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Tips Menghindari Injury Pada Ureter Like An Urologic Surgeon

This document provides tips to avoid ureteral injury during gynecologic surgery from a urologic surgeon's perspective. It notes that iatrogenic ureteral injury occurs in 0.2-1% of gynecologic operations. Risk factors include an enlarged uterus, previous pelvic surgery, ovarian tumors, endometriosis, and pelvic adhesions. The best way to prevent injury is thorough intraoperative identification and exposure of the ureter. Surgeons should maintain awareness of the ureter's location and visualize it if there is any doubt. Early urological assistance is also advised if needed. The document stresses being aware of possible ureteral injury in the postoperative

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23 views

Tips Menghindari Injury Pada Ureter Like An Urologic Surgeon

This document provides tips to avoid ureteral injury during gynecologic surgery from a urologic surgeon's perspective. It notes that iatrogenic ureteral injury occurs in 0.2-1% of gynecologic operations. Risk factors include an enlarged uterus, previous pelvic surgery, ovarian tumors, endometriosis, and pelvic adhesions. The best way to prevent injury is thorough intraoperative identification and exposure of the ureter. Surgeons should maintain awareness of the ureter's location and visualize it if there is any doubt. Early urological assistance is also advised if needed. The document stresses being aware of possible ureteral injury in the postoperative

Uploaded by

kuncoro
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Tips Menghindari

Injury pada Ureter


Like an Urologic Surgeon

Kuncoro Adi,SpU(K)
Trauma & Reconstructive
Departemen Urologi
AMC Hasan Sadikin Hospital – PadjadjaranUniversity,
Bandung, 2021
Greeting from Bandung, West Java-Indonesia
Malaysia
AMC Hasan Sadikin Hospital-
Singapore Padjadjaran University
• Most populated province in
Indonesia (48 mil of 270 mil)
• Government Teaching
Hospital
• 928 beds
• Reconstructive referral center
for western part in Indonesia
• JCI accredited
• NO-DISCLOSURE
@kuncoro202 Email: [email protected]
Tips Menghindari Injury pada Ureter
Like an Urologic Surgeon

We are very intimate


neighbors
BUT we have different
GOAL
Tips Menghindari Injury pada Ureter
Like an Urologic Surgeon
OBGYN
TRY TO AVOID THE DEER

Urology
 WE TRY and MUST HIT THE DEER
In This Presentations

• Epidemiology
• Avoiding Ureteral Injury
• Intra operative recognition
• Post operative suspicion and recognition
Missed diagnosis
Delayed diagnosis
ANOTHER COUNTRY NUMBER
Ureteral Trauma- a review of recent Guideline
•EUA Urological Trauma – 2020
•AUA Urotrauma Guidelines – 2018
•Ureteral Trauma :
 Incidence is 0,2 – 1 % of OBGYN operations
 50% - 82% of all ureteral trauma during obstetric-gynecologic
surgery
 One third were recognized at the time of surgery
 Iatrogenic : By far the majority
Various mechanism: Inadvertent clamping and ligation, partial/complete
transections, thermal injury or ischemia from devascularization
WHAT ABOUT US ???
INDONESIAN PEOPLE
• Indonesian number ??
• Paucity of Indonesian Cases?
• RSCM : 5/1425 (1969-1972)*
• 0,2%-0,9% (Oetama: 1970-1975)**
• 2/15 from 1223 (Mendrova, 1992-1997)***
• Present Time?

*Samil, KOGI II Surabaya. 1973 **Ihsan Oetama, Tesis, Jakarta.1976***Cavinus M, Tesis Semarang.2000
OUR EXPERIENCES

Iatrogenic ureteral injury


due to gynaecologic
surgery (2013-2019) :
92.5% (50/54)
Incidence of iatrogenic
ureteral injury due to
OBGYN operation : ???
Ureteral Injury

4 basic groups :
• Laceration and
excision
• Sutures and
ligatures
• Crush injuries
• Devascularizations
Risk Factors for
Ureteric Injury
• An enlarged uterus
• Previous pelvic surgery
• Ovarian neoplasma
• Endometriosis
• Pelvic Adhesions
• Distorted pelvic anatomy
• Intraoperative hemorrhage
• Radical hysterectomy
• history of pelvic irradiation

 Consider pre Op IVU-CT and ureter stenting in selected


cases
 Some cases we knew it will be unavoidable injury
Pre Op Urological consultation will be advised
Anatomical Considerations and Risk Factors
• Pelvic surgeon must become familiar with anatomical
• Anatomical change due to pathological variants
50 % - 75 % ureteral injuries reported
during gynaecologic surgery have
occurred in the absence of
recognizable risk factors.1,2,3
 uncomplicated, routine, and
normal pelvic anatomy

1. Liapis et all, Int Urogyn J.2001;12:391-394


2. Chan et all, Am J Obstet Gyn.2003;188:1273-1277
3. Symmonds, Clin Obstet Gyn.1967;19: 623-644
Preventing Ureteral Injury &
Complications
• Anatomical considerations
• Risk Factors
• Intra operative identification and exposure
 The best way to prevent
• Intra operative recognation of ureteral injury
 Better outcome of ureteral reconstruction
• Post operative clinical evaluation
 Missed and delay ureteral injury :
- Ureteral recon  more difficult
- Success rate of recon  decreased
- Organ (kidney) preservation ???
- Mortality
- Patient’s Cost
Intra operative identification and exposure
 The best way to prevent and minimized the change of ureteral injury
• Anatomical of ureter :
- Retroperitoneal organ  explore the retroperitoneal
- anterior or posterior approach depend on surgeon preference
• WE, Urologist :
- We want to HIT the deer
 we open the retro
- We want to COOK and EAT the deer
 we open the retro and do direct visualization of the ureter
 Preserve adventitia layer during ureteral dissection
 short application of diathermy in periureteral/ureteral area
• In order to avoid BLIND :
- ligation or entrapped in a sutures
- crushing by clamp
- made a complete or partial resection
- devascularization tissue or diathermy-related injury Lighted Ureteral Stent
 We can maintain constant awareness of ureter, mobilized and
visualized the ureter when in any doubt.
Intra Operative High Awareness
of Making Iatrogenic Ureteral
Injury

• One third were recognized at the time of surgery


- missed and delay diagnosis mostly
• Open explore retroperitoneal when in any doubt
• Seek early urological assistance where appropriate
• Abdomino-pelvic drain
• Missed diagnosis have better outcome >< Delayed
diagnosis

 Better outcome for the patients and surgeons


Post Operative Period with
High Awareness of making
iatrogenic ureteral injury

• One third were recognized at the time of surgery


- missed and delay diagnosis mostly
• Flank pain, fever, abdominal distention, prolong ileus
 Should raise the suspicion for urinary extravasation
• Persistent abdomino-pelvic drain
• Anuria in bilateral case
• US, IVU/CT Uro
Take Home Messages

• Appropriate approach and adequate exposure


• Maintain constant awareness of the location of the ureter,
mobilize and visualize the ureter in any doubt.
• Avoid blind under running of the bleeding areas
• Short applications of diathermy near the ureter
• Seek early urological assistance where appropriate
• Put abdomino-pelvic drain if you in doubt
• Post Operative Period with High Awareness of making
iatrogenic ureteral injury
TERIMA KASIH NEIGHBORS

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