Ureteric injuries in gynaecological surgery: an experience of 19 cases

ABSTRACT

To review the ureteric injuries resulting from gynaecological surgery presenting to Fauji Foundation Hospital Rawalpindi and discuss their management. A retrospective descriptive study. The study was conducted at the department of Urology Foundation University Medical College and Fauji Foundation Hospital Rawalpindi during July 2004 to June 2009. The present study was conducted at the department of Urology Foundation University Medical College and Fauji Foundation Hospital Rawalpindi during July 2004 to June 2009. Case files of all those patients who were managed during this period in our hospital for ureteric injury sustained in a gynaecological procedure were perussued in detail. It was found out whether the ureteric injury occurred in Fauji Foundation Hospital Rawalpindi or the patient sustained such injury in a peripheral hospital and was referred here for management. Information was obtained regarding the patients' age, type of gynaecological surgery, level and type of ureteric trauma and the time of its recognition. In case of those patients referred from peripheral hospitals the mode of presentation was found out from the available data. The investigations performed and the treatment offered was thoroughly reviewed for all these cases presenting with ureteric injury. A total of 19 patients of ureteric injury afflicted during hysterectomy were managed during this period in our hospital. The patients1 age ranged from 34 to 55 years [mean age 42.5 years]. 14 patients sustained ureteric injury during abdominal hysterectomy for fibroids. Five cases had ureteric injury while undergoing a radical hysterectomy. Seven patients had previous caesarian section. 17 patients had the ureteric injury involving the last five cm of the ureter while in two patients the ureter was injured approximately 10 cm from the ureterovesical junction. Four ureteric injuries occurred during abdominal hysterectomy at Fauji Foundation Hospital Rawalpindi. These four injuries were recognized by the gynaecologist during the procedure and were managed by the urologist by ureteroureteric anastomosis over a stent [two cases] and by ureteric reimplant over a stent [two cases]. Fifteen cases were referred to us from peripheral hospitals. In these patients the period from occurrence of ureteric injury to presentation at Fauji Foundation Hospital Rawalpindi ranged from two weeks to seven months [mean 2.5 months]. Eleven of these patients had severed ureter and presented with constant urinary leakage from the vagina in addition to normal voiding. Three ladies had a flank pain and tenderness on the affected side and one lady who came from a peripheral hospital had swinging pyrexia, unilateral flank pain and tenderness. These four cases had unilateral ligation of the ureter and did not have any urinary leakage. After open surgical exploration and ureteric reimplant all these fifteen cases had uneventful recovery. Ureteric injuries are not uncommon in gynaecological surgery. Every effort should be made to avoid this complication. Injuries recognized during gyaenecological surgery should be managed without delay while cases coming late require thorough evaluation and surgical management