1) Ĭlamping the lombo-ovarian ligament as close to the uterus as possible to avoid the lesion of the uterus at the level of the superior strait – evidenced in a cadaver by transillumination The ligature and the sectioning of the lombo-ovarian ligament as close as possible to the ovary, because, at the upper strait basin, the ureter can be clipped, ligaturated and cut along with it (as both elements going towards the interior get far from one another) ( Fig. The ligature and sectioning of the uterine vessels as close as possible to the uterus because the uterine vessels in the subligamentar segment of the pelvine area is the most frequent place in which the ureter is injured during abdominal hysterectomy abdominal (either angulated, either clipped, ligaturated and cut once with the uterine vessels especially during extracapsular techniques) The use of intracapsular techniques, with the ligature and sectioning of cardinal ligaments, uterosacrate and vezicouterin as close as possible to the uterus

No matter the way of dealing is used, the ureter should be identified in any type of pelvis surgery, and, in the difficult ones, its highlight should be accomplished from a retroperitoneal point of view. The careful mobilization of the bladderĪccording to the type of the surgery and the way of dealing with it, some gestures and steps should be taken into account in order to prevent iatrogenic ureteral injuries. The dissection with routinely highlight of the ureter and direct visualization The avoidance of blind clamping of the blood vessels – multiple pelvis surgery) the following can be used: intravenous urography, CT abdomen and pelvis with contrast material, RMN abdomen and pelvis or retrograde urography.

– at multiparous because of the relaxation of the means for ovary fixing, there is a change of relations between the ureter and the ovary – the retroligamentary segment, during the ovary mobilization, standing for one of the most frequent localizations of the iatrogenic ureteral injuries) or personal pathological history (i.e. congenital anomalies of the ureter and kidney in Ist degree relatives), physiological persons (i.e. In selected cases, according to the following: the history of the illness (i.e. Preventive strategies to reduce the risk of ureteral injury:Īll the patients who are going to undergo a pelvis surgery need a preoperative pelvic ultrasound that must exclude or warn the surgeon that there is an anatomical variant or aberrant trajectory of the ureter. Technical difficulties appear either due to bulky tumors or with the invasion in adjacent structures, which modifies the pelvis anatomy, or to the surgeon’s lack of experience. Bladder coexistent injury which masks the ureteral injury Massive intraoperative bleeding which forces “blind” clamping for the haemostasis Position changes of the ureter through: Congenital anomalies of the ureter or of the kidney The Anatomo-pathological risk factors that determine the modification of the pelvis anatomy are the following : the ureter is poorly vascularized–the terminal branches of the arteries, veins and lymphatic ureteral get anastomized and form a vascular periureteral network – which explains the avascular necrosis which appears a couple of days after the surgery, after stripping, as well as its destruction during the extensive dissections of the ureter. the ureter has variable trajectory-especially in the parietal segment of the pelvic area. the ureter has an intimate relation with high caliber elements which pump blood into the uterus and the annexes - the lombo-ovarian ligament (at the level of the upper strait basin) and the uterine artery in the broad ligament of the uterus, and thus, it can be ligature-clipped and cut together with them the ureter can also be angulated, with the appearance of a secondary obstruction, if the ligature of ovarian or uterine artery is made very close to the ureter. the ureter is a retro and subperitoneal organ but it also remains adherent to the posterior parietal peritoneum together with which it moves when this one is mobilized and thus it can be mistaken for a fold of the peritoneal and cut. Risk factors determined by the normal anatomy of the ureter: Risk factors for an iatrogenic ureteral injury

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