Iatrogenic Ureteral Injury

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Iatrogenic Ureteral Injury

• 75 of ureteral injuries occur during gynecologic
  surgery
• 0.4 to 2.5 for benign disease
• Only 1/3 recognized at time of surgery

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Ureteral Anatomy

• Lies Anterior to psoas
• Crosses over the iliacs
• Rt. over external
• Lt. Over common
• Crossed anteriorly by the gonadal vessels

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Ureteral Blood Supply

• Unique
• Renal, ovarian, common iliac, and aorta
• Abdominal ureter receives its blood supply from
  the medial side
• Pelvic ureter receives its blood supply from the
  lateral side

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Common Sites of Ureteral Injury
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Risk Factors for Ureteral Injury

• Most cases do NOT have an identifiable risk
  factor
• Disruption of normal anatomy
• Endometriosis, ovarian masses, Inflammation
  (Diverticulitis, PID)
• Pelvic malignancy present in 44 of cases
• Previous pelvic surgery
• Pelvic radiation

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Ureteral Injury Repair

• Depends on cause, location, and extent
• Minor trauma (ligature or crush) may be managed
  with stent and drainage
• Partial transection corrected with suture repair
  or resection
• Lower third
• Primary ureteroureterostomy (ligation)
• Bladder tube flap (Boari flap)
• Transureteroureterostomy (extensive urinoma or
  pelvic infection
• Procedure of choice Psoas Hitch

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Psoas Hitch Procedure
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Ureteral Injury Repair

• Mid Ureter
• Primary ureteroureterostomy
• Transureteroureterostomy
• Upper Ureter
• Autotransplant kidney
• Transposition of bowel

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