Anatomic considerations in gynecologic surgery.

A 52-year-old postmenopausal woman (gravida 0) presented with left-side pelvic pain and an enlarging left adnexal cyst measuring 5.7 × 2.8 cm. Her surgical history was significant for a laparoscopic ovarian cystectomy complicated by a ureteral injury that required 2 additional laparotomies for complete repair. At the time of surgery, the left ureter was found to be running above the ovary, which was enlarged by a cystic mass containing clear fluid. After lysis of adhesions and complete left-side ureterolysis, an uncomplicated total laparoscopic hysterectomy and bilateral salpingooophorectomy was performed. Ureteral injury is a rare but serious complication in gynecologic surgery, with an incidence of 1% to 3% in surgery for benign disease and 5% to 8% in surgery for malignancy.1 Risk factors for ureteral injury are conditions that disrupt the normal anatomy of the ureters, such as endometriosis, previous pelvic surgery, and large ovarian masses. However, 50% of all patients with ureteral injuries have no known risk factors.2 Ureteral injuries occur most commonly at 3 places: (1) the level of the infundibulopelvic ligament, (2) the distal uterosacral ligament, as the ureter courses under the uterine artery, and (3) before its insertion on the urinary bladder.3 The most frequent types of injury are transection (28%), laceration (24.8%), and obstruction (20.3%) due to a kinked, crushed, or ligated ureter.4 Several studies have established that identifying the anatomic course of the ureter is more effective in preventing injury than preoperative imaging with ultrasound, intravenous pyelogram, or computed tomography scan.5,6 Intraoperative cystoscopy with intravenous indigo carmine is a valuable tool for the detection of ureteral injuries.7 However, a normal cystoscopy does not guarantee an intact urinary tract, especially in the setting of a delayed thermal injury. The present case highlights the importance of meticulous dissection and identification of anatomic structures to minimize the risk of a ureteral injury during gynecologic laparoscopic surgery.