Injury of the ureter or bladder is one of the more serious complications of hysterectomy, and three fourths of ureteral injuries are associated with gynecologic operations. Most injuries involve the lower 3 cm of the ureter, and they usually are one-sided.
This study is a retrospective review of ureteral injuries that occurred in the past 7 years in conjunction with total laparoscopic hysterectomy (TLH), performed in 106 women, or subtotal LH (STLH) in 232. Ureteral injuries were diagnosed by postoperative vaginal sonography and confirmed by intravenous pyelography (IVP). Cystoscopy was performed in some cases at the end of hysterectomy by injecting indigo carmine intravenously. In earlier cases, bipolar cautery was used to occlude the uterine artery, creating the possibility that a nearby thermal injury could be misdiagnosed. Subsequently, the artery was secured with a new hemoclip, the Hem-o-lok, which made possible exact closure of the uterine artery.
Four of these women incurred ureteral injuries and one had a laceration of the bladder. None of the injuries occurred when cystoscopy was routinely performed or when bipolar cautery was avoided. The bladder injury, which complicated the TLH, was diagnosed intraoperatively and was repaired laparoscopically. Three of the ureteral injuries followed STLH, and one TLH. All these injuries were diagnosed 1 to 2 weeks postoperatively when patients described prolonged flank pain and lower abdominal pressure. None of the affected patients were febrile. Vaginal sonography demonstrated urinoma. After confirmation of the diagnosis by either IVP or computed tomography, 3 patients underwent nephrostomy for 3 weeks and then had the ureter reimplanted. The remaining patient had a ureteral stent placed.
The investigators believe that the risk of ureteral injury during TLH or STLH can be minimized by using a clip rather than cautery to control the uterine vessels and by routinely performing cystoscopy after total or subtotal laparoscopic hysterectomy.