A Review of Laparoscopic Ureteral Injury in Pelvic Surgery

							A Review of Laparoscopic Ureteral Injury in
              Pelvic Surgery



       Obstetrical and Gynecological survey
              Volume 58, Number 12



                               2004년 4월 29일
                                      임종인
                               Abstract
   Objective of this study
    – laparoscopic surgeries중 ureteral injury가 발생한 문헌을 review
    – Determine
        Reported rates of ureteral injury

        Initial laparoscopic surgeries during which ureteral injury occurred

        Time of injury recognition (intra- versus postoperative)

        Type

        Location

        Mode of injury repair

        Surgical laparoscopic instruments involved in ureteral injury.
   적절한 medical subject heading(MSH) terms 선택 및 사용
    – Medline computerized database 와 the online ACOG database 검색
    – 1966 – 2003년 사이에 출간된 복강경수술 중 발생한 요관손상에 관
      한 영문 literature 검색
   A total of 70 reported instances in 2491 reported cases
   Incidences of injury : <1% to 2%
   2491 cases
    – case reports, small series of studies, as well as longer,
       consecutive studies.
   Total 70 case중
    – The type of laparoscopic surgery
        Not described or specified : 18(25.7%) cases

        LAVH : 14 (20.0%)

    – Ureteral injury identification
        Intraoperatively : 6(8.6%) cases

        Postoperatively : 49(70.0%) cases

        Not specified : 15(21.4%) cases

    – Type of injury
        not specified or described : 36(51.4%)
           Transection : most common, 14 (20.0%)
    – Location of ureteral injury
        Not specified : 46(65.7%) cases

        At or above the pelvic brim : 10(14.3%) cases

    – Surgical laparoscopic instrument
        Electrocautery : 17(24.3%) cases

        Not reported : 34(48.6%) cases

    – Repair the ureteral injury
        Laparotomy - 43(61.4%) cases




   LAVH : the leading procedure in which injury occurred
   Electrocoagulation : 대부분의 injury의 원인
                       Target Audience

   Obstericians & Gynecologists, Family physicians



                     Learning Objectives
   After completion of this article, the reader should be able to
    1. Summarize the reported rates of ureteral injury
    2. Identify the location of the more common laparoscopic
        ureteral injury
    3. List the various types of laparoscopic ureteral injuries
                 Materials and Methods
   Laparoscopic surgeries중 발생한 ureteral injury에 대한 문헌
    의 분석 (1966-2003)
    – Appropriate MSH terms을 만들어 medline database 와 online
      ACOG database를 검색
    – Bibliographies을 manual로 검색


   Key terms : “Laparoscopic complication” and “ureter”
                                 Results
   Medline computerized database : 3344 articles
   ACOG database : 3690 articles
   Manual search of bibliographies

      30 articles discussed ureteral injury during laparoscopic surgery
      70 individual cases contained
            Rate of Injury and Initial Procedure

   Incidence rates : <1% to 2%

   Initial laparoscopic procedure
    – Not described : 18(25.7%) cases
    – LAVH : 14(20.0%) cases
    – Oophorectomy : 8 (11.4%)
    – Laparoscopic pelvic lymphadenectomy : 7 (10.0%)
    – Laparoscopic sterilization : 5 (7.1%)
    – Excision of endometriosis : 5 (7.1%),
    – Endometriosis ablation : 4 (5.7%)
    – Drainage of lymphoceles, electrocoagulation, and laparoscopic
       adhesiolysis : 각각 3 (4.3%)
                   Time of Injury Recognition

   Intraoperatively : 6 cases (8.6%)

   Postoperatively : 49 (70.0%) cases

   Not specified : 15 (21.4%) cases
                           Type of Injury

   Not described : 36 of the 70 (51.4%) cases
   Transection : 14 cases (20.0%)
   Laceration, obstruction, and stenosis : 각각 4 cases (5.71%)
   Fistula formation, necrosis, and ligation : 각각 2 cases (2.9%)
   Resection and burn injury : 각각 1 case (1.4%)
                      Location of Injury

   Not specified : 46 cases (65.7%)
   At or above the pelvic brim : 10 of the 70 cases (14.3%)
   At or above the uterine artery : 8 cases (11.4%)
   At or above the bladder : 6 cases (8.6%)
          Mode of Approach to Injury Treatment

   Laparotomy : 43 cases (61.4%)
   Not described : 15 cases (21.4%)
   Repair through laparoscopy : 8 cases (11.4%)
   Conservative, nonsurgical management : 4 cases (5.7%).
           Instrumentation Involved in the Injury

   Not specified :34 (48.6%)
   Electrocautery : 17 (24.3%)
   Endoscopic stapling : 12 (17.1%)
   CO2 laser : 4 (5.7%)
   Forceps : 2 (2.9%)
   Aspirating needle : 1 (1.4%).
                           Discussion
   Incidence of major complications in laparoscopic
    hysterectomy
    – 3.5%
    – Incidence of ureteral injuries
         Between 0.3% and 2%




   Rate of laparoscopic ureteral injury
    – Not comprehensively described and documented in the
       literature
   최근 Laparoscopic hysterectomies 와 retroperitoneal
    laparoscopic procedures 의 증가로 인해 Ureteral injury 좀더
    흔히 발생

   Härkki-Sirén et al.
     – Ureters : particularly vulnerable to injury during major operative
       laparoscopy
   Intraoperative diagnoses of ureteral injury
    – only 6(8.6%) cases


   Papers on classic (nonlaparoscopic) gynecologic
    procedures
    – Injury diagnosis 시 간 보 다 는 ureteral injury 를 detection 하 는
      method에 대해 기술
    – Hurt et al. : 5 methods
        1)   retrograde ureteral dye injection
        2)   intravenous dye injection
        3)   intraoperative ureteral catheterization
        4)   intravenous excretory urography
        5)   dissection of the ureter
   15(21.4%) cases가 diagnosis time을 보고 하지 않음
   Ureteral injury repair의 approach 방법
    – Laparotomy : 43(61.4%) cases
    – 15(21.4%)cases did not report
   Gordon and Lewis
    – Focal ureteral injuries
        Double J-shaped catheter를 삽입하여, urine leakage를 막고 ureter
         를 지지하여 spontaneous healing을 유도하여 치료 가능
    – More extensive damage
        end-to-end anastomosis 나 ureteral implantation을 위한

         laparotomy가 필요
   Preferred technique of ureteral injury repair
     – Dependent on the time of injury diagnosis
   59 cases
     – both time of ureteral injury diagnosis and mode of treatment
       were reported
     – Diagnosed postoperatively
            Laparotomy : 술후 진단된 49 case중 38 cases (77.6%)
            5 cases of ureteral injury : not treated using laparotomy
               – 4 cases : conservative treatment
               – 1 case : laparoscopic approach
            most often repaired using laparotomy
     – Diagnosed intraoperatively
         laparoscopic repair 증가

         6 cases

               – 2 cases : laparotomy
               – 4 cases : laparoscopy.
   The type and location of ureteral injuries
    –   Type : not specifically described in 51.4%
    –   Location : specified in even fewer cases
    –   Potential locations for ureteral injury
             Hurt et al. : classic, nonlaparoscopic pelvic surgeries
         1)   at the pelvic brim
         2)   Ureter가 uterine arteries 아래에서 cervix 외측으로 지나가는 부위
         3)   Ureters가 bladder로 들어가는 vaginal fornix의 외측 부위
             Gordon and Lewis : laparoscopic surgeries
         1)   at the infundibulopelvic ligament
         2)   where the ureter passes deep to the ovarian fossa
         3)   at the ureteral canal
   Our review
    –   at or above the pelvic brim : the most common site
   Instruments involved in ureteral injuries
     – 34 cases (48.6%) : not defined or specified
     – LAVH and electrocautery
         Identified as leading causes of laparoscopic ureteral injury

          (when data was available for analysis and review)
   In more than 50% of the cases
     – Location and type of injury were also not specified
     – In this review (most common findings)
          Electrocautery instrumentation

          Transection injuries

          At or above the pelvic brim
   Decrease the risk of this complication
    – Ostrzenski
        laparoscopic suturing and tying method

    – Laparoscopic suturing technique and the tying of an
       intracorporeal or extracorporeal
           staplers or electrocautery보다 좀더 안전한 method
    – Improved training in laparoscopic technique
         Recognition of intra- and retroperitoneal gross and functional

          anatomy
    – Lower urinary tract의 integrity를 확인하기 위한 intraoperative
      protocols 확립
    – 수술중에 urology consultation의 획득
           Decrease the delay in recognition of ureteral injury
           Increase of their intraoperative repair.
   laparoscopic surgeries 중 ureter injury 에 대 한 Data and
    discussion
    – Lacking in both breadth and depth


   Much of the reviewed literature on existing information
    – Cursory and incomplete.