Anatomically, ureters are approximately 25 cm long tubular structures that extend from the renal pelvis to the bladder trigone and are in the retroperitoneal space7,8. The abdominal ureter initially lies on the anterior surface of the psoas muscle, then descends posterolaterally cross over the iliac vessels, and descend with varied relationship to the pelvic brim. The ovarian vessels cross over the ureters anteriorly as they approach the pelvis. As the ureters enter the pelvis, the right crosses the external iliac artery and the left ureter crosses over the common iliac artery. They continue their course medial to the anterior division of the hypogastric artery and lateral to the peritoneum of the cul-de-sac into the midplane of the pelvis. The uterine arteries then cross them anteriorly before they tunnel into the cardinal ligaments. This point is approximately 1.5 to 2.0 cm lateral to the internal cervical os and vaginal fornices before it enters the trigone of the bladder7,8. The relationship of the ureters with these vessels especially the distal third makes it venerable to damage during surgical procedures in the pelvis.
Ureteral injury may occur when suturing an extended incision aimed to control bleeding within the broad ligament or in performing a hypogastric artery ligation8. Other common site includes the pelvic brim, over the iliac arteries, within the cardinal ligament, and at the anterolateral fornix of the vagina. Damage related to haemostatic sutures and dissection can be prevented by knowing that the renal artery, ovarian artery, common iliac artery, and aorta contribute blood supply to the ureter medially in the pelvic segment medial and laterally in the abdominal segment7. The peritoneum and interstitial/serosa layers too should always be preserved during ureteral dissection. The choice of management and outcome is worse in late diagnosis, coagulation, and devascularisation aetiologies, longer length damage, and in the woman.
This study reviewed IUI resulting from open surgeries that were managed by the urology units of two hospitals with the expertise of open ureteric reconstructive surgery in that rural part of Ghana. Open abdominal hysterectomy was the most common surgery (10/12) due to uterine fibroid, uterine fibroid with infertility or bleeding in the elective and postpartum haemorrhage in the emergency patients. This trend is similar to the literature review by Abboudi et al 2013 and tertiary hospital reviews in Ghana but differ from reported causes in Nigeria where mishaps during caesarean section led to 60% of the injuries9,10,11,12.
Injury to the left ureter was frequent (57.9%) in our study. The variable course of the left ureter that brings it close to pelvic structures and the right-handiness of surgeons have been considered predispositions to the frequent damage observed even though there is no proof to that13.
The risk factors reported by primary surgeons as a predisposition to these complications were adhensions from previous pelvic surgeries and haemorrhage during dissection. These factors are well published predictive factors for a difficult hysterectomy as reported with recommended guidance during the procedure10,9. Even though Primary surgeries conducted by both specialists and non-specialists resulted in ureteric injuries, Practical applications of the discussed anatomy and the proposed protocols appears better followed by a specialist surgeons.
Transection, ligation, devascularization, crush, and perforation are the types of injuries that occur. Transection (9/19) and ligation(8/19) were the commonest injuries recorded in the study. This may be due to lack of vigilance to identify the ureter during dissection or transection of the ligated uterine artery or blind transfixing bides leading to obstruction of the ureter as the injuries occurred in the pelvic part. This trend reveals the lack of sufficient art in the hysterectomy procedure. The Committee of the American Association for the Surgery of Trauma classified these injuries for better management into Grade I – hematoma, contusion or hematoma without devascularization, Grade II – laceration; <50% transection, Grade III – laceration; 50% transection, Grade IV – laceration; complete transection with < 2 cm of devascularization and Grade V – laceration; avulsion with > 2 cm of devascularization14. In this study, the transection and ligation injuries counted for the urine peritonities and the obstructive nephropathy with the late clinical presentation of anuria(60%) which is similar to other studies. Anuria may delayed diagnosis in patients with peri-operative hypovolaemia or a unilateral injury in bilateral functioning kidneys.
Majority of the missed cases were diagnosed 48–72 hours postoperatively. In neglected cases, urine peritonitis, septicaemia, and obstructive uropathy, fistula, and ureteric stricture may occur later which poses both a challenge to management and carry a poor prognosis after surgery with higher chances of patients developing renal hypertension, renal failure, fistula, and or urinoma formation and recurrent ureteral stricture15. The diagnosis was based on the presenting clinical symptoms, supported by blood urea nitrogen and creatinine elevation, neutrophilia or hydronephrosis, and free peritoneal fluid on ultrasound scan diagnosis and confirmed by exploration findings. The lack of advanced imaging and endourological investigation may potentially exclude minor injuries indicated in the classification
Patients with Urine peritonitis, obstructive nephropathy responded well to the intervention as was a single case of acute renal failure that was dialysed. Aside from their immediate complications none of the feared long-term complications was noticed during their follow-up period.
In the present study, all the cases with bilateral injuries were performed by non-specialised surgeons. This raises the question of the level of surgical mishaps in hysterectomy which is a common procedure and the true incidence of ureteric injuries since unilateral injuries potentially could show equivocal symptoms or show negative findings during ultrasound imaging.
It was however noted the patients with deranged renal function and had re-laparotomy did not fare worse than those with normal renal function.
Options of treatment include percutaneous urinary diversion for obstructive injuries, in patients not fit for exploration, the release of the stitch and double pig-tail stenting is optimal for traction injury without ischaemia or open surgical repair.
Aside from the endoscopic approach, options available for the distal segment injuries include ureteroneocystostomy with psoas hitch, a Boari tubularized bladder flap, transureteroureterostomy, and in rare cases renal autotransplantation or ureteral substitution with gastrointestinal segment. In this study, patients were treated with open surgery modality satisfactorily most of whom were refluxing ureteroneocystostomy(14/19), Boari tubularised flap(1/19), and ureteroureterostomy for a mid-segment damage and suture release all with stenting. The minimum and maximum hospital stay were 14 days and 32 days respectively with an average of 18.7 days. All of them had resolution of symptoms and normal renal function before discharge. The common complication was wound infection that resolved with antibiotics in 10/12 cases. In addition, we recorded 2 post-operative haemorrhage, 1 wound dehescence, and the need for a second repair operation in one. The was no mortality
This is a retrospective study with case selection criteria that might have led to low incidence. Our diagnosis of injuries was based on investigations of a referred case which may not capture cases that were primarily repaired without the need to refer. Conservatively managed cases were elsewhere or referred cases without clinical signs necessary for open diagnosis and repair were not included and could affect the numbers