••• Chapter 37^ Lower Urinary Tract Injuries During Gynecologic Surgery^373
❍ What percentage of ureteral injuries are recognized at the time of surgery?
20% to 30%.
❍ What should be done when ureteral injury is suspected?
Administer 5 mL or indigo carmine IV, followed by cystoscopy to verify bilateral excretion of dye from each
ureteral orifice.
❍ What should be done when a ureteral injury is diagnosed?
Severe or complicated injuries will often require urologic consultation and possible stent placement. The location
of the injury will dictate the type of repair (distal, middle, or proximal third). Most gynecologic surgical injuries
occur in the distal ureter, although some may occur in the middle portion of the ureter. Injury to the proximal
ureter is rare. Distal injuries may be repaired with an ureteroneocystostomy.
❍ What is the most common cause of ureterovaginal fistula?
Unrecognized clamp injury or suture ligation of the ureter.
❍ What should be done if the ureter is included in a clamped or ligated vessel?
The clamp should be removed and the ureter inspected. If the damage is minor, the area of injury should be
drained extraperitoneally. A suture should simply be removed. If after removal of a clamp or suture the ureter
appears pale, ureteral catheterization for 7 to 10 days should be performed to allow revascularization.
❍ How should a partially transected ureter be managed?
Repair with several interrupted sutures of 4-0 delayed absorbable sutures over a ureteral stent with retroperitoneal
drainage.
❍ How should a total transected ureter be managed?
Management of a total transection depends on location. If the transection occurs within 5 cm of the vesicoureteral
junction, ureteroneocystostomy (direct reimplantation of the ureter into the bladder wall) should be performed.
If the transection is higher and the ureter will not reach the bladder without tension, a psoas hitch is performed.
The bladder is mobilized and secured to the psoas muscle, and a tension-free ureteroneocystostomy is performed.
If the ureter is transected above the pelvic brim, a ureteroureterostomy is performed. Both ends of the ureter
are spatulated for 5 mm and approximated without tension over a silastic catheter with interrupted 4-0 delayed
absorbable suture. The stent should be left in place for 2 to 3 weeks. The repair should be drained extraperitoneally.
❍ What is a patient at risk of after ureteroneocystostomy, and how can this be prevented?
Vesicoureteral reflux. This can be prevented by tunneling the ureter in the submucosa of the bladder (Politano and
Leadbetter technique).
❍ What postoperative symptoms are associated with ureteral injury?
Flank pain or tenderness, fever, sepsis, ileus, abdominal distension, unexplained hematuria, urine leakage through
the vagina or skin, urinoma, oliguria or anuria, and elevated serum creatinine.
❍ What should be done if ureteral injury is suspected postoperatively?
IVP.