Management of ureteric injuries during gynecological operations: 10 years experience Panos Sakellariou a , Athanasios G. Protopapas b,* , Zannis Voulgaris b , Nikolaos Kyritsis a , Alexandros Rodolakis b , Georgios Vlachos b , Emmanuel Diakomanolis b , Stylianos Michalas b a Department of Urology, ‘‘Alexandra’’ Maternity Hospital, Athens, Greece b 1st Department of Obstetrics and Gynecology of the University of Athens, ‘‘Alexandra’’ Maternity Hospital, Vasilissis Sophias 80 Avenue, 115 28 Athens, Greece Received 28 October 2000; accepted 31 August 2001 Abstract Objective(s): To present our 10 years experience in the management of ureteric injuries occurring during gynecological surgery. Study design: Seventy-six patients had a variety of injuries. In 29 cases, the ureteric damage was diagnosed intraoperatively. Management of early-diagnosed injuries included suturing, ligature removal, end-to-end anastomosis, and reimplantation of the ureter. In 47 cases, the injury was diagnosed postoperatively. Ureteric catheterization was attempted in all cases presenting with obstruction. Catheterization failures were managed with ureterolysis, and reimplantation. Small ureteric fistula were managed with catheterization, and large communications with reimplantation. Two cases with urinomas were treated with surgical evacuation and anastomoses. Results: Management of early-diagnosed injuries was relatively easy in most cases. Postoperatively-diagnosed injuries were more difficult to treat. Catheterization failed in 28/44 (65.9%) ureters and surgical re-exploration was necessary. Long-term morbidity was minimal and no relapses occurred. Conclusion(s): Early recognition of a ureteric injury is the key to a complications-free repair. Unrecognized injuries cause prolonged morbidity, and their management can be difficult. Treatment of these injuries by experienced teams may minimize long- term consequences. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Ureter; Ureteric injuries; Gynecological surgery 1. Introduction Injury to the ureter is one of the most serious complica- tions of gynecological surgery. Unrecognized injuries in particular, can be the cause of prolonged postoperative morbidity leading to fistula formation, or even kidney loss [1,2], and represent a common reason for medicolegal action against gynecological surgeons [3]. The ureter runs in close proximity to the female repro- ductive organs during the whole length of its course from the pelvic brim to its bladder entry, and is placed at risk for injury during several pelvic procedures. Nevertheless, the incidence of ureteric injuries appears to be relatively low and in most series varies between 0.1 and 1.5% [1,2,4,5]. Increased awareness of the risk for ureteric damage during certain operative maneuvers is vital for injury prevention, whereas recognition of the injury before closure is the key to easy, successful, and complications-free repair. We present a series of 76 patients with ureteric injuries inflicted during a variety of gynecological operations. Many of these cases were referred to our unit from other hospitals and were managed either intraoperatively by members of our urogynecological team or were treated with a secondary procedure to deal with a complication related to a previously unrecognized ureteric injury. 2. Materials and methods From January 1987 to December 1996, 76 patients with ureteric injuries inflicted during gynecological operations, were managed by our urinary tract injury unit based at the ‘‘Alexandra’’ Maternity Hospital, University of Athens, Greece. This large teaching hospital is a major referral center for urinary tract injuries for the whole of southern Greece. European Journal of Obstetrics & Gynecology and Reproductive Biology 101 (2002) 179–184 * Corresponding author. Present address: 3 Aisopou Str, 151 22 Marousi, Athens, Greece. Tel.: þ30-1-8052-252. E-mail address: protom@aias.gr (A.G. Protopapas). 0301-2115/02/$ – see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII:S0301-2115(01)00521-8