A Review of Laparoscopic Ureteral Injury in Pelvic Surgery

Obstetrical and Gynecological surveyVolume 58, Number 12

2004 년 4 월 29일

임 종 인

Abstract Objective of this study

– laparoscopic surgeries 중 ureteral injury 가 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 – 2003 년 사이에 출간된 복강경수술 중 발생한 요관손상에

관한 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 case 중– 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 injury 의 원인

Target Audience

Obstericians & Gynecologists, Family physicians

Learning Objectives

After completion of this article, the reader should be able to1. Summarize the reported rates of ureteral injury2. Identify the location of the more common laparoscopic urete

ral injury3. List the various types of laparoscopic ureteral injuries

Materials and Methods

Laparoscopic surgeries 중 발생한 ureteral injury 에 대한 문헌의 분석 (1966-2003)– Appropriate MSH terms 을 만들어 medline database 와 online AC

OG database 를 검색– Bibliographies 을 manual 로 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 adhe

siolysis : 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 lapar

oscopy

Intraoperative diagnoses of ureteral injury– only 6(8.6%) cases

Papers on classic (nonlaparoscopic) gynecologic procedures– Injury diagnosis 시간보다는 ureteral injury 를 detection 하는 meth

od 에 대해 기술– Hurt et al. : 5 methods

1) retrograde ureteral dye injection2) intravenous dye injection3) intraoperative ureteral catheterization4) intravenous excretory urography5) dissection of the ureter

15(21.4%) cases 가 diagnosis time 을 보고 하지 않음

Ureteral injury repair 의 approach 방법– Laparotomy : 43(61.4%) cases– 15(21.4%)cases did not report

Gordon and Lewis– Focal ureteral injuries

Double J-shaped catheter 를 삽입하여 , urine leakage 를 막고 ureter 를 지지하여 spontaneous healing 을 유도하여 치료 가능

– More extensive damage end-to-end anastomosis 나 ureteral implantation 을 위한

laparotomy 가 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 re

ported– Diagnosed postoperatively

Laparotomy : 술후 진단된 49 case 중 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 surgeries1) at the pelvic brim2) Ureter 가 uterine arteries 아래에서 cervix 외측으로 지나가는 부위3) Ureters 가 bladder 로 들어가는 vaginal fornix 의 외측 부위 Gordon and Lewis : laparoscopic surgeries1) at the infundibulopelvic ligament2) where the ureter passes deep to the ovarian fossa3) 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 o

r extracorporeal staplers or electrocautery 보다 좀더 안전한 method

– Improved training in laparoscopic technique Recognition of intra- and retroperitoneal gross and functional anatomy

– Lower urinary tract 의 integrity 를 확인하기 위한 intraoperative protocols 확립

– 수술중에 urology consultation 의 획득 Decrease the delay in recognition of ureteral injury Increase of their intraoperative repair.

laparoscopic surgeries 중 ureter injury 에 대한 Data and discussion– Lacking in both breadth and depth

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