Causes and prevention of laparoscopic ureter injuries: an analysis of 31 cases during laparoscopic hysterectomy in the Netherlands

Background Ureter injuries are the most dreaded complication in gynecological surgery. Some risk factors for the occurrence of urinary tract injuries are known, but clear guidelines to prevent ureter injuries during laparoscopic hysterectomy (LH) are lacking. The aim of this study was to analyze all known ureter injuries that occurred during LH for a benign indication in the Netherlands, in order to identify patient- and surgeon-related risk factors.

Ninety-five LH-performing gynecologists were asked to recall all cases of known ureter injuries during LH in their hospital. After identification of ureter injuries, a structured interview was performed with a questionnaire that focused on the identification of predisposing factors which could account for the cause of the injury.

Forty-one injuries were detected in 37 patients (4 bilateral ureter injuries) in a 20-year period. The questionnaire could be completed for 31 cases. Predisposing factors were retrospectively assessed and classified into categories: patient-related (i.e., deep infiltrating endometriosis, intraligamentary fibroids) (n = 18), surgeon-related (insufficient experience and/or technique) (n = 16), or both (insufficient experience and difficult case) (n = 8). According to earlier-mentioned recommendations in a Delphi study among experts, in 48.4 % of these ureter injury cases, more than one of the recommended techniques or predisposing conditions were not applied or available. Only one ureter injury was diagnosed during the LH; the mean time to diagnose the injury was 29 days.

Incomplete learning curve, insufficient applied technique such as coagulation of the uterine artery without the use of a uterine manipulator, and/or from the contralateral side and/or without previously performed ureterolysis in case of distorted anatomy may be considered as the main predisposing factors. Similar content being viewed by others

Onwudiegwu U, Makinde OO, Badejo OA, Okonofua FE, Ogunniyi SO (1991) Ureteric injuries associated with gynecologic surgery. Int J Gynaecol Obstet 34(3):235–238 Harkki-Siren P, Sjoberg J, Tiitinen A (1998) Urinary tract injuries after hysterectomy. Obstet Gynecol 92(1):113–118 Makinen J, Johansson J, Tomas C et al (2001) Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod 16(7):1473–1478 Saidi MH, Sadler RK, Vancaillie TG, Akright BD, Farhart SA, White AJ (1996) Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol 87(2):272–276 Wattiez A, Soriano D, Cohen SB et al (2002) The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc 9(3):339–345 Garry R, Fountain J, Mason S et al (2004) The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 328(7432):129 Donnez O, Jadoul P, Squifflet J, Donnez J (2009) A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures. BJOG 116(4):492–500 Nieboer TE, Johnson N, Lethaby A et al (2009) Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 3: CD003677 Brummer THI, Jalkanen J, Fraser J et al (2011) FINHYST, a prospective study of 5279 hysterectomies: complications and their risk factors. Hum Reprod 26(7):1741–1751 Visco AG, Barber MD, Myers ER (2002) Early physician experience with laparoscopically assisted vaginal hysterectomy and rates of surgical complications and conversion to laparotomy. Am J Obstet Gynecol 187(4):1008–1012 Janssen PF, Brolmann HAM, Huirne JAF (2011) Recommendations to prevent urinary tract injuries during laparoscopic hysterectomy: a systematic Delphi procedure among experts. J Minim Invasive Gynecol 18(3):314–321 Koh LW, Koh PH, Lin LC, Ng WJ, Wong E, Huang MH (2004) A simple procedure for the prevention of ureteral injury in laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc 11(2):167–169 Lee CL, Soong YK (1995) Laparoscopic hysterectomy: is dissecting the ureter necessary? Int Surg 80(2):167–169 Roman JD (2006) Patient selection and surgical technique may reduce major complications of laparoscopic-assisted vaginal hysterectomy. J Minim Invasive Gynecol 13(4):306–310 Grainger DA, Soderstrom RM, Schiff SF, Glickman MG, DeCherney AH, Diamond MP (1990) Ureteral injuries at laparoscopy: insights into diagnosis, management, and prevention. Obstet Gynecol 75(5):839–843 Ostrzenski A, Radolinski B, Ostrzenska KM (2003) A review of laparoscopic ureteral injury in pelvic surgery. Obstet Gynecol Surv 58(12):794–799 Ko ML, Lin HW, Chen SC, Pan HS (2008) Should cystoscopy be routinely performed after laparoscopy-assisted vaginal hysterectomy? Minim Invasive Ther Allied Technol 17(3):195–199 O’Hanlan KA (2007) Cystoscopy with a 5-mm laparoscope and suction irrigator. J Minim Invasive Gynecol 14(2):260–263 Visco AG, Taber KH, Weidner AC, Barber MD, Myers ER (2001) Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy. Obstet Gynecol 97(5 Pt 1):685–692 Acknowledgments We are very grateful to the participating gynecologists for reporting their cases and collaborating in the analysis. Disclosures P. F. Janssen, H. A. M. Brölmann, and J. A. F. Huirne have no conflicts of interest or financial ties to disclose. Author information Authors and Affiliations Corresponding author Rights and permissions About this article Cite this article Janssen, P.F., Brölmann, H.A.M. & Huirne, J.A.F. Causes and prevention of laparoscopic ureter injuries: an analysis of 31 cases during laparoscopic hysterectomy in the Netherlands. Surg Endosc 27, 946–956 (2013). https://doi.org/10.1007/s00464-012-2539-2 Received: Accepted: Published: Issue date: DOI: https://doi.org/10.1007/s00464-012-2539-2