Sites prone to ureteral injury during complex gynaecological surgeries and preventive strategies: a case series

Weimin Gao, Gao W, Zhang Z, Zhen Zhang, Jiangnan Qiu, Qiu J, Zhou S, Shulin Zhou, Luo C, Chengyan Luo
Current medical research and opinion · 2026 · vol. 42(2) , pp. 357–363 · doi:10.1080/03007995.2026.2654327 · PMID:41955487
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⚙ AI-generated summary by claude@2026-07, 2026-07-31 ⓘ

This case series describes three complex gynecological surgeries, highlighting ureteral anatomy, injury-prone locations, and blunt ureterolysis techniques to prevent ureteral injury.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-14 · read from full text ⓘ

This case series studied ureteral injury risk and preventive surgical steps during complex gynecological operations, using three illustrative cases to highlight injury-prone ureter locations and the process of blunt ureterolysis. In one case, extensive sheet-like adhesions made the right ureter visually similar to the ovarian suspensory ligament; in another, concurrent ovarian endometrioma and pelvic endometriosis placed the right posterior broad and uterosacral ligaments extremely close to the ureter; and in the third, the authors described uncovering the ureteral tunnel during radical cervical cancer surgery with attention to a “knee-like” ureteral structure. The paper’s main limitation is its very small number of cases and descriptive design, without broader comparative evaluation. Relevance to endometriosis: the series explicitly describes a case with concurrent ovarian endometrioma and pelvic endometriosis that closely involved ureter-adjacent ligaments, though the paper is mainly about ureteral injury sites and prevention strategies in complex gynecologic surgery.

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Abstract

INTRODUCTION: Ureteral injuries (UIs) remain a major challenge to clinicians in complex gynecological surgery. In this study, we employed three cases to demonstrate the locations of the ureter prone to injury and the process of blunt ureterolysis, thereby avoiding UIs. CASE REPORT: Case 1 had undergone laparotomy ovarian cystectomy before. During the operation, extensive, sheet-like adhesions between the intestine, right ureter, and ovarian suspensory ligament were observed, and the ureter's appearance was strikingly similar to that of the right ovarian suspensory ligament. Case 2 presented with concurrent ovarian endometrioma and pelvic endometriosis, involving the right posterior broad ligament and the uterosacral ligament, both of which were extremely close to the right ureter. Case 3 demonstrated the process of uncovering the ureteral tunnel during radical surgery for cervical cancer, with particular emphasis on the handling of the ureteral knee-like structure. CONCLUSIONS: To effectively prevent UIs during complex gynecological surgeries, surgeons should integrate knowledge of ureteral anatomy, recognize injury-prone locations, and proficiently perform ureteral dissection with appropriate surgical instruments. This study provides a detailed description of the procedures to avoid UIs, offering a reference for clinicians to accumulate practical experience.
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Abstract

Introduction Ureteral injuries (UIs) remain a major challenge to clinicians in complex gynecological surgery. In this study, we employed three cases to demonstrate the locations of the ureter prone to injury and the process of blunt ureterolysis, thereby avoiding UIs. Case report Case 1 had undergone laparotomy ovarian cystectomy before. During the operation, extensive, sheet-like adhesions between the intestine, right ureter, and ovarian suspensory ligament were observed, and the ureter’s appearance was strikingly similar to that of the right ovarian suspensory ligament. Case 2 presented with concurrent ovarian endometrioma and pelvic endometriosis, involving the right posterior broad ligament and the uterosacral ligament, both of which were extremely close to the right ureter. Case 3 demonstrated the process of uncovering the ureteral tunnel during radical surgery for cervical cancer, with particular emphasis on the handling of the ureteral knee-like structure.

Conclusions

To effectively prevent UIs during complex gynecological surgeries, surgeons should integrate knowledge of ureteral anatomy, recognize injury-prone locations, and proficiently perform ureteral dissection with appropriate surgical instruments. This study provides a detailed description of the procedures to avoid UIs, offering a reference for clinicians to accumulate practical experience. Transparency Declaration of financial/other relationships The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose. Author contributions CL concepted the study, had full access to the data integrity and the accuracy of the data analysis. WG and ZZ carried out the investigation, data collection and wrote the original draft. JQ and SZ were involved in the statistical analyses, review and editing the manuscript. All authors participated in the interpretation of study results, and in the drafting, critical revision, and approval of the final version of the manuscript.

Acknowledgements

None. Ethics statement The study was conducted in accordance with the Declaration of Helsinki (revised 2013). Written informed consent was obtained personally from each patient for the use of their clinical data and surgical video in this study. The study is approved by the Ethics Committee of First Affiliated Hospital with Nanjing Medical University (No. 2024-SR-266).

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Condition tags

endometriosisendometrioma

MeSH descriptors

Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures Gynecologic Surgical Procedures

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