Ureteral complications from laparoscopic hysterectomy indicated for benign uterine pathologies: a 13-year experience in a continuous series of 1300 patients
Ureteral complications from laparoscopic hysterectomy indicated for benign uterine pathologies: a 13-year experience in a continuous series of 1300 patients
Franck Le?onard 1
Adolphe Fotso 1
Bruno Borghese 1
Nicolas Chopin 1
Herve? Foulot 1
Charles Chapron 1
0 The Author 2007. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology
1 Faculte ? de Me ?decine, Service de Gyne ?cologie Obste ?trique II et Me ?decine de la Reproduction (Pr Chapron), Unite ? de chirurgie gyne ?cologique, Groupe Hospitalier Universitaire (GHU) Ouest, Assistance Publique-Ho?pitaux de Paris (AP-HP) , Universite ? Paris V, CHU Cochin-Saint Vincent de Paul, Pavillon Lelong, 82, avenue Denfert Rochereau, 75014 Paris , France
BACKGROUND: The aim of this study was to evaluate the risk of ureteral injuries and to discuss how to avoid their occurence after laparoscopic hysterectomy indicated for benign uterine pathologies. METHODS: This observational study covers the period from January 1993 to December 2005 (retrospective study from 1993 to 2000 and prospective from 2001). We reviewed incidence, methods of diagnosis and management of ureteral injuries. RESULTS: The rate of ureteral injuries was 0.3% (four patients). Three patients presented a ureteral fistula diagnosed secondarily some time after the operation. The fourth patient presented a ureteral injury that was diagnosed peroperatively. Three out of four of the lesions were observed on the right side. In every case, there were preoperative risk factors connected with a past history of surgery, or the lateral location of uterine myomas. All four patients needed ureterovesical reimplantation. The outcome was good in all four cases. CONCLUSIONS: The rate of ureter complications after laparoscopic hysterectomy is low and comparable to that observed after hysterectomy by laparotomy. The risk should not prevent laparoscopic hysterectomy being used more widely. Prevention depends on training in the technique and the surgeon's experience.
hysterectomy; operative laparoscopy; laparoscopic hysterectomy; complications; ureteral injuries
Total hysterectomy for benign uterine lesions is the most
frequent gynaecological surgical operation not connected
(Dicker et al., 1982; Rutkow, 1986)
. In 1989,
Reich et al. demonstrated that this operation could be carried
out via laparoscopy
(Reich et al., 1989)
hysterectomy is indicated as alternative to laparotomy or when
vaginal surgery is difficult
(Chapron and Dubuisson, 1995)
Multicentre studies have shown that most total hysterectomies
are still carried out by laparotomy (Harkki-Siren et al., 1998;
Gimbel et al., 2001; Ma?kinen et al., 2001; Farquhar and
One of the major risks with total hysterectomy is that of
urological complications, notably ureteral lesions
et al., 1998; Vakili et al., 2005; Gilmour et al., 2006; Mteta
et al., 2006)
. This is due to the fact that the ureters are
located 2.3 cm from the lateral edge of the cervix in
women with normal pelvic anatomy (Hurd et al., 1992).
Even if operative laparoscopy is not inherently dangerous
(Chapron et al., 2002), some authors consider that the risk of
ureteral injury is higher after laparoscopic hysterectomy
compared with traditional hysterectomy (Harkki-Siren et al., 1998;
Ma?kinen et al., 2001; Johnson et al., 2005).
The goal of our work, which is based on a large and
continuous series of laparoscopic hysterectomy indicated for benign
patholgies, is to evaluate the risk of ureteral complications
and to discuss how to avoid their occurrence.
Materials and Methods
Between January 1993 and December 2005, all patients who
underwent laparoscopic hysterectomy were included in the study. All the
operations were carried out according to a technique described
(Chapron et al., 1994)
. The main characteristics of the
operative technique are as follows: (i) the total hysterectomy was indicated
for a benign pathology in every case; (ii) the operation was carried out
via laparoscopy from the (conservative or radical) adnexal phase right
up to the time of colpotomy; (iii) bipolar coagulation was used for all
haemostasis procedures and (iv) all surgical procedures were carried
out with reusable instruments (Karl Storz Endoscopie, Paris,
France). Patients with genital prolapse and/or urinary stress
incontinence were excluded.
The following are the main points in the operating technique aimed
at avoiding ureteral complications. Uterine cannulation is essential. It
provides the means for the assistant placed between the patient?s legs
to push the uterus towards the side away from the uterine artery being
treated, in order to increase the distance between the ureter and uterine
artery. Bipolar coagulation forceps used for uterine artery haemostasis
must be inserted via the supra pubic trocar homolateral to the artery.
With this configuration, the bipolar forceps will be perpendicular to
the lateral edge of the body of the uterus, and thus the ascending
portion of the uterine artery. Bipolar coagulation ? section of the
uterine artery must take place on the ascending portion of the
uterine artery, level with the middle third of the lateral edge of the
uterus, well above its arch. The ureter is at a good distance from
this point. It lies well outside and below the coagulation area, and
all the more so when exposure has been optimized using the uterine
cannulation. Once bipolar coagulation ? section of the uterine artery
has been achieved, dissection should continue but remaining without
fail inside from the uterine artery. All the haemostasis procedures
are then gradually carried out, as far as the cervix and the vagina.
By remaining strictly within this plane with the lateral edge of the
uterus inwards and the sectioned uterine artery outwards, it is
theoretically impossible to injure the ureter, which is located outside the
uterine artery. If there is any difficulty in achieving perfect
haemostasis, it is preferable to use clips to avoid secondary complications
due to electrocautery. In the event that adnexectomy is associated
with the total hysterectomy, the first phase must consist of identifying
the trajectory of the ureter, and if there are any adhesions, carrying out
preliminary adhesiolysis. When there are severe adhesions, it may be
necessary to use a retroperitoneal approach to identify the ureter
trajectory. In our experience, ureterolysis is not used systematically.
Ureterolysis is carried out only in difficult cases (abdomino-pelvic
surgery, endometriosis, myoma in the broad ligament etc. ).
Between January 1993 and December 2000, medical, operative and
pathological reports for each patient were collected retrospectively.
The same analyses were performed prospectively for patients operated
between January 2001 and December 2005. For each case, the
following data were systematically collected and entered into a data base:
(i) patient?s characteristics [age, height, weight, body mass index
(BMI), gravidity, parity, menopausal status, preoperative transvaginal
ultrasonography results (length, width and thickness of the uterus),
indications for laparoscopic hysterectomy, previous history of
vaginal delivery, of caesarean section and of adhesiogenous
abdominopelvic surgery (Leonard et al., 2005)]; (ii) operative and
post-operative results (operating time, uterine weight and associated
surgical procedure (adhesiolysis, adnexectomy etc.)]; (iii) surgeon?s
experience (junior or senior): by definition, we considered that only
those practitioners who had carried out more than 50 laparoscopic
hysterectomy could be considered as senior surgeons and (iv) ureteral
complications (incidence, surgical symptoms, methods of diagnosis,
ureteral side and site, type of injury, causal instrument, treatment
modalities, follow-up and sequelae).
During the study period, 1300 patients underwent a
laparoscopic hysterectomy. Patients? characteristics and indications
for laparoscopic hysterectomy are presented in Table 1. The
mean uterine weight was 257.5 + 160.7 g and the mean
operating time was 133.9 + 49.5 min. During the same anaesthesia,
adhesiolysis was carried out in 25.2% (327 patients) of cases,
aSometimes more than one for the same patient.
and in 40.4% (525 patients) of cases, adnexectomy was
associated with laparoscopic hysterectomy. The rate of ureteral
injuries was 0.3% (4 patients). Three patients presented a
secondary ureteral fistula. The fourth patient presented a ureteral
injury that was diagnosed peroperatively.
A summary of patients with ureteral injury after laparoscopic
hysterectomy is presented in Table 2. Details are the following:
This concerned a right ureterorectal fistula diagnosed 2 months
after laparoscopic hysterectomy. The operation was carried out
by a senior surgeon, and was indicated in a patient aged 38 for
heavy menorrhagia that persisted despite hormonal treatments,
in a context of adenomyotic uterus. The patient had a past
history of pelvic surgery on several occasions (endometriosis
and adhesiolysis). On the second day post-operatively, the
onset of fever associated with right lumbar pain prompted
renal ultrasound examination and intravenous pyelogram,
which revealed dilatation of the right pyelocalicial cavities.
No sign of any ureteral lesion was seen at ureteroscopy and a
double J catheter was installed as a precaution. When the
double J catheter was removed 2 months after laparoscopic
hysterectomy, gassy diarrhoea appeared. Cystoscopy revealed
a right vesicorectal fistula. During repair of this vesicorectal
fistula by laparotomy, a right ureterorectal fistula was also
discovered, which was repaired during the same anaesthesia by
ureterovesical reimplantation. Five years later, the patient has
no functional urinary symptoms, and renal ultrasound is
CT, Computed tomography; IVP, Intravenous pyelogram; PAS, previous adhesiogenous abdominopelvic surgery.
aInspection during surgical procedure by laparotomy.
bUreteral portion close to the uterine artery and the uterosacral ligament.
Laparoscopic hysterectomy was indicated for
menometrorrhagia with uterine myomas in a patient aged 40. A 4 cm myoma
had developed in each of the two broad ligaments. The
operation was carried out by a skilled surgeon and went perfectly
well. On the 10th post-operative day the patient was taken
back into hospital in a context of febrile occlusion.
Investigation by abdominopelvic scan revealed the existence of
intraperitoneal effusion with moderate dilatation of the right
pyelocalicial but no visible obstacle. Intravenous pyelogram
did not reveal any fistula. Installation of a double J catheter
relieved the symptoms and the renal cavity dilatation ceased.
When the double J catheter was removed 2 months after the
operation, the appearance of vaginal discharge enabled the
diagnosis of ureterovaginal fistula to be made. An
ureterovesical reimplantation was carried out. Three years later, the
patient is cured with no urinary sequelae.
Laparoscopic hysterectomy with bilateral salpingo-
oophorectomy was indicated for persistant menometrorrhagia associated
with severe dysmenorrhea for a 51-year-old patient with
considerable adenomyosis. The operation was carried out by a
skilled surgeon but was difficult due to the presence of
endometriosis on the posterior surface of the left broad ligament. The
immediate post-operative history was uncomplicated apart
from a delay in the return to normal bowel function (day 3).
On the third post-operative day, biological results were
normal. On the 10th post-operative day, the patient was
re-admitted to hospital for peritonitis. An intravenous
pyelogram revealed the presence of a fistula in the lower left
ureter. End-to-end ureteral anastomosis with installation of a
double J catheter took place by laparotomy. One month later,
the patient presented an uroperitoneum. An
ureterocutaneostomy was made. Four months later, ureterovesical
reimplantation was carried out by laparotomy. Now, 5 years after the
operation, the patient presents no sequelae.
This patient aged 48 presented a past history of several pelvic
surgery interventions, and suffered from pelvic pain associated
with menometrorrhagia in a context of uterine adenomyosis. A
laparoscopic hysterectomy with bilateral salpingoo
-ophorectoomy was decided. The existence of pelvic adhesions
subsequent to the previous operations increased the difficulty
of the operation, carried out by a junior surgeon. During
dissection of the right uterine artery using laparoscopic scissors, there
was partial section of the right ureter. During the same
anaesthesia and in collaboration with a urological surgeon, direct
suture was carried out with installation of a double J catheter.
The patient developed secondary ureteral stenosis with
dilatation of the right pyelocalicial cavities. After repeated ureteral
dilatation procedures failed, right ureteral reimplantation took
place 12 months later. Two years after treatment for this
complication, the patient presents no problems.
The rate of ureteral injuries was 0.3%. These operations were in
every case made more difficult because of peroperative risks
connected with a past history of surgery or uterine myomas
in a lateral location. Similarly to other authors
et al., 2002)
, we have observed that ureteral injuries occur
most frequently on the right side. In every case, the lesions
were observed at the distal ureter, close to the uterine artery and
the uterosacral ligament. None of the complications was
secondary to bipolar coagulation ? section of the infundibulopelvic
ligament for those patients who underwent adnexectomy
associated with laparoscopic hysterectomy. Only one of the
four ureteral injuries was diagnosed peroperatively. For the
other three patients, the complications were diagnosed some
time after the operation due to ureteral necrosis secondary to
the use of bipolar coagulation to ensure haemostasis of the
uterine pedicles. These ureteral injuries are serious
complications that justify specialized surgical management. All the
patients had to undergo ureterovesical reimplantation and
two laparotomies were needed for one patient (Case 3). At
present, some time after the event, all the patients have been
cured and have neither sequelae nor residual functional
It is appropriate to take these results into account when
specifying how total hysterectomies should be conducted. Our
results are indeed comparable to those seen by other teams
(Table 3). Provided the surgeons are experienced in
laparoscopic surgery, the risk of ureteral complications after
laparoscopic hysterectomy is comparable with the rate of 0.2 ? 0.4%
observed when total hysterectomy takes place by laparotomy
(Harkki-Siren et al., 1998; Ma?kinen et al., 2001; Carley
et al., 2002; Dorairajan et al., 2004; Vakili et al., 2005)
observation is essential, given that laparoscopic surgery
ought to be considered as an alternative to laparotomy
(Chapron and Dubuisson, 1995). In other words, the fact of
carrying out a total hysterectomy by laparoscopy rather than by
laparotomy does not increase the risk of ureteral complications
(Chapron et al., 2002). This factor is all the more important in
that for each of the four complications we observed, there were
preoperative risk factors (previous adhesiogenous
abdominopelvic surgery, endometriosis and myomas in the broad
ligament) which counter-indicated vaginal surgery as a method
for this operation. The risk of ureteral complications must no
longer be used as an argument against the more widespread
use of laparoscopic hysterectomy. The only real problem is
that of training for surgeons in this technique in order to be
able to reduce the number of hysterectomies carried out by
laparotomy. Evaluation of the learning curve of laparoscopic
hysterectomy demonstrates that the majority of major
complications occur during the learning stage (Kreiker et al., 2004).
One of the characteristics of ureteral injuries is that they are
often only diagnosed after the operation
(Saidi et al., 1996; Oh
et al., 2000)
. In our experience, only one of the four ureteral
complications was diagnosed during laparoscopic
hysterectomy. The problem is that routine cystoscopy does not
guarantee recognition of all ureteral injuries (Councell et al., 1994;
Dwyer et al., 1999; Dandolu et al., 2003). The value of
cystoscopy to diagnose ureteral injury seems greater when uterine
vessel haemostasis is performed by suture rather than by
(Ribeiro et al., 1999)
. Although there is
no consensus at present
(Gilmour et al., 1999; Visco et al.,
Vakili et al. (2005)
, we recommend cystoscopy
after intravenous injection of indigo carmin for all cases of
difficult laparoscopic hysterectomy. After operative laparoscopy,
the recovery ought to be uneventful. In case of fever, flank pain
or haematuria, the surgeon must be ready to consider the
possibility of ureteral complications and to request blood samples
and radiological investigation. Prompt recognition is essential
to minimize secondary morbidity.
The modalities for prevention of ureteral injuries during
laparoscopic hysterectomy are summarized in Table 4. The
most important points are the following. The surgeon must
be certain where the ureters are located during all phases of
aPrevious adhesiogeneous abdomino-pelvic surgery, dense adhesions, deep
endometriosis and large myomas in the broad ligament.
the operation. Because with operative laparoscopic surgery the
surgeon has a much improved visibility of the pelvic structures,
we do not agree with the use of ureteral stents as recommended
by some authors
(Phipps and Tyrrell, 1992; Paulson, 1996)
especially since stents may lead to complications (Wood
et al., 1996). In difficult situations (associated adnexal
masses adherent to the lateral pelvic sidewall, endometriosis,
dense adhesions and myoma in the broad ligament), the
surgeon must be capable of using a retroperitoneal approach
and carrying out ureterolysis (Kadar, 1995). Although some
(Wattiez et al., 2002)
recommend using a uterine
manipulator to improve exposure, systematic use of this
instrument does not significantly reduce the risk of ureteral injuries.
In case of bleeding near the ureter during ureterolysis,
haemostasis must not be performed with bipolar coagulation but by
using endoscopic clips to avoid thermal injuries. Bipolar
coagulation of the uterine artery must be performed only at
the level of the ascending branch in order to remain as far as
possible from the ureter. The surgeon?s experience in these
advanced laparoscopic surgical procedures is an essential
factor. The risk levels for ureteral complications during
laparoscopic hysterectomy are shown to be three to four times higher
in multicentre studies (Harkki-Siren et al., 1997, 1998;
Ma?kinen et al., 2001) than for expert surgeons
Reich, 1994; Nezhat et al., 1995; Wattiez et al., 2002)
study) (on average 1.3 versus 0.3). The results presented in
the national Finnish register (Ha?rkki-Siren et al., 2001) also
show that ureteral injuries are more common in local hospitals
where the expertise is not as great as in university teams (2.7%
versus 0.9%). Whatever the surgeon?s experience, ureteral
injuries significantly decrease with expertise (O?Shea et al.,
2000; Ha?rkki-Siren et al., 2001; McMaster-Fay and Jones,
2006). Finally, to prevent complications secondary to these
ureteral injuries, management must include collaboration
with an urologist.
The risk of ureteral complications after laparoscopic
hysterectomy is comparable to that observed with laparotomy, provided
the surgeon has sufficient experience. This risk should no
longer be used as an argument against laparoscopic
hysterectomy being used more widely. Careful identification and if
necessary ureterolysis are the most important means of
avoiding injury. Early diagnosis is the best way to prevent long-term
sequelae. The challenge in the years to come is that of teaching
this technique in order to increase the surgeons? experience,
with the aim of reducing the numbers of hysterectomies still
carried out by laparotomy.
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Submitted on January 3 , 2007; resubmitted on March 20 , 2007 ; accepted on March 29, 2007