Surgical Endoscopy

, Volume 27, Issue 3, pp 946–956 | Cite as

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

  • Petra F. Janssen
  • Hans A. M. Brölmann
  • Judith A. F. Huirne
Article

Abstract

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.

Methods

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.

Results

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.

Conclusions

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.

Keywords

Laparoscopic hysterectomy Ureter injury Predisposing factors Recommendations Learning curve 

Notes

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.

References

  1. 1.
    Onwudiegwu U, Makinde OO, Badejo OA, Okonofua FE, Ogunniyi SO (1991) Ureteric injuries associated with gynecologic surgery. Int J Gynaecol Obstet 34(3):235–238PubMedCrossRefGoogle Scholar
  2. 2.
    Harkki-Siren P, Sjoberg J, Tiitinen A (1998) Urinary tract injuries after hysterectomy. Obstet Gynecol 92(1):113–118PubMedCrossRefGoogle Scholar
  3. 3.
    Makinen J, Johansson J, Tomas C et al (2001) Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod 16(7):1473–1478PubMedCrossRefGoogle Scholar
  4. 4.
    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):272–276PubMedCrossRefGoogle Scholar
  5. 5.
    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):339–345PubMedCrossRefGoogle Scholar
  6. 6.
    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):129PubMedCrossRefGoogle Scholar
  7. 7.
    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):492–500PubMedCrossRefGoogle Scholar
  8. 8.
    Nieboer TE, Johnson N, Lethaby A et al (2009) Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 3: CD003677Google Scholar
  9. 9.
    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):1741–1751PubMedCrossRefGoogle Scholar
  10. 10.
    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):1008–1012PubMedCrossRefGoogle Scholar
  11. 11.
    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):314–321PubMedCrossRefGoogle Scholar
  12. 12.
    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):167–169PubMedCrossRefGoogle Scholar
  13. 13.
    Lee CL, Soong YK (1995) Laparoscopic hysterectomy: is dissecting the ureter necessary? Int Surg 80(2):167–169PubMedGoogle Scholar
  14. 14.
    Roman JD (2006) Patient selection and surgical technique may reduce major complications of laparoscopic-assisted vaginal hysterectomy. J Minim Invasive Gynecol 13(4):306–310PubMedCrossRefGoogle Scholar
  15. 15.
    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):839–843PubMedGoogle Scholar
  16. 16.
    Ostrzenski A, Radolinski B, Ostrzenska KM (2003) A review of laparoscopic ureteral injury in pelvic surgery. Obstet Gynecol Surv 58(12):794–799PubMedCrossRefGoogle Scholar
  17. 17.
    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):195–199PubMedCrossRefGoogle Scholar
  18. 18.
    O’Hanlan KA (2007) Cystoscopy with a 5-mm laparoscope and suction irrigator. J Minim Invasive Gynecol 14(2):260–263PubMedCrossRefGoogle Scholar
  19. 19.
    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):685–692PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Petra F. Janssen
    • 1
  • Hans A. M. Brölmann
    • 1
  • Judith A. F. Huirne
    • 1
  1. 1.Department of Obstetrics and GynecologyVU University Medical CenterAmsterdamThe Netherlands

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