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LAVH ureteric injuryFrom: David McCoubrey (mccd@glen-net.ca)Sat May 4 13:50:06 1996
I have had two recent ureteric injuries performing lavh with endoscopic stapling devices. Both times it involved the left ureter with 1 or 2 staples incorporated into the ureter at the third firing( at the level of the uterine artery). The first patient presented one week after surgery with non-descript symptoms including left inguinal pressure and mild left flank discomfort. She was afebrile and urinalysis and creatinine were normal. I hunched at the possibility of ureteric injury and did an immediate IVP. Left hydronephrosis was noted without extravasation of contrast. We were able to pass a stent at cystoscopy and proceeded to dissect the ureter retroperitoneally and remove the offending staple laparoscopically. A small ureteric hole was noted where the staple was and we sutured it intracorporeally with 4-0 biosyn. The stent was left in situ for 6 weeks, with no further problems. I used the Autosuture stapler for this case. The second patient was more complex. I used the Ethicon 35V stapler for the lavh. The surgery was complicated with persistent mild bleeding at the right uterosacral ligament. While I was effecting hemostasis with cautery, the right uterine artery began to bleed! The staple line appeared to be missing staples where it was bleeding(probable misfire). I was able to achieve hemostasis immediately with an intracorporeal suture and a hemoclip after dissecting out the lacerated uterine artery in the retroperitoneum. A urologist placed a right ureteric stent prior to repair of the artery, and it was noted to be free from the injured artery. The left side looked fine. Three and a half weeks after surgery the patient presented to the emergency room with abdominal bloating. Ultrasound revealed massive abdomino-pelvic ascites. IVP demonstrated extravasation of urine from the LEFT ureter into the peritoneal cavity. No hydronephrosis was noted and creatinine was normal. Cystoscopy and retrograde studies showed a kinked left ureter 4 cm from the UV angle. We could not pass a stent so we proceeded to do a formal ureteroureterostomy retroperitoneally. Repair was successful. 2 staples were found in the ureter. The patient recovered uneventfully. I have done more than 50 lavh and 15 adnexectomies prior to these two injuries, which occurred a month apart! Both times the uterine specimens showed tight approximation of the staple lines to the lower uterine segment. I don't think I wandered too laterally with the stapling device. I always try to identify the ureters in the retroperitoneum prior to starting, but usually do not dissect them out. Is there anyone out there with similar mishaps? Any suggestions on changing my operative approach? Currently I am not firing at the uterine artery level and converting to vaginal hysterectomy early to avoid further ureteric injuries. I would enjoy comments from the "audience". Sorry for the length of this posting, but I thought it would be entertaining to say the least.....
-- David McCoubrey MDCM FRCSC OBGYN Cornwall, Ontario , CANADA
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