Management of delayed presentation of ureteral injuries after gynaecological operations

ABSTRACT

This study was designed to evaluate the management of cases of ureteral injuries presenting late after gynaecological operations for benign conditions. Twenty-six cases of ureteral injuries presented one month to 30 months after gynaecological surgeries for benign diseases were evaluated. Clinical presentation include4 intermittent vague abdominal pain in 10 cases, periureteral urinomas in 6 cases, continuous urine leakage via the vagina in 4 cases, incidentally discovered hydrourctcronephrosis in three asymptomatic patients and silent renal losses in three cases. Excretory urography showed hydroureteronephrosis in 20 cases, revealed the presence of ureterovaginal·fistula [UVF] in three cases [11.5%] and radiologically non-functioning rental units in three cases [11.5%]. Retrograde urography, performed in four cases, confirmed the diagnosis of UVF. The results indicated that certain predisposing factors were noticed in only 17 cases [68%]. The mechanism of ureteral injuries was transection in ten women [40%] and ligation in fifteen [60%]. The sites of injury were near the inferior margin of the sacroiliac joint in 21 women [84%] and near the ureterovesical junction in four [16%]. Ultrasound-guided percutaneous drainage of six urinomas was performed successfully. Adjunctive percutaneous nephrostomy was needed in ten cases [40%]. In 23 patients, attempts at retrograde ureteral stentipg were unsuccessful and exploration for urcteral reconstruction was done in the form of ureterovcsical reimplantation [12 cases], Boari bladder flap of [7 cases] and psoas hitch [4 cases]. Nephrectorny was perfonned in two cases [8%]. The outcome of reconstructive surgery was good in 21 [84%] out of the 23 cases. In two [8%] cases of ureterovesical reimplantation, re-obstruction occurred and required revision of the ureteroneocystostomy. It is concluded that although an intraoperative diagnosis of ureteric injury is preferable, delayed presentation is associated with high success rate after reconstructive surgery. Reimplantation of the ureter and Boari flap were the most commonly used procedures with good outcome: