Most Common Sites of Ureteral Injury in Gynecologic Surgery
The four most common sites of ureteral injury during gynecologic surgery are: (1) at the pelvic brim where the ureter crosses over the iliac vessels, (2) at the level of the uterine artery where the ureter passes through the cardinal ligament, (3) at the uterosacral ligament, and (4) at the ureterovesical junction.
Anatomical Distribution of Ureteral Injuries
1. Pelvic Brim/Iliac Vessel Crossing
- This is where the ureter crosses over the iliac vessels at the pelvic inlet
- Particularly vulnerable during mobilization of the infundibulopelvic ligament during oophorectomy
- Risk increases when operating on large adnexal masses or in cases with distorted anatomy
2. Uterine Artery Crossing
- Where the ureter passes beneath the uterine artery in the cardinal ligament
- Often referred to as the "water under the bridge" anatomical relationship
- High-risk area during hysterectomy when securing the uterine vessels
- Accounts for a significant percentage of injuries during total abdominal hysterectomy 1
3. Uterosacral Ligament
- The ureter runs close to the uterosacral ligament near its attachment to the cervix
- Particularly vulnerable during procedures involving the posterior cul-de-sac
- Common site of injury during vaginal hysterectomy and procedures for endometriosis
4. Ureterovesical Junction
- Where the ureter enters the bladder
- At risk during anterior colporrhaphy, anti-incontinence procedures, and radical hysterectomy
- Injuries at this location can be particularly challenging to repair 2
Risk Factors for Ureteral Injury
Several factors increase the risk of ureteral injury during gynecologic surgery:
- Endometriosis (particularly with deep infiltrating lesions)
- Pelvic inflammatory disease
- Previous pelvic surgery
- History of pelvic radiation
- Congenital anomalies
- Large pelvic masses distorting normal anatomy
- Malignancy with local invasion 3
The incidence of ureteral injury is significantly higher in patients with these risk factors (2.7%) compared to those without (0.9%) 3.
Prevention Strategies
- Direct visual identification of the ureter during laparotomy in patients with suspected ureteral injury 4
- Use of adjunctive maneuvers including careful ipsilateral ureteral mobilization
- Injectable dyes such as methylene blue or indigo carmine can help visualize the ureter 4
- Consider prophylactic ureteral stenting in high-risk cases, which has shown lower injury rates (1.0% vs 3.1%) 3
- Retrograde pyelography may be performed in equivocal cases 4
Management of Ureteral Injuries
When ureteral injury occurs, prompt recognition and appropriate management are essential:
- For injuries proximal to the iliac vessels, primary repair over a ureteral stent is recommended 4
- For incomplete injuries diagnosed postoperatively, attempt ureteral stent placement 4
- When stent placement is unsuccessful, perform percutaneous nephrostomy with delayed repair 4
- Immediate repair should be performed when possible, though it may not be appropriate in unstable patients 4
Clinical Pearls
- The "simple" abdominal hysterectomy, rather than technically complex procedures, accounts for most ureteral injuries 1
- Intraoperative identification should be the primary goal when injury occurs, though this is not always possible 5
- Delayed diagnosis can lead to serious complications including fistula formation and loss of renal function 5
- The incidence of ureteral injury in laparoscopic procedures (1.1%) is similar to that in laparotomy (1.2%) 3
Understanding these common sites of injury and implementing appropriate preventive measures can significantly reduce the risk of ureteral damage during gynecologic surgery.