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10.1576/toag.6.4.203.27016 www.rcog.org.uk/togonline

Ureteric injury in obstetric REVIEW

The Obstetrician
& Gynaecologist

and gynaecological surgery 2004;6:203–208

Swati Jha, Aravinthan (Arri) Coomarasamy,

Kiong Kong Chan Keywords
complications,
Ureteric injury is rare in obstetric and gynaecological practice but, gynaecology,
when it occurs, it has serious implications in terms of both morbidity injury, obstetrics,
trauma, ureter
and litigation. In this review, we evaluate the incidence, aetiology,
preventive strategies, diagnosis and management of ureteric injury by
systematically reviewing the literature. The incidence of ureteric injury
varies between 0.1% and 30%, depending on the type of surgery.
Prevention can be attempted by preoperative and intraoperative
precautions, although the effectiveness of these measures has not
been fully evaluated. Diagnosis of ureteric injury may be made
intraoperatively but 70% are diagnosed postoperatively. Management
depends on the timing of diagnosis, the aetiology, the length and Author details
location of the injury, the extent of the causative operation and the
condition of the woman.

Introduction
Many obstetricians and gynaecologists share a
common fear of injury to the ureter. Its inci-
dence is low but ureteric injury may have seri-
ous implications in terms of morbidity and
litigation. The morbidity arising from ureteric
injury includes increased hospital stay, secondary
invasive interventions, reoperation, potential loss
of renal function and deterioration of the
woman’s quality of life.1,2 Ureteric injury is the
most common complication of gynaecological
surgery leading to litigation. It accounts for 17%
of nonobstetric legal action initiated against
obstetricians and gynaecologists in the USA.3
Intraoperative injury to the ureter is possible not
only during complicated surgical procedures but
also during uncomplicated procedures. Hence, it
is not just the domain of the gynaecological
oncologist or interventional laparoscopist.
Preventive strategies, early diagnosis and appro-
priate management can limit the morbidity
Methods
An electronic search of the Cochrane Database
of Systematic Reviews (2003), Medline Swati Jha MD MRCOG,
Specialist Registrar in Obstetrics
(1966–2003) and EMBASE (1980–2003) was and Gynaecology, Honorary
conducted using a combination of medical Lecturer in Public Health and
Epidemiology, City Hospital,
subject headings and text words.Three subsets of Dudley Road, Birmingham, UK.
citations were generated:
1. studies of the ureter (‘ureteric’, ‘ureter’ and
‘urinary’)
2. studies of complications (‘complications’,
‘injury’, ‘trauma’ and ‘harm’)
3. studies in obstetrics and gynaecology
(‘obstetrics’, ‘gynaecology’ and ‘gynecology’).
Aravinthan (Arri)
These subsets were combined using ‘AND’ to gen- Coomarasamy MD MRCOG,
Specialist Registrar in Obstetrics
erate a subset of citations relevant to our review and Gynaecology, Honorary
question. Studies were included if they evaluated Lecturer in Public Health and
Epidemiology, Education Resource
the incidence, aetiology, preventive strategies, diag- Centre, Birmingham Women’s
nosis and management of ureteric injury in obstet- Hospital, Metchley Park Road,
Edgbaston, Birmingham, B15 2TG,
ric and gynaecological practice.The reference lists UK. email: arricoomar@blueyonder.
of all known primary and review articles were co.uk (corresponding author)

associated with ureteric injury.
Despite comprehensive literature searches, we
were unable to locate up-to-date, rigorously
developed guidelines or systematic reviews on
the subject of ureteric injury in obstetric and
gynaecological practice. Our objective was,
therefore, to review the evidence on the inci-
dence, aetiology, preventive strategies, diagnosis
and management of ureteric injury in obstetric
and gynaecological surgery.
examined to identify cited articles not captured by
electronic searches. Articles cited frequently were
used in the Science Citation Index to identify
additional citations. No language restrictions were
placed in any of our searches.
Meta-analysis and formal grading of evidence
Kiong Kong Chan FRCS FRCOG,
was not feasible owing to the extensive variation Consultant Surgeon in
in research questions and study designs.We found Gynaecological Oncology, Director
of Gynaecological Oncology,
79 relevant primary articles from our literature Birmingham Women’s Hospital,
searches, which form the basis of our review. Birmingham, UK.

203
© 2004 Royal College of Obstetricians and Gynaecologists
RGJN001-04_203-208 10/15/04 7:58 PM Page 204

REVIEW Incidence Sites of injury

The Obstetrician
& Gynaecologist
2004;6:203–208
Ureteric injury has an incidence of 0.2–1.0%
during any abdominal or pelvic surgery.4
Obstetric or gynaecological surgery accounts for
approximately 50% of all these injuries.1,5 The
reported incidence may be low because many
ureteric injuries are not recognised or reported.6
Despite the prevalence of ureteric injury being
higher following gynaecological cancer surgery,
it is benign gynaecological surgery that accounts
for most cases. Reports show conflicting results
when comparing the incidence of ureteric
injury following laparoscopic surgery with the
incidence following open gynaecological surgery.
Some studies report similar figures7 while others
report a significantly higher incidence after
laparoscopic surgery.8 Despite the incidence of
all major complications associated with
laparoscopy declining, the incidence of ureteric
injury has stayed constant at approximately 1%.9
Table 1 outlines the risk of ureteric injury asso-
ciated with various obstetric and gynaecological
procedures.
Although injury to the ureters during laparo-
scopic surgery is infrequent, 38% occur during
the treatment of endometriosis.10
Aetiology
The close attachment of the ureter to the peri-
toneum makes it particularly vulnerable during
abdominopelvic surgery. Ureteric injuries are
possible even in the most straightforward proce-
dures. Certain factors have been recognised as
increasing the risk:
Injury occurs most frequently in the lower third
of the ureter (51%), followed by the upper third
(30%) and the middle third (19%).13 The most
common sites of injury are:
• lateral to the uterine vessels
• the area of the ureterovesical junction close
to the cardinal ligaments
• the base of the infundibulopelvic ligament
as the ureters cross the pelvic brim at the
ovarian fossa
• at the level of the uterosacral ligament.
Most studies show the most common site of
injury to be lateral to the uterine vessels,14 but
Daly et al.6 report this to be at the ovarian fossa.
During laparoscopy the ureter is injured most
frequently adjacent to the uterosacral ligaments.10
Types of injury
The ureter may be injured in one of several
ways. Intraoperatively, there may be ligation or
kinking by a ligature, crushing by a clamp, divi-
sion, complete or partial transection, devascular-
isation or diathermy-related injury. The
incidence of different forms of injury are
complete transection, 61%; excision, 29%; ligation,
7% and partial transection, 3%.13
In the postoperative period, avascular necrosis
may occur following extensive dissection of
periureteric tissue with impairment of the anas-
tomotic blood supply. Another mechanism of
injury is the kinking and subsequent obstruction
over a haematoma or lymphocele.

• an enlarged uterus6,11
Classification
• previous pelvic surgery6,11
• ovarian neoplasms6,11 According to the Organ Injury Scaling System
• endometriosis6 developed by the Committee of the American
• pelvic adhesions6,8 Association for the Surgery of Trauma,15 ureteric
• distorted pelvic anatomy6,8 injuries are classified as follows:
• coexistent bladder injury
• massive intraoperative haemorrhage.12 • grade I haematoma; contusion or
haematoma without devascularisation
• grade II laceration; < 50% transection
Table 1. Risk of ureteric injury in obstetric and gynaecological procedures • grade III laceration; ≥ 50% transection

Subspecialty Procedure
Incidence
(%) References
• grade IV laceration; complete transection
with < 2 cm of devascularisation
Obstetric Emergency caesarean section
Caesarean hysterectomy
0.027–0.09
0.5–8.0
39,40
16,18
• grade V laceration; avulsion with > 2 cm of
devascularisation.
Keilland rotational forceps Not available
Gynaecological Abdominal hysterectomy 0.04–3.0 1,8 This anatomical classification does not, however,
Vaginal hysterectomy 0.02–0.47 8,41
Subtotal hysterectomy 0.03 8 appear to have clear prognostic implications.
Wertheim’s hysterectomy 1–30 34,42
Urogynaecology Burch colposuspension 0.09–3.3 23,43
Transvaginal tape Not available Prevention
Laparoscopy Adnexectomy 2.9 8,27
Laparoscopically assisted vaginal hysterectomy 1.39–6.0 Preoperative and intraoperative measures can be
Adhesiolysis Not available taken to try to reduce the risk of ureteric injury
Diathermy ablation of endometriotic deposits Not available
(Box 1). Appropriate investigations should be
© 2004 Royal College of Obstetricians and
204 Gynaecologists
RGJN001-04_203-208 10/15/04 7:58 PM Page 205
performed preoperatively, depending on the
underlying pathology and proposed operation.
For example, when there is suspected pathology
of the urinary tract, a preoperative intravenous
urogram (IVU) or ultrasound scan can identify
ureteric dilatation and disclose anatomical varia-
tions. In their review of 493 women, Piscitelli
et al.11 found that abnormal IVU findings are
most likely to occur in women with a uterine
size of 12 weeks or larger, when adnexal masses
are 4 cm or larger and in women with an abnor-
mal pelvic examination.
A preoperative IVU does not appear to have a
role in preventing ureteric injuries in routine
procedures.12,16 Similarly, prophylactic ureteric
catheterisation has not been shown to reduce the
risk of ureteric injury in routine cases.17 Ureteric
catheterisation may, however, assist the identifi-
cation of ureteric injury intraoperatively and
optimise the subsequent management in cases
where dissection is difficult.18
Intraoperative measures to prevent injury
include an appropriate operative approach,
adequate exposure, full examination of the
disease in the pelvis and seeking early urological
assistance where appropriate.18
Blind clamping of blood vessels has been identi-
fied as the predominant cause of ureteric injury
in obstetric procedures.19 Thus the control of
bleeding by specifically identifying bleeding
points rather than blind clamping is likely to
reduce this risk.
When dissecting masses, it is important to stay
close to the pathology and, whenever possible,
to identify the ureter in its course before dis-
section.Adequate mobilisation of the bladder in
a downward and outward direction is likely to
reduce the risk of ureteric injury because the
ureters are moved away from the uterine vessels
and thus away from the operative field.20 There
is evidence that direct visualisation of the
ureters in the pelvis reduces the risk of ureteric
injury.19 A decrease in ureteric injury during
abdominal hysterectomy from 0.7% to 0.2% has
been reported when the ureters are dissected
out.19 When direct visualisation is not possible
either from extreme scarring, large masses or
restricted access, direct visualisation of ureteric
function via cystoscopy or telescopy can be
employed.21
Caution is necessary when using laser and
electrocautery because a large proportion of
ureteric injuries during laparoscopic surgery are
associated with diathermy.8 Short applications
are likely to reduce the risk of ureteric injury
© 2004 Royal College of Obstetricians and Gynaecologists
because the depth of penetration depends on REVIEW
diathermy duration and power.
The Obstetrician
& Gynaecologist
Diagnosis
2004;6:203–208
Diagnosis of ureteric injury may be made intra-
operatively or postoperatively. Approximately
70% of ureteric injuries occurring during
gynaecological procedures are diagnosed post-
operatively.22
Intraoperative diagnosis
Intraoperative identification enables prompt
repair and is associated with decreased morbid-
ity and fewer legal risks.23 Maintenance of a
Box 1. Preventive strategies to reduce the risk of
ureteric injuries
• Appropriate operative approach
• Adequate exposure
• Avoid blind clamping of blood vessels
• Ureteric dissection and direct visualisation
• Mobilise bladder away from operative site
• Short diathermy applications
high index of suspicion and attempts at verify-
ing ureteric integrity should, therefore, be
essential components of pelvic surgery. The
presence of vermiculation does not prove viabil-
ity, as is sometimes believed, and there is no
foolproof mechanism to rule out intraoperative
devascularisation. In situations where visualisa-
tion of the ureters is not feasible, intravenous
administration of methylthioninium chloride or
indigo carmine (5 ml) is an accurate means of
demonstrating ureteric patency.24 Intraoperative
transurethral cystoscopy or telescopy (through
cystotomy) using an abdominal approach may
be required to visualise ejaculation of dye-
stained urine from both ureteric orifices.
Bubbles or blood-tinged urine coming through
the ureteric orifices may indicate ureteric
injury. The use of intraoperative cystoscopy and
telescopy during urogynaecology procedures
has shown an incidence of urinary tract injury
of 2.6–8%,25,26 whereas its use in major benign
gynaecological procedures found otherwise
undetected injury in 0.4% of cases.21
A decision analysis model has shown that routine
cystoscopy is cost-effective if the rate of ureteric
injury exceeds 1.5% for abdominal hysterectomy
or 2% for vaginal hysterectomy or laparoscopically
assisted vaginal hysterectomy.27 Cystoscopy
should therefore be considered in complex cases
(Table 1).
205
RGJN001-04_203-208 10/15/04 7:58 PM Page 206
REVIEW Postoperative diagnosis
The Obstetrician Postoperative symptoms of ureteric injury tend
& Gynaecologist to be variable (Box 2). Flank pain and fever are
the most common symptoms. Haematuria, a
2004;6:203–208 reliable indicator of renal trauma, is absent in
approximately 30% of ureteric injuries.1,28
Women may occasionally present with a
retroperitoneal urinoma29 (localised collection of
Box 2. Symptoms and signs of ureteric injury
• Fever
• Haematuria
• Flank pain
• Abdominal distension
• Abscess formation/sepsis
• Peritonitis/ileus
• Retroperitoneal urinoma
• Postoperative anuria
• Urinary leakage (vaginally or via abdominal wound)
• Secondary hypertension
urine), which can be confirmed by an ultrasound
scan. Postoperative anuria, though uncommon,
should prompt urgent evaluation. Urine leakage,
other than from the urethra, should prompt the
search for a fistula. A late presentation is the
development of hypertension secondary to
obstructive uropathy. It should be noted,
however, that typical symptoms might occur in
only 50% of women with ureteric injuries.
In suspected cases, investigations are needed to
establish renal function, to rule out hydronephrosis
and to evaluate continuity of the ureter.
Commonly used investigations for assessing
ureteric patency are shown in Box 3.
Intravenous urogram
Hydronephrosis, ureteric integrity and drainage
(in a series of sagittal images) and any extra-
vasation can usually be seen on an intravenous
urogram (IVU). Whereas extravasation of dye is
characteristic of ureteric injury, findings may be
Box 3. Radiographic investigations for ureteric
injuries
• Intravenous urogram
• Abdominal and pelvic computerised tomography scan with
intravenous contrast
• Retrograde ureterogram
• Renal ultrasound
• Cystoscopy
• Contrast-dye tests
© 2004 Royal College of Obstetricians and
Gynaecologists
206
more subtle, ranging from delayed function to no
abnormality at all, even when ureteric injury is
present.
Computed tomography
A computed tomography (CT) scan with intra-
venous contrast can also assess ureteric patency.
Contrast extravasation confined predominantly
to the medial peri-renal space is the most consis-
tent finding.30 The absence of contrast material
in the distal ureter on delayed CT images is
diagnostic of a complete ureteric transection.
Visualising ureteric integrity and continuity is
often more difficult with CT than with an IVU
because CT images are a series of cross-
sections. Rapid sequence spiral CT fails to
demonstrate this, hence delayed films need to
be explicitly requested.31 CT scanning has the
advantage of imaging for other concomitant
conditions.
Retrograde ureterogram
When the results of an IVU and CT scan are
inconclusive, a retrograde ureterogram may be
necessary to evaluate the course of the ureter.
This identifies the anatomic site of obstruction,
even when missed on an IVU or CT scan, by
delivering a higher density of contrast material
to the injured site. A retrograde ureterogram is,
however, more invasive than either an IVU or
CT scan and requires cystoscopy.
Renal ultrasound
Renal ultrasound is perhaps the best noninvasive
method to visualise the kidney. Hydronephrosis
and retroperitoneal urinomas are shown with
great sensitivity. Renal ultrasound cannot,
however, assess either renal function or continu-
ity of the ureter.
Cystoscopy
Postoperative anuria, caused by bilateral
ureteric obstruction, usually requires cysto-
scopic evaluation. Ejaculation of urine from
both ureteric orifices is diagnostic of ureteric
patency. If in doubt, a retrograde ureterogram
may be performed.
Contrast-dye tests
Contrast-dye tests are normally combined with
cystoscopy and may be particularly useful if a uri-
nary fistula is suspected.The path of the fistula can
usually be determined by the simultaneous admin-
istration of intravenous indigo carmine (a blue
RGJN001-04_203-208 10/15/04 7:58 PM Page 207
dye) and placement in the bladder of Congo red
through a transurethral catheter.
A full blood count and an electrolyte profile
must be taken in suspected cases of ureteric
injury.A full blood count may serve as a guide to
infection. Postoperative estimation of serum
urea, creatinine and sodium may aid diagnosis in
several ways. Measuring serum creatinine levels
on the second postoperative day might be useful
in evaluating ureteric patency. Increases of
greater than 0.2 mg/dl may be indicative of
unilateral ureteric obstruction.24 If the ureters
are patent bilaterally, creatinine elevations are
normally less than 0.3 mg/dl.32 Serum creati-
nine levels are, however, influenced by factors
other than ureteric obstruction. These include
intraoperative blood loss, fluid replacement and
the use of potentially nephrotoxic medication
such as nonsteroidal inflammatory drugs,
furosemide and aminoglycosides.
Postoperative uraemia occurs when ureteric
injury causes total urinary obstruction.This may
be caused either by a bilateral ureteric injury or
from a unilateral injury occurring in a solitary
functioning kidney. Anuria is the only immedi-
ate sign of imminent uraemia and women with
anuria require immediate intervention to pre-
serve their renal function.
Hyponatraemia may occur after ureteric injury33
and tends to follow the spillage of dilute urine
into the retroperitoneum. Reabsorption of free
water from this dilute retroperitoneal urinoma
causes a decrease in serum osmolality and serum
sodium, which produces a sodium-sparing and
free water-excreting response by the kidneys.
Management
Renal deterioration is inevitable unless urine
flow is restored because the ureter is the sole
conduit from the kidney. There are major
variables guiding a surgeon’s approach to the
management of ureteric injuries: time of diagno-
sis, aetiology, length and location of the injury,
extent of the causative operation and the condi-
tion of the woman. The precise nature of the
injury should be defined before deciding the
best method of repair. A complete assessment of
renal function and delineation of the ureter’s full
length are performed by radiography and labora-
tory investigations.
There is no specific medical therapy for ureteric
injury, although potential concomitant condi-
tions such as infection and renal failure should be
treated medically. General principles of ureteric
reconstruction are given in Box 4.
© 2004 Royal College of Obstetricians and Gynaecologists
Management of ureteric injury by the urologist REVIEW
depends on the length and location of the
The Obstetrician
injury34 (Table 2).When ureteric injury is recog-
& Gynaecologist
nised at the time of surgery, immediate recon-
struction or reimplantation delivers the best
2004;6:203–208
results.35 Retrograde ureterography is a useful
test to localise the lesion and determine further
management.
Box 4. General principles of ureteric repair44
1. Tension-free anastomosis by ureteric mobilisation
2. Ureteric dissection preserving adventitial sheath and its
blood supply
3. Minimal use of fine absorbable suture to attain watertight
closure
4. Use of peritoneum or omentum to surround the anastomosis
5. Drain the anastomotic site with a passive drain to prevent
urine accumulation
6. Stent with a ureteric catheter
7. Consider a proximal diversion
All transected ureters need stenting to maximise
urinary diversion. A double-J stent may be used
for this purpose. A passive retroperitoneal drain,
such as a Penrose drain, should be used to limit
urinoma formation. Active drains may prolong
leakage by exerting negative pressure and should
be avoided. The bladder needs to be decom-
pressed using a Foley’s or Malecot’s catheter.
When recognition of ureteric injury has been
delayed, repair should not be delayed.36
Exceptions include sepsis, extensive haematoma
or abscess formation at the site of injury, or when
the woman is haemodynamically unstable. In
these situations it is preferable to perform percu-
taneous nephrostomy drainage of the renal pelvis
or a retrograde ureteric stent placement, and
delay surgery until the complication is resolved.
Complications commonly encountered follow-
ing surgery for ureteric injury are given in Box 5.
Table 2. Management options for ureteric injury
Injury Management
Needle injury No action unless bleeding or leakage
Partial transection Stent placement
Complete transection (no loss of length)
5 cm from vesicoureteric junction Ureteroneocystostomy
5 cm from vesicoureteric junction Ureteroureterostomy
Complete transection (loss of length) Psoas hitch
Boari flap with a psoas hitch
Transureteroureterostomy
Ureteroileocystostomy
Ureterocalycostomy
Renal autotransplantation
207
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REVIEW Conclusion tive strategies, diagnosis and management of

iatrogenic ureteric injuries.
The Obstetrician Berard (1841) and Simon (1869) recorded the
& Gynaecologist earliest ureteric injury repairs in obstetric and If a woman is not making satisfactory postoperative
gynaecological surgery.37 The ureter and its recovery, the possibility of ureteric injury should be
2004;6:203–208 course were poorly understood at this time but considered. Radiographic investigations form the
many contributions have since been made to basis of diagnosis because symptoms and laboratory
increase understanding of the aetiology, preven- investigations tend to be non-specific.These should
be performed sooner rather than later if there is the
Box 5. Complications following surgery for ureteric slightest suspicion of ureteric injury. The surgeon
injury must keep detailed operative notes on intra-
operative surgical difficulties, specifically stating
• Stricture visualisation of the ureters. An explanation to the
• Excessive drainage woman of her injury and its implications should
• Stent and nephrostomy related problems always be made and documented.
• Urinary tract infection
• Ureteric obstruction or reflux It has been said that ‘the venial sin is injury to the
• Boari flap complications ureter, but the mortal sin is failure of recogni-
• Haematoma tion’.38 Familiarisation with the issues discussed in
• Wound infection this review may lead to appropriate management
and reduction in morbidity. ■

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