Injury to the ureter is one of the most serious complications associated with gynecologic surgery. Gynecologists should be skilled in the prevention and early detection of ureteral injuries and, when the need arises, be prepared to consult with surgeons with specialized skills in this area (urologist). Notwithstanding the possibility of injury to the ureters, such injury to the ureter should be identified before the operation is concluded and immediately repaired. If the gynecologist does not posses the required training in repairing an ureteral injury, an intraoperative consultation with a urologist to perform the ureteral repair is mandatory.
The close anatomical association between the ureters and the female reproductive organs is well known to any surgeon operating in the abdomen and pelvis of a woman. Working knowledge of the location of the ureters at all times during a surgical procedure is essential to prevent their injury. It is a well know and accepted fact that injury to the ureter at the time of a gynecologic operation performed through the abdomen can be almost completely avoided by the simple preliminary measure of routine identification of the ureters above the level of disease as the initial step in every abdominal hysterectomy. The principles that contribute to the safety of the ureter in all pelvic procedures include: adequate exposure of the surgical field; appropriate dissection of the retroperitoneal spaces; clamping and suturing under direct vision.
The most common Injuries to the ureter are:
Crushing injury from misapplication of a surgical clamp
Ligation with a suture
Partial or complete transection
Pulling angulation of the ureter with subsequent obstruction
Resection of a portion of the ureter
Ischemia from stripping of the ureteral sheet
Ischemia from electrocoagulation of the ureteral circulation
The most specific way of preventing ureteral injury during a pelvic laparotomy is to identify the ureters as they enter the pelvis over the bifurcation of the common iliac arteries and to trace the pelvic course of each ureter during the retroperitoneal dissection of the pelvic sidewalls. It is an accepted fact that surgeons who do not have sufficient knowledge of the pelvic anatomy to practice routine and constant identification of the ureter should not be operating in the pelvis.
Most ureteral injuries are preventable, identifiable and treatable at the time of the abdominal or pelvic surgical procedure if the surgeon and/or surgical assistant performs the proper and required dissection and identification of the ureters before cutting and suturing the tissues which contained the left ureter. Eventhough an injury to the ureter at the time of abdominal hysterectomy can occur regardless of the experience of the surgeon, proper identification of the ureters at the time of the surgical procedure allows:
the prevention of an ureteral injury
the ureteral injury to be recognized
immediately repaired to obviate further complications or the need for a subsequent operative procedure or in the alternative can lead to the formation of a genitourinary fistula.
The proper dissection of the ureters at the time of the abdominal gynecologic procedure greatly decreases (even to the degree of eliminating) the chances of sustaining an ureteral injury (complete transection of the ureter) during a surgical procedure. During abdominal procedures, the ureters should be identified visually. Once the ureters are identified, they should be retracted gently from the operative field. Failure to properly visually identify the ureters during the abdominal hysterectomy and retract them from the operative field is a clear deviation from the acceptable standard of care.
Some indications for the surgical procedure (large uterine fibroid(s)), should alert the operating surgeon that an enlarged uterus is associated with a distortion of the normal pelvic anatomy. As such, it became mandatory for the operating surgeon and his assistant to identify the ureter before any tissues are cut and/or sutured as part of the abdominal or pelvic surgical procedure. Failure to do so is a clear deviation of the acceptable standard of care for a gynecologist performing and/or assisting in the performance of an abdominal and/or pelvic surgical procedure and increases the chances for injury to the ureter to occur.
The failure of a surgeon (or assistant) to timely identify that a ureter had sustained an injury (complete or partial transection) before completing the abdominal or pelvic surgical procedure and closure of the abdominal cavity is a clear deviation from the acceptable standard of care expected from a gynecologist performing an abdominal or pelvic surgical operation. Early detection and repair of intraoperative injuries to the ureter(s) usually can restore normal function, prevent postoperative complications and possibly subsequent surgery. If you believe that you or your loved one have been injured as a result of a gynecologic error that was diagnosable, avoidable and/or preventable, you may have a valid cause of action. The injury may be the result of a medical provider's mistake in handling your gynecologic condition and the result of medical negligence. Dr. Borten has over 35 years of experience as a gynecologic surgeon to fully evaluate the merits of your potential case. Allow the medical malpractice attorneys at Gorovitz & Borten help you assert your rights and get the compensation you deserve.
Contact Information For a free confidential consultation and receive a response within 24 hours (when possible), please contact us by phone, fax or e-mail with your question or concern.
Website disclaimer: The materials on this website have been prepared by Gorovitz & Borten, P.C. for informational purposes only and are not intended, and should not be construed as legal advice. This information is not intended to create and receipt of it does not constitute a lawyer-client relationship. Similarly, any submission or receipt of information using electronic "Contact Us" form does not create a lawyer-client relationship. Internet and online readers should not act upon any of the information contained on this website without seeking professional counsel. (See Terms and Conditions).