EVALUATION AND TREATMENT OF IATROGENIC URETERAL INJURIES DURING OBSTETRIC AND GYNECOLOGIC OPERATIONS FOR NONMALIGNANT CONDITIONS

Twenty-one iatrogenic ureteral injuries (20 patients) as a result of o bstetric and gynecologic operations are presented. All injuries occurr ed during operations for benign conditions, such as Cesarean section a nd transabdominal hysterectomy. Pelvic adhesions as a result of repeat Cesarean section, markedly enlarging the uterus at the time of abdomi nal hysterectomy, and massive hemorrhage during surgical treatment wer e the main causes of ureteral injury. Nine meters were transected (eig ht patients) and 12 meters had postoperative obstruction. Fistulas occ urred between the affected meter and the vagina (five patients), uteru s (one patient) and skin (one patient). The existence and the site of such a fistula is clearly demonstrated roentgenographically using intr avenous urograms while a urethral catheter filled with contrast media is inserted into the bladder. Only a few ureteric injuries (two patien ts) were diagnosed and managed during the initial gynecologic operatio n. The remainder underwent delayed repair procedures. In most patients , the upper urinary tract was protected by percutaneous nephrostomy. T he preferred operation for definitive correction was ureteroneocystost omy using the psoas hitch procedure. Direct localization by difficult dissection of the injured ureteral site was unnecessary with ureterone ocystostomy because this procedure bypasses the site of the injury to the meter This procedure can be applied in most injuries to the meter, distal or proximal, which occur during gynecologic and obstetric oper ations. Penal salvage was achieved in all instances, with no operative or postoperative complications.