least some
of the more common reconstructive procedures for iatrogenic
injuries to the urinary tract.
ANATOMY
ANATOMY OF
OF URINARY
URINARY TRACT
TRACT Some may argue that the most
important surgical tool for a surgeon is his or her knowledge
and understanding of the anatomy in which he operates (7). In
ancient Rome and Greece dissection of the human body was
forbidden. As a result, documented knowledge was limited to
animal anatomy and knowledge gained through other religions,
such as the Islam religion which did not share such restric-
tions (8). The coming of the Italian Renaissance gave birth to
an increased curiosity of the human body and great artist such
as Michelangelo (1475–1564) who worked closely with
anatomist Realdo Colombo (1516–1559) and Leonardo
DaVinci (1452–1519) (9-10). As we study anatomical pictures
and drawings as they developed with time it becomes quite
apparent that when we improve our ability to reproduce human
anatomy we increase our knowledge and understanding of this
anatomy. Modern technology through computers and highly
advanced imaging techniques has not only added increasing
detail to anatomical structures, but also confers the ability to
study anatomy in an additional dimension through 3-dimension
virtual reality models and the convenience of models as close as
your nearest computer. These models allow students to maneu-
ver and reorient structures through the touch of a button (11-
12). In a 1999, Stenzl et al. (13) published one such virtual real-
ity model of the urinary tract that will contribute to the educa-
tion of doctors and students for years to come. The possibility
exists that this additional information may contribute to a
decrease in the number of surgical complications.
KIDNEYS
KIDNEYS The kidney is a complex, autoregulating organ res-
ponsible for maintaining the fluid balance for the entire body
and also performs multiple ancillary functions. It is perfused
with approximately 1,200 ml of blood per minute, roughly
20% of a humans total blood volume. Intraoperative injury to
the kidney can result in significant fluid balance problems,
uremia and/or substantial blood loss. Several aspects of its
anatomical structure and location serve to protect this organ
from both iatrogenic and traumatic injury. The kidneys are
65
Intraoperative injuries of the urinary tract
located retroperitoneally between the level of the 12th thoracic
and third lumbar vertebrae. The right kidney lies slightly
lower than the left because of inferior displacement by the
liver. The left kidney is slightly longer and slightly thicker than
the right and lies closer to the midline.
Multiple layers of supporting adipose tissue and fascia sur-
round the kidney. The perirenal fat refers to the layer of adi-
pose tissue between the peritoneum and the posterior abdom-
inal wall. The perirenal fat is enclosed by Gerota’s fascia. This
is in turn is enclosed by another layer of adipose known as the
Pararenal fat. Additional protection is provided to the kidneys
by their position between the abdominal organs and muscles
of the back. More specifically, the kidneys lie against the psoas
muscles and as a result, the longitudinal axis of the kidneys is
parallel to the obliquely aligned psoas. Because the hila are
rotated anteriorly the lateral borders are posterior (14). Lat-
erally layers of fascia of the kidneys fuse behind the ascending
and descending colon. The medial border of each kidney has a
marked depression, the hilum, which contains the renal vessels
and renal pelvis (14). The blood supply to the kidneys is from
the renal arteries, the fifth branches of the abdominal aorta.
Surgeons should be aware of the common occurrence of polar
arteries when dissecting around the poles of the kidney. This
is said to be present in 30% of patients in a small series. Before
reaching the kidneys the renal artery divides into the anterior
and posterior branches and then subdivide into lobar arteries
which supply the lower, middle and upper third of the kidney.
Lobar arteries are further divided into interlobular arteries
that supply the cortex tissue and the kidney capsule. Other
interlobular branches supply the glomerular capsules of the
nephron as efferent arterioles. These arterioles further divide
to become the glomeruli. The renal veins follow a pattern sim-
ilar to the arteries and empty into the vena cava.
Sympathetic nerve fibers to the kidney come mainly from the
greater splanchnic nerve and the celiac ganglion (15).
URETER
URETER The ureter is 22-30 cm in length, tubular structure con-
necting the renal pelvis to the urinary bladder. One half of its
length is in the boney pelvis and one half is above the pelvis.
The ureters are covered by smooth muscle, which is divided
into an inner layer of longitudinal muscle and an outer layer
of circular muscle. A layer of adventitia surrounds the ureter
containing a supply of blood and lymphatics that feed the
ureters. The ureter runs retroperitoneally along the top of the
psoas muscle and enters the pelvis by traveling over the bifur-
cation of the iliac vessels. The ureter then travels along the
medial leaf of the broad ligament in women and passes 2.3 cm
lateral to the cervix. Hurd et al. (16) studied 1181 CT scans
and found that the distance from the cervix to ureter was less
than 0.5 cm in 12% of his population. More surprisingly, he
found there was also an indirect relationship between the size
66
of the patient and the distance of the ureter from the cervix.
The ureter finally travels under the uterine artery to the blad-
der (Figure 1) (17).
The blood supply to the ureter is from several sources including
the aorta, renal artery, ovarian artery and common iliac artery.
This blood supply is derived from the medial aspect within the
abdominal cavity, and from the lateral in the pelvis. A series of
longitudinal vessels travel parallel to, and in close proximity to
the ureter beneath the adventitia. Preservation of this plexus of
vessels is essential to assure viability of the ureter. Knowledge of
the ureteral vasculature is an important consideration when
performing either laparoscopic or open ureteral mobilization.
The surgeon should use a medial to lateral sweeping technique
when mobilizing the ureter within the pelvis (18).
Innervation of the ureter is complicated and somewhat poorly
understood. Primary innervation is by unmyelinated fibers
originating from renal, ovarian and sympathetic plexuses. It is
supplied by both the sympathetic nervous system, originating
from T11-L1 and the parasympathetic system (19-22). In the
mucosa of the ureter, nerve fibers form networks on the lumi-
nal aspect of the muscle layer and beneath the basement
membrane of the epithelial (23-27). Despite this complex net-
work of nerves, peristalsis of the ureter can continue despite
denervation, transplantation and in vitro (28-29). It is
believed that nerves play a role of modulation in ureteral
peristalsis through timing of peristalsis and urine bolus (30).
BLADDER The bladder is a hollow, muscular organ with the
ability to distend to a capacity of up to 500 ml or more and the
flexibility to contract to an organ small enough to be entirely
contained within the pelvis. It is an organ whose importance
is often taken for granted until old age or trauma results in
urinary incontinence. Fortunately, its location behind the
symphysis pubis helps to protect the bladder from trauma.
Internally, it is lined by a transitional epithelium, which is 6
cell layers in thickness. The next layer is a thick layer of elas-
tic connective tissue called the lamina propria. The surround-
ing muscle fibers known as the Detrusor envelope the lamina
propria in a somewhat random orientation playing an essen-
tial role in emptying the bladder. Finally, the bladder is sur-
rounded by a layer of peritoneum and floats on a sea of adi-
pose and loose connective tissue known as the space of Retz-
ius. Within the bladder a triangular segment of epithelium,
the trigone connects the left ureteral orifice to right ureteral
orifice to the urethra. This anatomical landmark will prove to
be important when discussing injury location.
Blood supply to the bladder is provided by the inferior and
superior vesical arteries. Both are branches of the internal
iliac artery. Additional supply comes from any adjacent arter-
ies arising from the internal iliac vessels.
CME Journal of Gynecologic Oncology 2002; 7:65–77

Innervation to the bladder is also complex. It is essential to
understand in great detail when dealing with problems related
to urinary continence. It is likewise important for pelvic sur-
geons to understand the basic anatomy of bladder innervation
to minimize injuries resulting in retention or incontinence. In
addition, it would allow the surgeon to most appropriately
prepare his or her surgical approach.
The act of micturation is a precisely coordinated event requir-
ing input from three sets of related nerves in order to function
properly. Parasympathetic input via the pelvic nerve, sympa-
thetic via the hypogastric, and somatic via the pudendal nerve
mediate this event. The pelvic nerve carries the most important
afferent neurons. With its origin at the S2-S4 level of the spinal
cord, the parasympathetic efferent pathway represents the
most important excitatory input to the bladder. It results in
stimulation of the detrusor muscle. Parasympathetic input into
Uterine artery
and vein
Right ureter
A Internal iliac
artery
Figure 1. The course of the ureter as it passes the infundibulopelvic ligament and travels under the uterine vessels during hysterectomy
(From: Lee RA. Atlas of Gynecologic Surgery. Figure. 253, page 176. W.B. Saunders, Philadelphia, Pennsylvania, 1992. Reprinted with permission of the author and publisher.)
CME Journal of Gynecologic Oncology 2002; 7:65–77
Chapter 22
the urethra elicits an inhibitory effect on urethral smooth muscle.
Sympathetic preganglionic neurons located at T11-L2 elicit
contractions of the bladder base and urethral smooth muscle as
well as relaxation of the bladder body. In addition, sympathetic
input to bladder parasympathetic ganglia facilitates and
inhibits parasympathetic transmission. Finally, somatic efferent
pathways from S2-S4 innervate the external striated urethral
sphincter muscle and the pelvic floor musculature. Combined
activation of sympathetic and somatic pathways elevates blad-
der outlet resistance and contributes to urinary continence.
Sensory information including bladder fullness are relayed to
the spinal cord via the pelvic and hypogastric nerves which
communicate with the spine at S2-S4 and T11-L2 (31-32).
URETHRA
URETHRA The female urethra is a tubular structure approxi-
mately 3.5 cm in length that provides a conduit for urine to exit
Right
ureter
Cervix
Uterine
B artery
C
Right
Cardinal ureter
ligament
67
Intraoperative injuries of the urinary tract
Table 1. Conditions that may contribute to loss of reduced exposure or visibility
Large pelvic masses
Pregnant uterus
Obesity
Pelvic hemorrhage
Malignant disease
Inadequate incision
Inadequate retraction and lighting
Table 2. Conditions that may distort anatomy
Cervical and broad ligament myomas
Cancer
Endometriosis
Chronic inflammatory disease
Prior pelvic surgery
Radiation therapy
Congenital anomalies
Pelvic organ prolapse
Pelvic adhesions
the bladder to the most distal aspect of the vagina. Its innerva-
tion is described in the section above. New radiologic advance-
ments for visualization of the urethra, such as 3-dimension
ultrasound and MRI will most likely lead to a better under-
standing of normal and abnormal urethral anatomy in the near
future. These advancements may prove to be helpful in the
diagnosis of iatrogenic injury and improve on our ability to
treat incontinence and other pathology related to the urethra.
RISK
RISK FACTORS
FACTORS The majority of injuries to the urinary tract take
place in patients with few if any risk factors for injury. How-
ever, an awareness of such risk factors allows the surgeon to
take extra precaution in such patients. One of the principal
rules of surgery is to obtain good exposure. Most of the
known risk factors for injury in some way compromise that
exposure (33-34). Below is a list of risk factors that had been
published by ACOG in a 1997 educational bulletin. After
reviewing over thirty publications between 1998 and 2001 on
the subject, the list was found to be quite complete and rep-
resentative (Tables 1 and 2).
Some of the risk factors listed above increase the risk of uri-
nary tract injury in more than one way. For example, any sur-
geon who has operated on an obese patient recognizes that
visualization is compromised by greater distances between
the abdominal wall and the cul de sac as well as by the adipose
tissue itself. What may not be as well known is that as the
68
body mass index increases the distance between the ureter
and cervix decreases. This was demonstrated quite nicely by
Hurd et al. (16) in a study that a randomly selected a sample
of 52 pelvic CT scans from1181 and studied for a relationship
between age, weight and distance from ureter to cervix.
TYPES
TYPES OF
OF INJURIES
INJURIES
KIDNEY
KIDNEY Renal injuries related to gynecological surgery are
rare events. Not even in a recent publication of a multi-insti-
tutional study of complications in 1085 laparoscopic urologic
procedures including 130 adrenalectomies, can one find a
single direct intraoperative injury to the kidney (35). Perhaps
this is a result of the kidneys’ retroperitoneal location and sur-
rounding adipose cushion as described in the anatomy section
of this chapter. In the past, an injury to the kidneys would
probably be a significant concern only to gynecological oncol-
ogists. However, as we continue to become more minimally
invasive, we increase both the number of laparoscopic proce-
dures we perform, as well as the types of procedures we are
able to accomplish laparoscopically. Consequently, we will
probably soon discover new complications resulting from
laparoscopic trocars and instruments with one possibility be-
ing damage to the kidney and or renal pelvis. A January 2001
case report is published in which a 23 year old man suffered
an intraoperative injury to a horseshoe kidney while undergo-
ing laparoscopic inguinal herniorrhaphy (36). Such an experi-
ence might serve as a warning for today’s gynecologic sur-
geons to take necessary precautions and care as they increase
their use of laparoscopy.
Table 3. Types of surgical ureteral injuries during open or laparoscopic surgery
Transection
Suture ligation
Crush
Devascularization-ischemic necrosis
Kink
Fibrotic stricture
Cautery thermal injury
Table 4. Types of surgical ureteral injuries during endourologic surgery
Perforation
Stricture formation
Avulsion
Ischemic necrosis
Mucosal false passage
Intussusception
Prolapse into the bladder
CME Journal of Gynecologic Oncology 2002; 7:65–77
 Chapter 22

URETER
URETER The ureter is the second most commonly injured organ Table 5. Organ Injury Scaling System of the Committee of the American Association for
of the urinary tract during gynecological surgery with abdom- the Surgery of Trauma
inal hysterectomy being the most common culprit accounting
for 86% of all gynecological injuries to the ureter (35). There Grade 1 hematoma contusion or hematoma without devascularization
are several types of ureteral injuries some only occur with Grade 2 laceration <50% transection
endourological procedures and others are more common in Grade 3 laceration >50% transection
open and laparoscopic procedures (37-39). In this chapter we Grade 4 laceration complete transection with 2 cm of devascularization
will focus on the latter. It is important to differentiate, as Grade 5 laceration avulsion with >2 cm of devascularization
often, the type of injury will dictate the correct course of
treatment (Tables 3 and 4).

As with any surgical complications, it is always important to URETHRA

URETHRA Most iatrogenic urethral injuries result from urologic
know when to communicate with a specialist, in this case the endoscopic procedures, however, there are occasions when a
urologist, in order to provide the best care for the patient. It urethral laceration or injury occurs during an aggressive dis-
is equally important to be able to efficiently and effectively section in an anterior colporrhaphy, urethral diverticulum
communicate with the specialist. As a result, an awareness repair or sling procedure. Consequently, we will limit discus-
and perhaps memorization of the Organ Injury Scaling Sys- sion to two types of urethral injuries, those that disrupt only
tem of the Committee of the American Association for the an outer layer and those that tear through and enter the lu-
Surgery of Trauma may facilitate the care of the patient as men. Such injuries can occur by an excessively aggressive dis-
well as help with documentation (Table 5). section during anterior colporrhaphy, various sling proce-
dures, including tension-free vaginal taping, or during repair
BLADDER
BLADDER The bladder is the most commonly injured urinary of a urethral diverticulum.
tract organ during both benign and malignant surgery. His-
torically the majority of bladder injuries occurred at the dome DIAGNOSISDIAGNOSIS OF
OF URINARY
URINARY TRACT INJURIES The ability to diagnose
TRACT INJURIES
of the bladder. This is important, since an injury to the blad- an iatrogenic injury to the urinary tract is one of the most cri-
der base can potentially involve the ureters and be much more tical skills in caring for surgical patients. The surgeons ability
morbid. Most injuries occur secondary to extension of the to successfully diagnose such problems in a timely fashion, ide-
abdominal incision through the abdominal wall during ally, while still in the operating room, will often determine
laparotomy and during dissection of the bladder from the cer- whether the patient simply stays in the operating room longer
vix. The incidence of bladder injuries after major gy- suffers significant and perhaps permanent morbidity. In 1996,
necological surgeries is somewhere between 0 and 2.9% with Selzman et al. (43) reviewed charts of 156 patients represent-
an average of 0.8%, based on review of 27 publications bet- ing 20 years of urologic and gynecologic surgical patients with
ween 1950 and 1999 representing 91,682 patients (40). A sub- iatrogenic injuries and defined the method and timing of diag-
ject that has not been quite as thoroughly studied is the inci- noses and treatment and subsequent morbidity. They found
dence of bladder injuries resulting from laparoscopic proce- that when identified at injury and treated properly, such
dures or the type and location of such injuries. At present the injuries lead to loss of renal function less often than those
incidence appears to be 0.02-8.3% based on an extensive diagnosed later (43). Preston (44) published “Iatrogenic
review of 1372 articles between 1970 and 1996.
Most injuries occur at the dome as a result of dis-
section of the bladder from the cervix (41-42) Table 6. Studies of the incidence of bladder injury in patients undergoing laparoscopy
(Table 6). An additional type of bladder injury that
must now be considered includes trocar injuries Study Year Operation Number of No bladder %
and injuries from various laparoscopic instruments operations injuries
such as the laparoscopic stapler, an instrument
rarely, if ever used in open gynecologic surgery. Harkki-Siren (63) 1998 Lsc hysterectomy 2741 24 0.8
Ou et al. (64) 1994 Lsc hysterectomy 839 8 1
Laparoscopic bladder injuries include needle Liu and Reich (65) 1994 Lsc hysterectomy 518 6 1.1
injuries and or small puncture wounds through the Saidi et al. (66) 1996 Major lsc surgery 953 11 1.1
mucosa of the bladder, such as in the case of injury Dweyer et al. (67) 1999 Lsc burch colposusp 178 3 1.7
with a tension-free vaginal taping trocar. In addi- Councell et al. (68) 1994 Lsc hysterectomy 171 5 2.9
tion, one could tear only serosa, or could lacerate Speights et al. (69) 2000 Lsc PVDR/Burch 171 4 2.3
deep into the bladder wall and involve the trigone.
The type of injury will dictate the method of repair. Lsc laparoscopic PVDR paravaginal defect repair

CME Journal of Gynecologic Oncology 2002; 7:65–77 69

Intraoperative injuries of the urinary tract

ureteric injury: common medicolegal pitfalls” in 2000 in which In the event that the diagnosis is not made in the operating
he stated that it is the cases that result in significant morbidity room, one must turn to his or her clinical skills. As always,
and inconvenience to patients that are more likely to result in begin with history and physical. In the event of a ureteral
legal action being taken. As would be expected, injuries with- injury the patient may present postoperatively with flank pain,
out long-term sequelae seldom lead to malpractice suits (44). abdominal pain/peritonitis, fever, watery vaginal discharge,
oliguria or ileus. As many of these symptoms can often occur
Intraoperative cytoscopy with intravenous indigo carmine in in postoperative patients for many other reasons, it is impor-
association with vaginal and laparoscopic gynecological pro- tant to maintain a high level of suspicion. Symptoms usually
cedures at risk for ureteral injuries establishes an intraopera- occur about 48 hours after surgery.
tive diagnosis of ureteral obstruction and, consequently is
extremely useful to evaluate the urinary tract in real time. Once the suspicion of ureteral injury exists, laboratory evalu-
When performing open procedures that place the bladder ation including a serum creatinine may be helpful. As demon-
and ureters at high risk we recommend routine cystoscopy. strated in a retrospective study of postoperative patients by
Although there is conflicting literature regarding this prac- Walters et al. (45) at the Mayo Clinic Scottsdale serum creati-
tice, many experts feel that significant postoperative morbi- nine will rise an average of 0.3 in the case of ureteral obstruc-
dity is avoided and the evidence for this practice is continuing tion.
to build (Tables 7 and 8).
Serum creatinine and urinalysis should be routinely obtained
Suspicious drainage fluid, i.e. vaginal discharge, intraabdomi-
Table 7. Studies done in support of intraoperative cystoscopy in gynecological surgery nal drainage or aspirates from masses suspected of being a
urinomas should be sent for a creatinine level and to compare
Jabs et al. (61) 2001 Prolapse and incontinence surgery 224 cases to the serum creatinine. High creatinine levels are diagnostic
*Visco et al. (70) 2001 Cost-effectiveness in hysterectomy * of urine extravasation.
Stevenson et al. (71) 1999 Burch 109 cases
Rieiro et al. (72) 1999 Laparoscopic hysterectomy with 118 cases Intravenous injection of indigo carmine followed by visual
vault suspension monitoring of the suspected fluid collection can also be uti-
Pettit et al. (73) 1994 Major vaginal surgery 236 cases lized if the suspected collection is extracorporal, such as a
Jackson Pratt drain from the peritoneal cavity. If the collec-
* if incidence for ureteral injury is >1.5% in abdominal hysterectomy and 2% in vaginal tion is urine, one can expect for it to turn blue within 8-15
and laparoscopic hysterectomy minutes.

Ultrasound is useful to evaluate for hydronephrosis and CT and

Table 8. Studies do not support intraoperative cystoscopy in gynecological surgery or MRI can also be used to evaluate for urinoma, abscess or
hydronephrosis. IVP may be able to localize the injury (46-49).
Handa et al. (74) 2001 Complex urogynecoloic surgery 157 cases
Gill et al. (75) 2001 Burch 181 cases Large urethral fistulas are usually diagnosed quite simply
Tulikangas et al. (76) 2000 Antiincontinence surgery 347 cases visual examination. Small urethral fistulas may be difficult to
Klutke et al. (77) 1998 Burch 97 cases diagnose and may require a double contrast technique for its
diagnosis. If not recognized at the time of surgery these
patients may present with incontinence.

If there is still uncertainty despite cystoscopy one can consider REPAIR

the retrograde passage of ureteral stents. If the stents pass
easily the ureter can be considered patent. It may be thera-
peutic occasionally relieving a slight kinking of a ureter. An
alternative method of diagnosis is a retrograde uterogram and
if this is unsuccessful antegrade ureterogram may also be con-
sidered. It is important to emphasize that a negative cys-
toscopy or easy ureteral stents passage does not eliminate the
possibility of ureteral devascularization with sufficient necro-
sis and fistula or fibrosis development to result in ureteral
stenosis. Additionally, laparoscopic thermal necrosis, later
resulting in fistula, is not diagnosed with this technique.
REPAIR OF
OF URINARY
URINARY TRACT
TRACT INJURIES
INJURIES
KIDNEY
KIDNEY It is unlikely that a gynecologist will encounter a kid-
ney with the exception of an unrecognized pelvic kidney or
transplanted kidney. Most, if not all injuries to the kidney
should probably be dealt with by a urologist.
URETER
URETER The method of repair of an injury to a ureter depends
on the location and the type of injury as well as the desire to
preserve the obstructed kidney. For the sake of this chapter
we will assume that the operating surgeon would want to pre-
serve the affected kidney, although at times nephrectomy is
the procedure of choice.

70 CME Journal of Gynecologic Oncology 2002; 7:65–77

 Chapter 22

In the event of a needle injury or minor crush injury to the
ureter, one should remove the offending instrument and exa-
mine the ureter. If peristalsis and adequate perfusion are pre-
sent and there is no indication of leaking urine, no additional
management is needed. In the event of an extensive crush
injury or ligation which has been in place undetected, a urete-
ral stent should be placed. These stents should be left for at
least 10 to 14 days after surgery and the ureters should be
evaluated for healing before removal. In the case of ureteral
transection, various types of repair are available depending
on location of injury, integrity of remaining ureter and timing
of the diagnosis (50). General principles of ureteral surgery
include: 1. careful debridement, 2. creation of a watertight,
tension-free, spatulated or fish-mouth anastomosis, and 3.
adequate ureteral and retroperitoneal drainage (51). It is im-
portant to preserve the adventitia in order to maintain good
ureteral blood supply (52).
sue using great care not to destroy its blood supply. A fish-
mouth incision is made on the ureteral end and re-implanted
under direct visualization through the cystotomy The ureter is
passed into the bladder through the cystotomy, the site deter-
mined by the operator’s finger placed inside the bladder push-
ing against the optimal reimplantation site. An incision is
made over the finger and extended through the bladder
mucosa (Figure 2). A curved forceps is then used to bring the
ureter into the bladder. Tunneling the ureter through the
Distal end
of ureter
Wall of
back of
bladder

PRIMARY CLOSURE This method of repair is limited to superficial

lacerations of the adventitia with intact blood flow. A few
interrupted 4.0 or 5.0 absorbable sutures are placed approxi-
mating the ends of the injured adventitia. Care must be taken
to avoid including the underlying muscularis in the sutures. If
the laceration is greater than 1 cm, it should be repaired in the Finger in bladder
same fashion, however, a 7 or 8 French ureteral stent should to identify site for
ureteroneocystostomy
be placed by cystotomy or cystoscopy. The catheter can be
removed about 10 days after insertion. Injuries in which the Figure 2. Identification of the optimal site of ureteral reimplantation using the surgeons
muscularis is interrupted are treated similarly but including finger
the muscularis and mucosa in a single layer of interrupted (From: Lee RA. Atlas of Gynecologic Surgery. Figure 443, page 304. W.B. Saunders,
sutures. Closure is always performed perpendicular to the Philadelphia, Pennsylvania, 1992. Reprinted with permission of the author and publisher.)
length of the ureter.
Five to six sutures, including full
REIMPLANTATION Ureteral reimplantation thickness of ureter and mucosa
or ureteroneocystostomy, can be used Peritoneal flap muscularis of bladder
in the event of transection of the distal
ureter. Most authors define distal
ureteral injuries as either those that
occur in the distal third of the ureter
or as those that occur within 5 cm of
the ureterovesical junction. The B
importance of the distance is that one
must always avoid excess tension on
the reimplanted ureter. The majority
of injuries to the ureter in gynecologic
surgery occur at the distal portion.

Identifying and resecting the damaged Supporting

Cystotomy site sutures of peri-
segment of ureter is first performed A for placement of toneum to outer C
and a non-absorbable suture is used to ureter wall of bladder
ligate the ureteral stump at the blad-
der level. At this point a cystotomy is Figure 3. Attachment of the ureter to the bladder under direct visualization through cystotomy
made. The proximal end of the ureter (From: Lee RA. Atlas of Gynecologic Surgery. Figure 444, page 305. W.B. Saunders, Philadelphia, Pennsylvania, 1992.
is mobilized with its surrounding tis- Reprinted with permission of the author and publisher.)

CME Journal of Gynecologic Oncology 2002; 7:65–77 71

Intraoperative injuries of the urinary tract
Peritoneal flap
over spatulated
ureter
B mucosa
Partially
A cloased
cystotomy
Proposed site of
flap in dome of
bladder
Figure 4. Creation of the bladder flap with reimplantation of the ureter into the bladder
(From: Lee RA. Atlas of Gynecologic Surgery. Figure 447, page 308. W.B. Saunders, Philadelphia, Pennsylvania, 1992. Reprinted with permission of the author and publisher.)
bladder wall is important in children to prevent the long-term
sequelae of vesico-ureteral reflux. In adults this issue is much
less significant and a direct anastomosis is appropriate. The
ureter is secured to the bladder mucosa using 4.0 absorbable
sutures (Figure 3). The ureter is further secured at the blad-
der peritoneum with 3.0 of the same suture. The cystotomy is
then closed in two layers using 3.0 absorbable suture. A
ureteral stent is placed across the anastomosis and an
indwelling Foley catheter or suprapubic catheter decompres-
ses the bladder. The stent is left in place for 10-14 days. Once
the stent is an imaging study should be accomplished at 3 to 6
months to ensure continued patency of the ureter.
PSOAS HITCH In the event that the injury occurs high enough in
the ureter that an anastomosis would result in tension, yet is
still in the distal portion of the ureter, the bladder may be
extended to the injury. One such procedure is called the psoas
hitch. The bladder is freed from the symphysis and the ante-
rior peritoneum extending from the abdominal wall is incised.
One can achieve additional length by closing a horizontal inci-
sion made in the bladder in a vertical fashion. Once adequate
length is achieved, secure the bladder to the tendinous por-
tion of the psoas muscle using 5-6, 2.0 absorbable sutures. At
this point proceed with reimplantation of the ureter to the
bladder as described above.
When a long distal segment of ureter is lost a Boari
BOARI FLAP
flap can often bridge relatively long gaps. Cutting an oblique
flap from the dome of the bladder creates a Boari. The
72
Peritoneal flap to
serosa of bladder Ureteral Closed
catheter cystotomy
Ureteroneocystotstomy
Mucosa-to-
approximation
Closure of
cystotomy
Tied ureteral
C
stump
remaining cystotomy is closed in a vertical fashion extending
the flap up to the ureter. The ureter is anastomosed with the
flap and the remainder of the flap is closed in a tubular fash-
ion. Stents and drains are placed with postoperative IVP’s
recommended (Figure 4).
URETEROILEOCYSTOSTOMY This procedure is useful in the rare case
of an injury in which a very long segment of ureter is lost. In
this case all of the previously described procedures would
result in an excess of tension at the anastomosis site. These
procedures should be used only when absolutely necessary as
they result in a greater risk for morbidity when compared to
the other procedures described (Figure 5).
The ureteroileocytostomy is completed by first isolating and
resecting a segment of the ileum maintaining its mesentery
and blood supply. The remaining bowel is approximated using
an end-to-end anastomosis. The side of the bowel segment
proximal to the ureter implantation remains open until after
the ureter has been fixed to the mucosa of the segment. The
other end of the bowel segment is then anastomosed to the
bladder dome using 3.0 absorbable sutures. Ureteral stents
and drains are placed as with all other procedures and post-
operative follow up with 3 month and 12 month IVP’s is ad-
vised.
KIDNEY MOBILIZATION If while attempting a psoas hitch, one finds
that there is still inadequate ureteral length to complete the
reimplantation, one can consider mobilization of the ipsila-
CME Journal of Gynecologic Oncology 2002; 7:65–77
 Chapter 22

teral kidney. This is accomplished by incising the peritoneum

lateral to the colon, displacing the colon medially freeing the
Ileoileostomy
kidney retroperitoneally and displacing the kidney inferiorly.
It may be necessary to suture the renal capsule in its new loca-
tion to the psoas muscle to maintain the downward displace-
ment (Figure 6).

URETEROURETEROSTOMY If ureteral injury occurs in the proximal

ureter, an uretero-ureteral end-to-end anastomosis may
often be performed. The ureteral edges should be débrided
of any devitalized tissue. Next, spatulate both ends, staying
with the basic principles of ureteral surgery, allowing for a
greater luminal diameter at the anastomosis site. Approxi-
mate the posterior aspect of the two ends of the ureter by Peritoneal flap
placing about three, 5.0 absorbable sutures through the
entire wall of the ureter. Once this is done, place a ureteral Suture closure of
catheter into the lumen of the ureter so that it extends from distal end of ileum
above the anastomosis to the ureteral orifice and into the
Ureteroileostomy
bladder. Continue the re-approximation over the stent.
Finally, place a drain under the anastomosis but be sure that
the drain is not in contact with the ureter as the suction from Ileocystostomy
the drain may create enough negative pressure to facilitate a
leak (Figure 7). The patient should be followed after such a Figure 5. Reanastomosis of remaining ileum and formation of ureteroileocystotomy
repair with imaging studies every three months in order to (From: Lee RA. Atlas of Gynecologic Surgery. Figure 448, page 309. W.B. Saunders,
ensure luminal patency. Philadelphia, Pennsylvania, 1992. Reprinted with permission of the author and publish er.)

Normal location of kidney

Figure 6. Mobilization of the kidney with bladder extension, securing the

bladder to the psoas muscle
(From: Lee RA. Atlas of Gynecologic Surgery. Figure 446, page 307. W.B.
Saunders, Philadelphia, Pennsylvania, 1992. Reprinted with permission of
the author and publisher.)

Peritoneal flap
Mobilized kidney 0 delayed absorbable
suture

0 delayed absorbable
suture

Iliopsoas muscle
B
Tied distal end of
ureter Closed cystotomy

CME Journal of Gynecologic Oncology 2002; 7:65–77 73

Intraoperative injuries of the urinary tract

using 4-0 chromic gut or polygly-

colic acid and intracorporeal knots.
The author’s personal experience
was with 4-0 Vicryl suture and re-
Ureteroureterostomy sulted in an excellent outcome.
Spatulated ureter

Although laparoscopic repair of

ureteral injuries appears to reduce
morbidity when compared to
laparotomy, and have successful
outcomes, a high skill level in
laparoscopic suturing is required to
perform such procedures and long
term follow up in large numbers of
patients are necessary before this
procedure becomes a standard of
care.
Ureteral catheter
BLADDER
BLADDER Needle injuries to the
bladder can usually handled very
A B
conservatively by removing the
needle with no additional treat-
Figure 7. Approximation of the spatulated ureteral ends over a stent with placement of a drain lateral to the incision ment needed.
(From: Lee RA. Atlas of Gynecologic Surgery. Figure 445, page 306. W.B. Saunders, Philadelphia, Pennsylvania, 1992.
Reprinted with permission of the author and publisher.) The tension-free vaginal taping is a
relatively new procedure, offering
a relatively new complication and
Recently, there have been case reports in both the gynecology challenge regarding repair of such an injury to the bladder,
and urology literature of successful repair of ureteral injuries that is perforation of the bladder with a tension-free vaginal
laparoscopically. Such publications demonstrate that just as taping trocar. According to recent publications including
the introduction of new surgical procedures can lead to some multi-center prospective studies, the incidence of blad-
unforeseen complications, it can also
lead to unforeseen benefits (17, 53). Second layer of closure of
In May 2001, Tulikangas and col- cystotomy
leagues (54) published a retrospective
Cystotomy closure
case series in which they followed 4
patients who had undergone laparo-
scopic repair of ureteral injuries for 6-
33 months. They found that no
patients required repeat surgery and
none showed evidence of acute renal
failure (54).
B
The technique used in most cases was Peritoneum covering
first to define the exact location of the cystotomy closure
injury using indigo carmine under Cardinal ligament
direct laparoscopic visualization. A Closed vaginal
First layer of suture lina
After both ends of the injured ureter bladder closing
Clamp on cardinal Cut edge of
were trimmed and spatulated, a 7 vagina
ligament
french ureteral catheter was then
placed retrograde through the ureteral Figure 8. Closure of a cystotomy in two layers
defect aligning both ends of the injury. (From: Lee RA. Atlas of Gynecologic Surgery. Figure 441, page 303. W.B. Saunders, Philadelphia, Pennsylvania, 1992.
Next, both ends were approximated Reprinted with permission of the author and publisher.)

74 CME Journal of Gynecologic Oncology 2002; 7:65–77

 Chapter 22

der perforation secondary to tension-free vaginal taping is

between 0-6 (55). The treatment in all cases was removal of
the trocar and observation with excellent results. Thus, the
treatment for bladder perforation during tension-free vaginal
taping, consistent with manufacturer’s suggestion, is simply
removal of the trocar and observation.

If an injury occurs to the serosa of the bladder only, a simple

running, imbricating 3.0 absorbable suture can be used for
repair. If the laceration penetrates all layers of the bladder,
and does not involve the trigone, the closure should take
place in two layers using an absorbable suture in a running
fashion (Figure 8). If there is any doubt about the potential for
leakage after the closure, sterile milk or Indigo Carmine can
be instilled into the bladder to test for leakage. An indwelling
Foley catheter is usually left in place between 3 and 10 days
after cystotomy repair.
When injuries occur in the trigonal area, interrupted, absor-
bable sutures should be used with careful attention not to
obstruct the ureters or urethra. The patency of the ureters
and urethra should be tested once the repair is completed.
Finally, ureteral stents and an indwelling Foley catheter
should be utilized until healing (56).
As with the ureter, there have been successful attempts at
repair of cystotomy using laparoscopic techniques (Figure 9).
URETHRA
URETHRA Repair of the urethra is undertaken rarely by the
average gynecologist than repair of the other organs dis-
cussed. However, the simplicity with which the urethra can be
repaired in most cases prevents repair of urethral injuries
from being an extremely intimidating experience to most.
Lacerations to the urethra can be repaired with 4.0 or 5.0
interrupted absorbable sutures placed through all layers of
the urethra if the injury penetrates all layers. These patients
should have a Foley catheter inserted during the postopera-
tive period in order to promote healing (57-58).
PREVENTION
PREVENTION OF
OF URINARY
URINARY TRACT
TRACT INJURIES
INJURIES History has taught us
that as pelvic surgeons, the only way to completely avoid
injury to the urinary tract is not to operate in the vicinity of
the urinary tract. As this is not a reasonable alternative, we set
our goals at a more obtainable means of preventive practice.
Whether operating through the laparoscope or a laparotomy,
the basic principles of surgery should apply. Exposure, expo-
sure, exposure and counter traction are probably the four
most important things to remember. In the case of laparos-
copy, this can be affected by the quality of your instruments
and lenses. For example, repeated fogging or poor lighting
can significantly hinder the surgeon’s ability to visualize the
surgical field. Next, it is important to have a thorough under-
standing of the environment in which you work, the anatomy.
Figure 9. Laparoscopic repair of cystotomy using a Cook needle driver
(From: J. Magrina teaching files, Mayo Clinic Scottsdale, with permission.)
Whenever possible, one should practice the same techniques
for laparoscopy as they practice for laparotomy. For example,
if performing a laparoscopic salpingo-oophorectomy, one
should identify the ureter prior to ligating the infundibulo-
pelvic ligament. Just as the most common places of ureteral
injury in an abdominal hysterectomy are at the infundibulo-
pelvic ligament and para-cervical area, so they are in laparo-
scopic hysterectomies.
Some experts advocate preoperative placement of ureteral
stents, both illuminated and simple as well as preoperative
IVP’s. However, these procedures come with their own risks
and costs. Furthermore, the literature has been far from over-
whelmingly in favor of either of these procedures as effective,
cost efficient means of prevention.
A preventive method that is universally accepted is the main-
tenance of a drained bladder during surgery. The decrease in
size of the drained bladder makes it less of a target. In addi-
tion, a deflated bladder is much more difficult to penetrate
than one that is fully distended (59-60).
The author’s favorite rule for limiting morbidity is, “know
when to call for help”. Knowing your limitations and staying
within them is always in the best interest of both the surgeon
and the patient.
CONCLUSION
CONCLUSION It can be expected that with the recent surge in
minimally invasive procedures, there is bound to be a similar
surge in minimally invasive complications that are new and
foreign to practicing pelvic surgeons. In addition, as long as
we operate near the urinary tract, we will continue to have the
more recognized complications. Hopefully, occasionally

CME Journal of Gynecologic Oncology 2002; 7:65–77 75

Intraoperative injuries of the urinary tract
updated review articles, such as this, together with intermit-
tent retraining and refreshing of skills will help limit the com-
plication rates and morbidity in all of surgery. Similarly, such
review articles might help us to better handle such problems
when we are inevitably confronted with them.
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