Tips Menghindari

Injury pada Ureter

Like an Urologic Surgeon

Kuncoro Adi,SpU(K)
Trauma & Reconstructive
Departemen Urologi
AMC Hasan Sadikin Hospital – PadjadjaranUniversity,
Bandung, 2021
Greeting from Bandung, West Java-Indonesia
Malaysia
AMC Hasan Sadikin Hospital-
Singapore Padjadjaran University
• Most populated province in
Indonesia (48 mil of 270 mil)
• Government Teaching
Hospital
• 928 beds
• Reconstructive referral center
for western part in Indonesia
• JCI accredited
• NO-DISCLOSURE
@kuncoro202 Email: kuncoro202@gmail.com
Tips Menghindari Injury pada Ureter
Like an Urologic Surgeon

We are very intimate

neighbors
BUT we have different
GOAL
Tips Menghindari Injury pada Ureter
Like an Urologic Surgeon
OBGYN
TRY TO AVOID THE DEER

Urology
 WE TRY and MUST HIT THE DEER
In This Presentations

• Epidemiology
• Avoiding Ureteral Injury
• Intra operative recognition
• Post operative suspicion and recognition
Missed diagnosis
Delayed diagnosis
ANOTHER COUNTRY NUMBER
Ureteral Trauma- a review of recent Guideline
•EUA Urological Trauma – 2020
•AUA Urotrauma Guidelines – 2018
•Ureteral Trauma :
 Incidence is 0,2 – 1 % of OBGYN operations
 50% - 82% of all ureteral trauma during obstetric-gynecologic
surgery
 One third were recognized at the time of surgery
 Iatrogenic : By far the majority
Various mechanism: Inadvertent clamping and ligation, partial/complete
transections, thermal injury or ischemia from devascularization
 WHAT ABOUT US ???
INDONESIAN PEOPLE
• Indonesian number ??
• Paucity of Indonesian Cases?
• RSCM : 5/1425 (1969-1972)*
• 0,2%-0,9% (Oetama: 1970-1975)**
• 2/15 from 1223 (Mendrova, 1992-1997)***
• Present Time?

*Samil, KOGI II Surabaya. 1973 **Ihsan Oetama, Tesis, Jakarta.1976***Cavinus M, Tesis Semarang.2000
OUR EXPERIENCES

Iatrogenic ureteral injury

due to gynaecologic
surgery (2013-2019) :
92.5% (50/54)
Incidence of iatrogenic
ureteral injury due to
OBGYN operation : ???
Ureteral Injury

4 basic groups :
• Laceration and
excision
• Sutures and
ligatures
• Crush injuries
• Devascularizations
Risk Factors for
Ureteric Injury
• An enlarged uterus
• Previous pelvic surgery
• Ovarian neoplasma
• Endometriosis
• Pelvic Adhesions
• Distorted pelvic anatomy
• Intraoperative hemorrhage
• Radical hysterectomy
• history of pelvic irradiation

 Consider pre Op IVU-CT and ureter stenting in selected

cases
 Some cases we knew it will be unavoidable injury
Pre Op Urological consultation will be advised
Anatomical Considerations and Risk Factors
• Pelvic surgeon must become familiar with anatomical
• Anatomical change due to pathological variants
50 % - 75 % ureteral injuries reported
during gynaecologic surgery have
occurred in the absence of
recognizable risk factors.1,2,3
 uncomplicated, routine, and
normal pelvic anatomy

1. Liapis et all, Int Urogyn J.2001;12:391-394

2. Chan et all, Am J Obstet Gyn.2003;188:1273-1277
3. Symmonds, Clin Obstet Gyn.1967;19: 623-644
Preventing Ureteral Injury &
Complications
• Anatomical considerations
• Risk Factors
• Intra operative identification and exposure
 The best way to prevent
• Intra operative recognation of ureteral injury
 Better outcome of ureteral reconstruction
• Post operative clinical evaluation
 Missed and delay ureteral injury :
- Ureteral recon  more difficult
- Success rate of recon  decreased
- Organ (kidney) preservation ???
- Mortality
- Patient’s Cost
 Intra operative identification and exposure
 The best way to prevent and minimized the change of ureteral injury
• Anatomical of ureter :
- Retroperitoneal organ  explore the retroperitoneal
- anterior or posterior approach depend on surgeon preference
• WE, Urologist :
- We want to HIT the deer
 we open the retro
- We want to COOK and EAT the deer
 we open the retro and do direct visualization of the ureter
 Preserve adventitia layer during ureteral dissection
 short application of diathermy in periureteral/ureteral area
• In order to avoid BLIND :
- ligation or entrapped in a sutures
- crushing by clamp
- made a complete or partial resection
- devascularization tissue or diathermy-related injury Lighted Ureteral Stent
 We can maintain constant awareness of ureter, mobilized and
visualized the ureter when in any doubt.
Intra Operative High Awareness
of Making Iatrogenic Ureteral
Injury

• One third were recognized at the time of surgery

- missed and delay diagnosis mostly
• Open explore retroperitoneal when in any doubt
• Seek early urological assistance where appropriate
• Abdomino-pelvic drain
• Missed diagnosis have better outcome >< Delayed
diagnosis

 Better outcome for the patients and surgeons

Post Operative Period with
High Awareness of making
iatrogenic ureteral injury

• One third were recognized at the time of surgery

- missed and delay diagnosis mostly
• Flank pain, fever, abdominal distention, prolong ileus
 Should raise the suspicion for urinary extravasation
• Persistent abdomino-pelvic drain
• Anuria in bilateral case
• US, IVU/CT Uro
Take Home Messages

• Appropriate approach and adequate exposure

• Maintain constant awareness of the location of the ureter,
mobilize and visualize the ureter in any doubt.
• Avoid blind under running of the bleeding areas
• Short applications of diathermy near the ureter
• Seek early urological assistance where appropriate
• Put abdomino-pelvic drain if you in doubt
• Post Operative Period with High Awareness of making
iatrogenic ureteral injury
TERIMA KASIH NEIGHBORS