URETERIC INJURY IN OBST ETRICS AND GYNAECOLOGICAL SURGERY AND URINARY DIVERSIONS

Prof. M.C. Bansal. Founder Principal & Controller ; Jhalawar Medical College And Hospital Jhalawar Ex Principal & Controller ; Mahatma Gandhi Medical College and Hospital Sitapura, Jaipur.

OUTLINE

• INTRODUCTION• APPLIED ANATOMY• COMMEN SITES OF INJURY OF URETERS• TYPE OF INJURY OF URETER• PREDISPOSITION• IDENTIFICATION OF URETRIC INJURY• SPECIFIC INJURY• MANAGEMENT• PREVENTION• CLINICAL SCENARIOS• CONCLUSION.

OBJECTIVE

• FUNCTIONAL ANATOMY.

• ISSUES SURROUNDING URETERAL INJURY.

• BASIC PRINCIPLES OF INJURY AVOIDANCE,RECOGNITION AND MANAGEMENT.

APPLIED ANATOMY OF

PELVIC URETER

• The ureters are the muscular ,thick walled narrow tubes(Right and Left)

• Each measures 25-30 cm in length and extends from renal pelvis to its entry in the bladder.

PELVIC URETER

• The ureter are located retroperitonealy and run from the renal pelvic to urinary bladder.

• The abdominal segment lies on the psoas muscle and enter the pelvis by crossing the common iliac vessel from lateral to medial aspect at their bifurcation just medial to ovarian vessel.

• At the level of ischial spines it runs in the broad ligament and enter the ureteric canal formed by the cardinal ligament, crossed by the uterine vessels running anterior to ureter.

• Here, It is 1.5 cm lateral to cervix.

• The ureter runs medially and enter the bladder close to the anterior vaginal wall . On left side it even can cross the vaginal angle . Ureters while running at base of broad ligament ,are also very close to utero sacral ligament.

• The ureter is supplied by : Renal , Gonadal, Common iliac , Internal iliac, vescical Uterine arteries and the Abdominal aorta.

• The venous drainage generally follows the arterial supply.

BLOOD SUPPLY

LYMPHATIC DRAINAGE• Lymph drains into sub mucosal ,intramuscular

and adventitial plexuses ,which all communicates.

INNERVATION• The ureter is supplied from the lower three

thoracic , first lumber and second to fourth sacral segment of spinal cord by branches from the renal and aortic plexuses and the superior and inferior hypogastric plexuses.

INCIDENCE

• 75% ureteric injuries take place during gynaecological procedures.

• Abdominal Hysterectomy is the most common procedure.

• 30% chance of injury during gynaec-oncosurgery.

• 0.5-1% ―Abdominal Hysterectomy.• 0.1 % —Vaginal Hysterectomy.• 9-10%-Wertheim's Hysterectomy

Common sites of ureteric injury

• At the pelvic brim during clamping of infundibulopelvic ligament.

• At the bifurcation of common iliac artery during internal iliac artery ligation.

• Lateral pelvic wall above the uterosacral ligament.

• Base of broad ligament , ureter passes under the uterine artery.

• Ureteric canal-During Wertheim hysterectomy.

• Intramural portion near the insertion into the trigon when base of bladder is injured or repaired.

• Upper vagina during clamping of vaginal angle.

RISK FACTORS FOR URETERIC INJURIES

1. ANATOMICAL RISK FACTORS.

2. PATHOLOGICAL RISK FACTORS.

3. TECHNICAL RISK FACTORS

1.ANATOMICAL RISK FACTORS:

A)THE URETER:

• Has close attachment to the peritoneum.

• Closely related to female genital tract.

• Has variable course.

• Not easily seen or palpated.

2.PATHOLOGICAL RISK FACTORS:

1. Congenital anomalies of ureter or Kidney.2. Ureteric displacement by: Uterine size ≥12 weeks. Prolapse. Tumour{ovarian neoplasm}. Cervical fibroid/Ca. broad ligament swellings(fibroids , incarcirated ovarian tumours or hematomas)3.Adhesions: Previous pelvic surgery. Endometriosis. PID. Extention of carcinomatous indurations in broad ligaments , post irradiation.4.Distorted pelvic anatomy.

3.TECHNICAL RISK FACTORS

• Massive intraoperative haemorrhage.

• Coexistent bladder injury.

• Technical difficulties.

• Inexperienced surgeon.

TYPES{CAUSES}OF INJURYINTRAOPERATIVE• Crushing from misapplication

of a clamp.• Ligation with a suture.• Transection{partial or

complete}• Angulation of the ureter with

secondary obstruction.• Ischemia from ureteral

stripping , LASER or electrocoagulation.

• Resection of a segment of ureter.

• Any combination of these injuries may also occur.

POSTOPERATIVE

• Avascular necrosis following werthiem.

• Kinking-peritonisation of vaginal stump after hysterectomy.

• Subsequent obstruction over:

-Haematoma or -Lymphocele

In ½ OF THE cases URETERIC INJURy is not identified at the time of primary injury during

surgery

ABDOMINAL• Hysterectomy.• Wertheim’s hysterectomy.• Oophorectomy.• Uterine suspension.• Burch colposuspension.• Vesicovaginal fistula repair.

LAPROSCOPIC• Division of adhesions.• Electrocoagulative injury

while uterine arteries are coagulated or ligated.

• Transection of uterosacral ligament.

• Colposuspension• Treatment of endometriosis.• Sterilisation

(electrocoagulation)

PROCEDURE ASSOCIATED WITH URETERIC INJURIES

VAGINAL• Hysterectomy.• Anterior colporrhaphy• Cervical biopsy.• Vesicovaginal fistula

repair.• Culdoplasty

Prevention strategies to reduce the risk of ureteric injuries

• General preventive strategies: Preoperative Intraoperative

• Specific Preventive strategies:

GENERAL PREVENTIVE STRATEGIES

A .Preoperative measure:• Intravenous urogram(IVU).• Ultrasound scan.

• Previous investigations ,can identify ureteric dilatation and disclose anatomical variations.

• Preoperative stenting in conditions of anatomical distortion.

INTRAOPERATIVE PREVENTION

• Surgeon is to constantly and equivocally know where ureter is all times.

• Appropriate operative approach.• Adequate exposure.• Avoid blind clamping and ligature of blood

vessels.• Mobilise bladder away from operative site• Stay outside vascular sheath .• Limit the zone of coagulation to avoid thermal

injury.• Ureteric dissection and direct visualisation.

IDENTIFICATION OF URETER

• The peritoneal reflection anterior to the uterus is incised and the bladder is pushed down with blunt or sharp dissection.

• Pelvic ureter is identified on the medial aspect of the broad ligament during the opening of perivescical and perirectal spaces while performing extended hysterectomy or removing broad ligament tumors.

IMAGING

• No proof that preoperative IVU or CE-CT reduces risk of injury.

• Endometriosis , PID uterovaginal prolapse and previous intra -abdominal surgery are associated with increased prevalence of abnormal IVU finding.

SPECIFIC PREVENTIVE STRATEGIESA}During Abdominal hysterectomy:-

Clamp infundibulopelvic ligament after lifting up the ligament dissection and palpation ,clamp near to the ovary.

-Always clamp{cardinal , Uterosacral} ligaments close to the uterus.

-Never to open vagina unless urinary bladder is dissected down properly and sufficiently.

-Use of intrafacial technique.

SPECIFIC PREVENTIVE STRATEGIES

B}During Vaginal surgery :1. Prevention of ureteric injuries can be achieved by adequate development of vescico-uterine space , by: -Downward traction on the cervix. -Counter traction upward by Sim’s speculum below the bladder.2. All clamp:-Small bites. -Close to the uterus.3. Avoid double clamping of uterosacral ligament.4. Vaginal Oophorectomy should be avoided or done cautiously.5. During anterior colporrhaphy: -Avoid too lateral dissection . -Avoid deep suture :as the distance between needle and ureter in upper vagina ≤0.9 cm.

• C)During laparoscopy:can be achieved by:• -Moving the fallopian tubes away from pelvic

side walls before coagulation.• -The bleeding points at uterosacral ligaments

should be secured with sutures or clips instead of electrocoagulation.

• -In LAVH place stapler or suture across uterine vessels and cardinal ligaments instead of electrocoagulation.

GOOD SURGICAL SKILL

MANAGEMENT

AIM OF MANAGEMENT

• Preservation of function.• Anatomical continuity.

• Decision depends on- Time of detection Extent of injury Site of injury General condition of patient

Upper ureteric injuries

• Primary ureteroureterostomy

• If there is extensive loss of the ureter, autotransplantation of the kidney can be done as well as bowel replacement of the ureter.

STENTING Insert a silicone internal stent

through the anastomosis before closure.

Advantages :1. Maintenance of a straight

ureter with a constant caliber during early healing,

2. The presence of a conduit for urine during healing,

3. Prevention of urinary extravasation,

4. Maintenance of urinary diversion,

5. Easy removal

Ureteric 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

Psoas Hitch Procedure

Upper, Middle, Lower Segments

Laboratory findingsRetrograde Urethrogram

Rule out urethral injury▪ Insert catheter▪ Inflate balloon▪ Inject dye (20 ml, water

soluble)▪ Visualize (X-ray)

Laboratory findingsCatheterization

Hematuria Culture initial

catheterization ▪ Infection

Contra indication▪ bloody urethral discharge

Laboratory findingsCT Scan / Cystogram Check bladder

integrity▪ Catheterize▪ Inject dye▪ Radiograph

imaging▪ X-ray▪ CTS

▪ Drainage Film

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Urinary diversion

• to divert urine from the bladder to a new exit site.

• Usually through a surgically created opening (stoma) in the skin.

Introduction

• Diversion of urinary pathway from its natural path

• Types:– Temporary–Permanent

Indications of permanent urinary diversion

• When the bladder has to be removed• When the sphincters of the bladder & the detrusor

muscle have been damaged or have lost their normal neurological control

• When there is irremovable obstruction in the bladder & distal to that

• Ectopic vescicae• Incurable vescico- vagina fistula

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Indications• Tumour necessitating removal of entire bladder

• Pelvic malignancy

• Birth defects

• Strictures

• Trauma to ureters and urethra

• Neurogenic bladder

• Chronic infection causing severe uretral and renal damage

• Intractable interstitial cystitis and

• Incontinence

Temporary urinary diversion

• Suprapubic cystostomy• Pyelostomy or nephrostomy or

urethrostomy (with indwelling catheters)

Illustration of suprapubic tube placed to aid bladder drainage

Suprapubic Cystostomy

A nephrostomy is a surgical procedure by which a tube, stent, or catheter is inserted through the skin and into the kidney.

Permanent urinary diversion• Uretero - sigmoidostomy• Ileal conduit• Colon conduit• Ileocaecaecal segment• Lowsley’s operation

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Types of urinary diversions

Cutaneous urinary diversions•Ileal conduit (ileal loop)•A 12 cm loop of ileum led out through abdominal wall•Stents used •The space at cystectomy site drained by a drainage system•After surgery a skin barrier and a transparent disposable urinary drainage bag•Constantly drains

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Complications of ileal conduit

• Wound infection • Wound dehiscence• Urinary leakage• Ureteric obstruction• Small bowel obstruction • Ileus• Stomal gangrene• Narrowing of the stoma• Pyelonephritis • Renal calculi

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Cutaneous Ureterostomy…

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Vescicostomy

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Nephrostomy…

Uretero- sigmoidostomy

• Complications:– Reflux of urine– Hyperchloraemic acidosis– Renal infection– Stricture formation

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Continent Urinary Diversions

• Continent Ileal Urinary ReservoirIndiana Pouch• Most common continent urinary diversion• Periodically catheterized Koch PouchCharleston PouchUreterosigmoidostomy • Voiding occurs from rectum

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Koch Pouch II

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ureterosigmoidostomy

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Potential complications

• Peritonitis due to disruption of anastomosis

• Stomal ischaemia and necrosis due to compromised blood supply to stoma

• Stoma retraction and separation of mucocutaneous border due to tension or trauma

Bladder reconstruction

Recto sigmoid pouch

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Nursing process : The patient undergoing urinary diversion surgery

Preoperative assessment :• Cardiopulmonary assessment• Nutritional assessment • Learning capacity assessment Preoperative nursing diagnosis• Anxiety• Knowledge deficitPreoperative planning and goals• Relief of anxiety• Ensuring adequate nutrition• Explaining surgery and its effects

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Nursing Management• In the immediate postoperative period urine volumes are

monitored hourly• An output below 30 ml/h dehydration or obstruction• Promote urine output – a catheter may be inserted through

urinary conduit• Provide stoma and skin care – consult with enterostomal

therapist• Skin care specialist consulted• Stoma looked for color – dark purplish –blood supply

compromised• Skin inspected for irritation • Bleeding • Wound infections

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Postoperative nursing interventions

• Monitor urinary function• Prevent complications

infection, sepsis, respiratory, complications, fluid and electrolyte imbalances, fistula formation.

• Ryle’s tube aspiration • Ambulate quickly• Maintain peristomal integrity• Relieve pain• Improve body image• Exploring sexuality issues• Treat peritonitis• Look for stomal ischaemia and necrosis• Look for stomal retraction and separation

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• Neomycin, kanamycin

• Immediately after operation – catheter in rectum – to prevent reflux into ureters and infection of the newly formed ureteric opening into the intestines

• Monitoring fluid and electrolytes : intestinal mucosa absorb urine water and electrolytes; diarrhoea due to potassium and magnesium; maintain the balance. Pt advised to empty the rectum every 2 hours to ↓ build up of pressure and thereby the absorption of urinary salts

• Retrain the rectum – special sphincteric exercises – learn the differentiate between the need to defaecate and the need to urinate

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• Promoting dietary measures – avoid chewing gum, smoking.

• Salt intake restricted to prevent hyperchloremic acidosis. Potassium increased to make up for potassium lost in acidosis

• Monitoring and managing potential complications : - pyelonephritis due to reflux of bacteria from rectum – long term antibiotics – late complication due to irritation - adenocarcinoma

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Managing ostomy appliance

• Empty the pouch when 1/3 full to prevent weight pulling down

• A small amount of urine is left to prevent collapse of the bag against itself

• The collecting bottle and tubing is rinsed with cold water daily and once in a week with a 3:1 solution of water and white vinegar

• Continuing care – look for metastases

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• Look for leakage of urine from the appliance

• Urine pH is kept below 6.5 by administration of ascorbic acid

• Appliance to be fitted properly to prevent skin from getting irritated by urine

• If the urine is foul smelling C&S done

• Ileal conduit – mucosa – mucus produced – urine gets mixed with mucus – patient encouraged to take lot of fluid to wash out the mucus.

• Appliances : reusable or disposable

• Skin barrier used to protect skin from urine

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Promoting home and community care

• Teach patients self care

• Control odour : food that gives odour to urine avoided e.g. Cheese, eggs

• Deodorizers or dilute white vinegar introduced into the drainage bag

• Ascorbic – acidifies – suppresses odour

• Aspirin introduced into bag to deodorize may cause ulceration of the stoma

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• Home and community care

• Teaching self care

• Continuing care

Future aspects

1. More than 40 variants of continent diversion, no single best technique

2. Which bowel segment ?3. Which continent technique ?4. Which anti-reflux technique ? Only long term follow up can answer these

questions