URETERIC INJURY PPT2 corrected_073603.pptx

Management of iatrogenic bladder and ureteric injury

1. URETERIC INJURIES IN GYNAECOLOGY BY DR OCHULOR H.E 22/1/2016 Ureteric injuries in gynaecology 1

2. OUTLINE Introduction Epidemiology Relevant anatomy Risk factors Types of injuries Classifications Signs and symptoms Management Complications Prevention Medico legal considerations conclusion 22/1/2016 Ureteric injuries in gynaecology 2

3. INTRODUCTION Ureteral injury is one of the most serious complications of gynaecological surgery. Less common than injuries of the bladder or rectum. It’s rare in obstetric and gynaecological practice but when it occurs, it has serious implications in terms of both morbidity and litigation. 22/1/2016 Ureteric injuries in gynaecology 3

4. Epidemiology 0.2 to 1% of all pelvic operations It is mostly not recognised and reported 70% recognized post operatively Ureteric injury accounts for 17% of non-obstetrical legal actions are initiated against obstericians and gynaecologists(RCOG) LUTH,TAH...75% of ureteric injury.(Tijani, Afolabi, Onwuzurigbo, Akanmu..2011) 22/1/2016 Ureteric injuries in gynaecology (9 4

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6. Relevant Anatomy Embryology At 4-5wks…Ureter is developed as an ureteric bud which arises from the caudal end of mesonepric duct .The bud grows laterally and invades the center of the metanephric blastema, the primordial renal tissue. 22/1/2016 Ureteric injuries in gynaecology 6

7. Embryology(Contd) The metanephrogenic blastema forms glomeruli, proximal tubules and distal tubules. The ureteric bud divides into branches forming the renal pelvis, infundibulae, calyces, and collecting tubules which will provide a conduit for urine drainage in the mature kidney--The induction of the kidney. 22/1/2016 Ureteric injuries in gynaecology 7

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11. Relevant Anatomy 3 Layers-Transitional -Smooth muscle -Adventitious sheath 25-30 cm. length -Abdominal-> 12-15cm. -Pelvic-> 12-15cm. 22/1/2016 Ureteric injuries in gynaecology 11

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14. Relevant Anatomy Blood supply Segmental blood supply from nearly all the visceral branches of the anterior division of the internal iliac arteries Upper segment-Renal and Ovarian arteries. Middle segment-Directly from aortic branches and common iliac arteries Lower segment-Uterine, vagina, middle heamorrhoidal, vesical, hypogastric arteries 22/1/2016 Ureteric injuries in gynaecology 14

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17. Relevant Anatomy Venous and Lymphatic drainage Venous drainage corresponds to the arteries. Sympathetic supply- Hypogastric and pelvic plexus Parasympathetic-Sacral Plexus 22/1/2016 Ureteric injuries in gynaecology 17

18. Relevant Anatomy Course of the ureter Abdominal and Pelvic part Abdominal :Lies on the anterior surface of the psoas muscle,crosses over the common iliac vessels to the pelvic inlet They are crossed anterioly by the ovarian vessels as they approach the pelvis. B.Pelvic part:deep in the pelvis,the ureter passes under the uterine artery approx 1.5cm lateral to the cervix at the level of the internal os. 22/1/2016 Ureteric injuries in gynaecology 18

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20. Relevant Anatomy Possible sites of Injury At the pelvic brim during ligation of infundibulo-pelvic ligaments At the base of the broad ligament,where it passes beneath the uterine arteries As it passes through it’s tunnel in the cardinal ligament. As it passes its course on lateral pelvic wall just above the uterosacral ligaments. At the vagina vault as it enters the bladder. 22/1/2016 Ureteric injuries in gynaecology 20

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22. Relevant Anatomy Possible sites of injury (contd) 6.Where it transverses through the musculature of bladder(Intra vesical part) 7.Lateral pelvic side wall over the iliac vessels during lymph node dissection 8. Congenital malformed ureter e.g Duplex ureter. 22/1/2016 Ureteric injuries in gynaecology 22

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24. COMMON SITES OF INJURY 22/1/2016 Ureteric injuries in gynaecology 24

25. RISK FACTORS Huge pelvic mass Previous Pelvic surgeries Pelvic adhesions Endometriosis Gynaecological malignancy Distorted pelvic anatomy Congenital malformations Massive Intraperitoneal Haemorrhage 22/1/2016 Ureteric injuries in gynaecology 25

26. Types of Ureteric injury Ligation with a suture Crushing by clamps Transection(complete or partial ) Simple kinking or angulation Diathermy related injuries Segmental resection(accidental or planned) Thermal injury during laparoscopic surgeries. Loss of blood supply during devasularization..Ureteral stripping 22/1/2016 Ureteric injuries in gynaecology 26

27. TRANSECTION 22/1/2016 Ureteric injuries in gynaecology 27

28. CLASSIFICATION According to Organ Injury System developed by the Committe of the American Association for Surgery and trauma, ureteric injuries can be classified as follows… Grade 1..Heamatoma,contusion or heamatoma without devascularisation Grade 11.. Partial Laceration;<50% transection Grade 111..Laceration;>50% transection 22/1/2016 Ureteric injuries in gynaecology 28

29. CLASSIFICATION Grade IV : Transection with <2cm of devascularization Grade V : avulsion with >2cm of devascularisation This anatomical classification however does not appear to have clear prognostic implication. 22/1/2016 Ureteric injuries in gynaecology 29

30. ABDOMINAL HYSTERECTOMY High risk area : -Lateral to uterosacral ligaments -ureter crosses d uterine artery -tunnel of Werthiem Tunnel of Wertheim-space just beneath the uterine artery,1-2cm lateral to the isthmus of the uterus , immediately lateral to the uterosacra l ligament -termination into the bladder 22/1/2016 Ureteric injuries in gynaecology 30

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32. Myomectomy Massive Uterine fibroid or cervical fibroid protruding into broad ligament: -Ureter may be anterior, lateral or posterior. 22/1/2016 Ureteric injuries in gynaecology 32

33. Complex Adnexectomy High risk area: -Ureter; between the Pelvic brim & Tunnel of Wertheim . 22/1/2016 Ureteric injuries in gynaecology 33

34. Caesarean hysterectomy Bloody environment Distorted uterus Many prefer sub total hysterectomy to avoid ureteric injury 22/1/2016 Ureteric injuries in gynaecology 34

35. Ureteral injury associated with laparoscopy Thermal injury to ureter is common More likely to be diagnosed 2-5 days after surgery High risk area: -Where Uterine vessels are stapled or electrocoagulated -Where the infundibulopelvic ligament is transected(pelvic brim) -At the uterosacral ligaments. 22/1/2016 Ureteric injuries in gynaecology 35

36. Vaginal hysterectomy Ureteric injury is relatively uncommon Traction on the cervix pulls the uterus farther from the ureter. Culdoplasty-Places ureter at risk Prevention; Palpatory ureteral identification Placing an allis clamp on the vagina cuff in the area of uterosacral ligament. 22/1/2016 Ureteric injuries in gynaecology 36

37. Radical pelvic surgery The more radical the surgery more likely the ureter can be injured 22/1/2016 Ureteric injuries in gynaecology 37

38. Symptoms(Post –op) Unilateral cramping Fever Flank pain Unusual delay of return of bowel function Abdominal distension Watery vagina discharge Haematuria Anuria(1 st clinical sign of bilateral ureteral injury) 22/1/2016 Ureteric injuries in gynaecology 38

39. Signs Unexplained pyrexia, Paralytic illeus/peritonitis Ascites Frank urine in drain / vagina / abdominal incision site Retroperitoneal urinoma. 22/1/2016 Ureteric injuries in gynaecology 39

40. Management Multidisciplinary Principles of management guided by - Timing of diagnosis -Type of injury -Length of injury -Location of injury -Extent of causative operation -Condition of woman 22/1/2016 Ureteric injuries in gynaecology 40

41. Management History Examination Investigation Surgical treatment 22/1/2016 Ureteric injuries in gynaecology 41

42. INVESTIGATION FBC/Diff...Leucocytosis E/U/CR…Rise in creatinine Renalultrasound( bestnon -invasive)- hydronephrosis..sensitivity IVU..Best imaging study Ureter continuity, function of ipsilateral kidney &drainage of ureter. Abdominal and pelvic computerized tomography scan. Regrograde ureteropyelogram.. cystoscope+ cystografin dye under fluoroscopy) 22/1/2016 Ureteric injuries in gynaecology 42

43. INTRAOPERATIVE DIAGNOSIS Only 1/3rd of the ureteric injuries are diagnosed intraoperatively Intraoperative: Directly visualisation Extravasation of urine Proximal ureter may be dilated if obstructed distally DYETEST:methyleneblue(5-10mls)/Phenazopyridine HCl( pyridium ) Extravasation within 3-5min. 22/1/2016 Ureteric injuries in gynaecology 43

44. Management Surgical management Immediate Delayed If the diagnosis of injury to the ureter is already delayed,repair should not be delayed,Unless Sepsis Extensive hematoma Abscess formation Hemodynamic instability Coagulopathy In these cases, percutaneous nephrostomy tube/ stent should be inserted & when resolves then definitive surgery to be done. 22/1/2016 Ureteric injuries in gynaecology 44

45. Management Surgical therapy; Removal of ligature Ureteral stenting Ureteral resection and ureteroureterostomy Transureteroureterostomy Ureteroneocystostomy 22/1/2016 Ureteric injuries in gynaecology 45

46. Management Ureteral ligation ..if a clamp or ligature constricts the ureter, this should be removed immediately,ureter examined,if peristalsis is preserved,minimal damage has occurred.conservative management. Ureteric stenting with or without ureterotomy …done cystoscopically when there’s partial transection of the wall of the ureter.. - acts as structural backbone for the ureter - removed 6wks after placement 22/1/2016 Ureteric injuries in gynaecology 46

47. Stent used in ureteric injuries 22/1/2016 Ureteric injuries in gynaecology 47

48. Management Ureteral resection and ureteroureterostomy ..done in extensive ischaemia or necrosis of the ureter, the injured segmant can be excised and ureter re- anastomose to established flow of urine -If injury is above the pelvic brim. 22/1/2016 Ureteric injuries in gynaecology 48

49. Management Transureteroureterostomy(TUU )- Used when a surgeon wants to avoid the pelvis because of previous trauma, surgery and radiation therapy A urinary reconstruction technique that is used to join one ureter to the other across the midline. It offers patients with distal ureter obstruction an option to live without internal urinary stent. 22/1/2016 Ureteric injuries in gynaecology 49

50. Transuretouretostomy 22/1/2016 Ureteric injuries in gynaecology 50

51. Management Ureteroneocystostomy ;(Re-implantation of the ureter into the bladder). .Difficult to perform.Done if injury is below the pelvic brim(Lower 3 rd of the ureter) a.where visualization of ureter is difficult b. the vesical pedicles overlie the ureter 2 Types; Psoas hitch and Boari’s flap

52. Ureteroneocystotomy 1. Psoas hitch(success rate >85%) 2.Boari’s flap; a tube of bladder tissue constructed to replace the lower third of the ureter when this has been destroyed or damaged or has to be removed because of the presence of a tumour. 22/1/2016 Ureteric injuries in gynaecology 52

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54. PRINCIPLES OF URETERIC REPAIR Meticulous dissection of the ureter preserving ureteric sheath with its blood supply Mobilise the Ureter in a tension free manner Use minimal amount of fine absorbable suture to attain water tight closure Use of peritoneum/omentum to surround the anastomosis 22/1/2016 Ureteric injuries in gynaecology 54

55. PRINCIPLES CONT’D Passive drain to drain anastomotic sites and prevent urinary accumulation Stent the anastomotic site with urethral catheter Consider the proximal diversion- Percutaneous Nephrostomy tube(urinary diversion) (if defect is large/complete transection/ureter lies in bed of inflammation/sepsis/abscess/unfit for surgery) 22/1/2016 Ureteric injuries in gynaecology 55

56. Principles (contd) 22/1/2016 Ureteric injuries in gynaecology 56

57. Percutaneous nephrostomy tube 22/1/2016 Ureteric injuries in gynaecology 57

58. Complications When injury is minimal – Spontaneous resolution with subsequent healing. With complete obstruction… Hydronephrosis &loss of renal function In transection due to ureteral necrosis with urinary extravasation–urinary ascites-Urinoma. Fistula formation Uraemia Death 22/1/2016 Ureteric injuries in gynaecology 58

59. Complications following surgery for ureteric injury Strictures Excessive drainage Stent and nephrostomy related problems Urinary tract infection Ureteric obstruction or reflux Boari flap complication Heamatoma Wound infection 22/1/2016 Ureteric injuries in gynaecology 59

60. Prevention Preoperative assessment Intraoperative 22/1/2016 Ureteric injuries in gynaecology 60

61. Prevention(contd) Preoperative Proper identification of patients who are at risk of ureteric injury Adequate preoperative investigation Review by multidisciplinary team (Urologist, General surgeons, Nephrologist, Anaesthetist) 22/1/2016 Ureteric injuries in gynaecology 61

62. Prevention Intraoperative Appropriate operative approach Adequate exposure Liberal use of suction, abdominal packs to clear operative field Direct visualization, avoid blind clamping of vessels, always locate the ureter Reflect uterovesical peritoneum and mobilise bladder away from operative site Short diathermy application 22/1/2016 Ureteric injuries in gynaecology 62

63. Prevention Intraoperative (contd ) If not visualized, retroperitoneal dissection. Cauterize or laser with extreme caution near the ureter (clips & sutures are better choices),the area covered by cautery(usually 5 mm.) 22/1/2016 Ureteric injuries in gynaecology 63

64. Prevention Intraoperative (contd) Dissection through the space of Retzius (bladder &pubic bone) should be under direct visualization. Lateral paravaginal tissue dissection should be as minimum as possible. Marked lateral mobilization of bladder must be avoided. Urethrovesical junction should not be elevated so high 22/1/2016 Ureteric injuries in gynaecology 64

65. MEDICOLEGAL considerations Ureteric injuries are the most common cause of litigation in gynaecological surgeries. High index of suspicion should be kept in mind. To prevent litigation, any difficulty encountered intra-operatively should be properly documented &well explained, especially stating visualization of the ureter. Any suspicion of ureteric injury should be investigated and managed properly. Post op patients should have followup in both urology & gynaecological units. 22/1/2016 Ureteric injuries in gynaecology 65

66. CONCLUSION Ureteric injury is an uncommon but potentially serious complication of abdominal and pelvic surgery. Morbidity and mortality from this complication can be prevented, by proper pre op assessment and cautious intra operative techniques 22/1/2016 Ureteric injuries in gynaecology 66

67. Conclusion cont’d Anticipation and high index of suspicion, early urological referral and appropriate investigation of suspected ureteric injury is also of high importance. The surgeon has the responsibility to ensure that the patients are properly selected, pre and post operative events are meticulously documented. 22/1/2016 Ureteric injuries in gynaecology 67

68. Conclusion Venial(forgivable)sin is injury to the ureter but the mortal(deadly) sin is failure of recognition’---Dr HIGGINS. 22/1/2016 Ureteric injuries in gynaecology 68

69. REFERENCES Tijani K H, Onwuzurigbo K I, Ojewola R W, Afolabi B B , Akanmu N O. Iatrogenic ureteric injuries in a nigerian teaching hospital - experience in the last decade: Ajol, Vol 88; 9(2011) Sandip P V, Ramond RR. MD. Ureteral Injury During Gynecologic Surgery: Medscape,2015 Michael A P, Kris S, Abbey HD. Preventing and recognizing urinary tract injuries in pelvic surgery: Contemporary OB/GYN(2010) Swati J, Aravinthan A, Coomarasamy A, Kiong KC. Ureteric injury in obstetric and gynaecological surgery:Togonline, vol 6;203–208(2004) Berkmen F, Peker A E, Alagol H, Ayyildiz A, Arik A I, Basay S. Treatment of iatrogenic ureteral injuries during various operations for malignant conditions. J Exp Clin Cancer Res 2000; 19:441–5. Assimos D G, Patterson L C, Taylor C L. Changing incidence and etiology of iatrogenic ureteral injuries.  The Journal of Urology [1994, 152(6 Pt 2):2240-2246] 22/1/2016 Ureteric injuries in gynaecology 69

70. THANK YOU 22/1/2016 Ureteric injuries in gynaecology 70