Pelvic ureter

PELVIC URETER&

PREVENTION OF URETERIC INJURIES

Retropritoneal spaces

The retroperitoneal space of pelvic side walls contains:

• Pelvic ureter• Internal iliac vessels• Pelvic lymph nodes• Obturator nerve

The pelvic ureter

• Total length of ureter is 25-30 cm• Abdominal & pelvic portions are almost equal

in length.

Abdominal & pelvic portions are almost equal in length, 12-15 cm

Course & Relations

Structure

From outside inwards1. Fibres derived from the visceral layer of the

pelvic fascia2. Muscle coat: Outer: longitudinal

Intermediate: circular Inner : longitudinal

3. Mucous layer : lined by Transitional epithelium

Ureter is comparatively constricted at1. Where it crosses the pelvic brim2. Where it is crossed by the uterine vessels 3. In the intravesical part

Blood supply

• Segmental blood supply from nearly all the visceral branches of the anterior division of the internal iliac artery.

• Venous drainage corresponds to the arteries.

Lymphatics

• The lymphatics from the lower part drain into the external & internal iliac lymph nodes.

• The upper part into the lumbar lymph nodes.

Nerve supply

Sypathetic supply from: Hypogastric & Pelvic plexus

Parasympathetic supply from:Sacral plexus

Development

Ureter is developed as an ureteric bud which arises from caudal end of mesonephric duct.

Ureteric injuries

• Overall incidence is 0.5 – 1 % of all pelvic operations

• Incidence varies from 0.4 – 2.5 % for benign conditions as reported in different studies, but it can be as high as 30% in operations for malignancies

• About 75 % of ureteric injuries occur during an abdominal gynaecological surgeries with incidence 0.5 – 1 % for abdominal hysterectomy, compared to 0.1 % for vaginal hysterectomy.

Sites vulnerable to injury1. At the pelvic brim during ligation of

Infundibulo-pelvic ligaments.2. At the base of the broad ligament, where it

passes beneath the uterine arteries.3. As it passes through it’s tunnel in the cardinal

ligaments.4. Along the course on lateral pelvic wall just

above the uterosacral ligaments.5. At the anterior fornix of vagina as it enters the

bladder.

6. Where it traverses through the musculature of bladder (Intra vesical part).

7. Lateral pelvic side wall over the iliac vessels during lymph node dissection.

8. Any congenital malformation eg. Duplex ureter makes it more vulnerable to injury at any of these sites.

Nature of ureteral injury1. Simple kinking or angulation; obstruction2. Ischaemic injury resulting from trauma to

ureteric shaeth endangering its blood supply.3. Ligation with suture.4. Crushing injury by clamps.5. Transection - partial or complete6. Segmental resection - Accidental or planned.7. Thermal injury, during laparoscopic surgeries.8. Injury by staplers.

Gynaecological procedures associated with ureteric injuries

Abdominal• Hysterectomy• Wertheim’s hysterectomy• Oophorectomy• Uterine suspension• Vesicovaginal fistula repair

Vaginal• Hysterectomy• Anterior colporrhaphy• Vesicovaginal fistula repair• Cervical biopsyLaparoscopic• Hysterectomy• Colposuspension• Treatment of endometriosis• Sterilisation (especially electrocoaguation)

• Goodno JA, Powers TW, Harris VD. Ureteral injury in Gynaecologic surgery: a ten year review in a community hospital. Am J Obstet Gynecol 1995; 172: 1817-1822

• Liapis A, Bakas P, Giannopoulos V, Creatsas G. Ureteral injuries during gynaecological surgery. Int Urogynecol J 2001; 12: 391-394

Significantly pelvic malignancies were present in 44 %.a/w dense adhesions, large masses displacing the ureter & anotomical changes distorting the course of the ureter.

However it should be noted that half of all the ureteric injuries had no identifiable risk factors & occur in so called ‘simple hysterectomy’

Distortion of pelvic anatomy

1. Cervical fibroid or low corporeal fibroid2. Broad ligament tumours/ fibroids3. Pelvic endometriosis4. Large ovarian masses5. PID6. Gynaecological malignancies

7. Prev. pelvic surgery 8. Pelvic haematoma9. H/o pelvic irradiation10.Ovarian remnant (when needs removal)11.Congenital abnormalities like ureteric

duplication, mega-ureter, ectopic ureter or kidney.

Prevention of ureteric injuries

Preventive measures:• Pre operative intravenous urography• Placement of ureteric catheters.• Uriglow – ureteric catheters with incorporated

light source.

Abdomino pelvic surgery

• Adequate exposure• Most important axiom of surgery:

Any imp structure at risk of inadvertent injury must be carefully dissected & adequately exposed.

• To avoid blind clamping of blood vessels.• To not damage the shaeth of ureter; longitudinal

vessels• Recognised by Pale glistening appearance,

longitudinal vessels on surface, peristalsis.

1. Divide the round ligament near the lateral pelvic side wall, then open the lateral peritoneum 10-15 cm in a cephalad direction.

2. Place an index finger on the external iliac artery,3. By moving the finger upward (cephalad), the first

structure to be exposed, crossing & in contact with the iliac artery, will be the ureter.

4. As the index finger is placed on the ureter, the infundibulopelvic lig. should be behind the middle phalanx, can be safely clamped with the ureter clearly visible.

5. Followed towards the cardinal lig. where it passes under the uterine artery; Push laterally & downward moving it away from cervix.

Vaginal surgery• To develop an adequate vesico-uterine space• To clamp, cut & ligate only small bites of

paracervical & parametrial tissue• In post. culdoplasty ligation of uterosacrals to

support vaginal apex after the uterus is removed can kink or obstruct the ureters if not done carefully.

• Ant. colporrhaphy: Not to start too laterally or to insert deep sutures;distance between needle & ureter in upper third of vagina is only 0.9 cm (Hofmeister’s fluroscopic findings)

Laparoscopic surgery

• Retroperitoneal dissection to locate ureters• Electrocoagulation of bleeding points around

the uterosacral ligaments is risky, might better done with clips, sutures.

• Sometimes width & length of the stapler makes safe application difficult; uterines,cardinals pedicles are better ligated vaginally.

Medicolegal considerations• The first step in risk management & prevention

of litigation is at the initial consultaion for operation.

• The necessity & risks associated with the procedure to be performed should be discussed in detail with the patient & properly documented In case notes.

KEY POINTS FOR CLINICAL PRACTICE• Thorough knowledge of the anatomy of the

ureter is must & to be aware of the sites where it is liable to be injured.

• Preop intravenous urography or stent placement has not been shown to decrease the incidence of ureteric injuries.

• A high index of suspician & early investigations are necessary for diagnosis.

• Early diagnosis & management will reduce postoperative morbidity & save renal loss.

• Timings of repair should be individualised,as no difference in outcome in early & late repair.