Evaluation and treatment of iatrogenic ureteral injuries during obstetric and gynecologic operations for nonmalignant conditions.

Twenty-one iatrogenic ureteral injuries (20 patients) as a result of obstetric and gynecologic operations are presented. All injuries occurred during operations for benign conditions, such as Cesarean section and transabdominal hysterectomy. Pelvic adhesions as a result of repeat Cesarean section, markedly enlarging the uterus at the time of abdominal hysterectomy, and massive hemorrhage during surgical treatment were the main causes of ureteral injury. Nine ureters were transected (eight patients) and 12 ureters had postoperative obstruction. Fistulas occurred between the affected ureter and the vagina (five patients), uterus (one patient) and skin (one patient). The existence and the site of such a fistula is clearly demonstrated roentgenographically using intravenous urograms while a urethral catheter filled with contrast media is inserted into the bladder. Only a few ureteric injuries (two patients) were diagnosed and managed during the initial gynecologic operation. The remainder underwent delayed repair procedures. In most patients, the upper urinary tract was protected by percutaneous nephrostomy. The preferred operation for definitive correction was ureteroneocystostomy using the psoas hitch procedure. Direct localization by difficult dissection of the injured ureteral site was unnecessary with ureteroneocystostomy because this procedure bypasses the site of the injury to the ureter. This procedure can be applied in most injuries to the ureter, distal or proximal, which occur during gynecologic and obstetric operations. Renal salvage was achieved in all instances, with no operative or postoperative complications.