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Ureteral damage is one of the most common complications of gynecological surgery. Besides ureteral damage, damage of the bladder and rectum are also common during this type of surgery.

The damage of ureters is typically not recognized immediately and has the potential to become life-threatening or to result in permanent kidney damage or removal of a kidney.

What are ureters?

Ureters are a pair of tubes, one on the left and the other on the right side. They carry urine away from the kidneys to the bladder.

How can a ureter get damaged during surgery?

The frequency of ureteral damage following gynecological surgery is approximately one percent, with a higher percentage of damages occurring during abdominal hysterectomies.

The most common mechanisms through which a ureter can get damaged are:

  • Ligation with a suture
  • Resection of a segment of ureter
  • Partial or complete transaction
  • Ischemia from ureteral stripping
  • Ischemia from electrocoagulation
  • Crushing from misapplication of a clamp

Predisposing factors that can lead to ureteral damage during gynecological surgery are:

  • Pelvic inflammatory disease
  • Endometriosis
  • Anatomic anomaly of the urinary tract
  • Ovarian cysts larger than 4 cm
  • Radiation therapy
  • Advanced state of malignancy

How is ureteral damage diagnosed?

If ureteral damage is suspected during surgery, the ureter must be examined in the area of interest. Visualization and direct exploration of the ureter are recommended and a very accurate method of diagnosis. If no urine leak is noted in this case, and when we still suspect ureteral damage, further investigation into the integrity of the ureter is necessary.

This includes the use of Indigo carmine or methylene blue, which are injected in the ureter, bladder or even kidney. The blue-tinged urine helps confirm the damage. Indigo carmine can be also injected intravenously with Lasix (a diuretic that increases the excretion of urine).

Intravenous urography, retrograde urography, ultrasound or CT are used to diagnose the ureteral damage after the surgery.

Signs and Symptoms

  • Prolonged bowel obstruction after surgery
  • Fever and chills
  • Abdominal pain on the affected side
  • Abdominal mass that can be felt
  • Increased number of white blood cells
  • Prolonged drainage from the operative site or vagina
The main problem is that ureteral damages are not identified immediately, mostly when the damage to the ureter and kidneys are permanent. In this case the removal of the kidney is necessary.

Pathophysiology of the ureteral damage

Depending on the location, the extent of the damage, and the time it took to diagnosis, ureteral damage can lead to:

  • Spontaneous healing - if there is minor damage of the ureter, the healing can be complete and without any consequences. This can happen in cases of inadvertent ligation of the ureter.
  • Ureteral stricture - it usually happens when the ureter is electrocoagulated or striped causing the damage of the adventital layer and ureteral blood supply. This leads to urine retention and later hydronephrosis, because urine can't flow normally.
  • Ureteral necrosis - can occur in cases when there is a complete ligation of the ureter, section of the ureter wall or ischemia of the ureter. If not diagnosed on time, it leads to complete damage of the ureteral wall, leakage of urine into the peritoneum, formation of peritoneal abscesses or even peritonitis.
  • Uremia - can occur in cases when the damage of ureter leads to total urinary obstruction. This happens when both ureters are damaged, or when there is only one functional kidney. The sign of total urinary obstruction is anuria (no elimination of urine). This is an emergency, which needs immediate diagnosis and surgical treatment to prevent irreversible damage to the kidneys.

Treatment

Treatment depends on the location, type and extent of damage. It may involve:

  • Removal of the ligature
  • Ureteral resection
  • Ureteral stenting
  • Kidney removal

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