Ureteric Injury During Gynecological Laparoscopic Surgery – Prevention and Management скачать в хорошем качестве

Ureteric Injury During Gynecological Laparoscopic Surgery – Prevention and Management

Ureteric injury is one of the most serious complications encountered in gynecological laparoscopic surgery. Given the close anatomical proximity of the ureter to the reproductive organs, unintentional damage can lead to significant morbidity, including ureteric fistula, strictures, or loss of renal function. Dr. Lalit Shah, during his presentation at WALS 2025, highlighted the key preventive strategies and management protocols to mitigate this risk. Incidence and Risk Factors The incidence of ureteric injury during gynecological laparoscopic procedures ranges from 0.1% to 2.5%, depending on the complexity of the surgery. The most common risk factors include: Previous pelvic surgery or endometriosis Large uterine fibroids requiring morcellation Severe pelvic adhesions Ureteral endometriosis Use of thermal energy near the ureter Anatomical Considerations The ureter traverses the pelvic region closely related to key gynecological structures, making it vulnerable to injury at multiple sites: Near the uterosacral ligament At the level of the infundibulopelvic ligament during adnexal surgery Beneath the uterine artery at the level of the cardinal ligament At the bladder base during laparoscopic hysterectomy Prevention Strategies Preoperative Planning: Imaging techniques such as intravenous urography (IVU) or CT urography can help identify any anatomical variations. Intraoperative Identification: Routine ureteric tracing during dissection Use of indocyanine green (ICG) fluorescence imaging to visualize ureteric course Avoiding Thermal Injury: Limiting the use of electrocautery and energy devices near the ureter to prevent devascularization. Ureteric Stenting: In high-risk cases, preoperative stenting may help in intraoperative identification and reduce injury risk. Tissue Dissection Techniques: Adequate lateralization of the ureter and sharp dissection to avoid inadvertent damage. Recognition of Ureteric Injury Timely recognition of ureteric injury is critical to reducing long-term morbidity. Intraoperative signs include: Leakage of clear fluid suspected to be urine Lack of ureteric peristalsis Change in urine output or color on cystoscopy Management Strategies Immediate Repair (Intraoperative): Small injuries can be managed with primary suturing and stenting. Transected ureters require ureteroureterostomy or ureteroneocystostomy. Postoperative Diagnosis: If injury is detected postoperatively, CT urography and cystoscopy can confirm the site and extent. Management includes percutaneous nephrostomy or delayed surgical repair. Ureteric Reimplantation: For lower-third injuries, ureteroneocystostomy with or without a psoas hitch or Boari flap may be required. Upper and mid-ureteric injuries may necessitate ureteroureterostomy or ileal interposition grafts in extreme cases. Conclusion Ureteric injuries remain a major concern in gynecological laparoscopic surgery, but meticulous surgical techniques, routine identification of the ureter, and use of advanced imaging modalities significantly reduce the risk. Dr. Lalit Shah’s insights at WALS 2025 emphasized the importance of surgical awareness and timely intervention to ensure optimal patient outcomes. By implementing these preventive and management strategies, laparoscopic surgeons can minimize complications and enhance patient safety in gynecological procedures.