1 Division of Advanced Laparoscopic Surgery 2 Division of Reproductive Endocrinology, Columbia Presbyterian Medical Center 3 Columbia University College of Physicians and Surgeons, New York, New York, USA 4 Hospital das Clinicas da FMUSP, Rua Eneas de Carvalho Aguiar, 255, 10° andar, sala 10167São Paulo, Brasil CEP 05403000
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Abstract |
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Key words: complications/cystoscopy/hysterectomy/laparoscopy/ureter
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Introduction |
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Ureteral injury in gynaecological procedures continues to be a problem that frequently warrants additional corrective surgery and increases morbidity and mortality (Saidi et al., 1996). The risk of damage increases when the normal course of the ureter is either altered by primary gynaecological pathological factors or is inadequately visualized during intra-operative complications, such as bleeding (Wiskind and Thompson, 1995
). Early detection and repair of intra-operative ureteral injuries can restore normal function and avoid postoperative complication (Selzman et al., 1995
).
The aim of this study was to determine the usefulness of intra-operative cystoscopy in documenting the complication and therefore allowing the surgeon to proceed with immediate corrective action.
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Materials and methods |
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The main preoperative diagnoses (Table I) were symptomatic fibroids (70.3%) and pelvic pain with endometriosis (18.6%).
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Each uterine vessel pedicle was suture-ligated with 0-Vicryl on a blunt-tip needle, using extracorporeal knot technique. The upper uterine blood supply was ligated using 20 Vicryl, either on a curved needle or a free ligature, which was placed around the infundibulopelvic ligament (when oophorectomy was indicated or desired) or around the uteroovarian ligament (when ovarian preservation was possible and desired). A spoon electrode divided the broad ligament and the round ligament just lateral to the uteroovarian artery anastomosis. After dividing the round ligaments at their midportion, scissors or a spoon electrode was used to separate the vesico uterine peritoneal fold and the bladder was mobilized free from the uterus and upper vagina. The cardinal ligaments on each side were divided and the vagina was entered posteriorly, near the cervicovaginal junction. A 4 cm vaginal delineator was placed in the vagina, identifying anterior cervicovaginal junction and the lateral fornices. They were incised using a CO2 laser to complete the circumferential culdotomy.
The uterus was morcellated, if necessary, and pulled out of the vagina. A vaginal delineator was placed back into the vagina for closure of the vaginal cuff. A High McCall culdoplasty was performed. A rectal probe was used to ease the identification of the rectum and the left and the right uterosacral ligaments. A 0-Vicryl suture was placed through the left uterosacral and then through the left cardinal ligament with a few cells of the posterolateral vagina just below the uterine vessels, and along the posterior vaginal epithelium with a few bites over the right side. Finally, the same suture was used to fix the right posterolateral vagina and right cardinal ligaments to the right uterosacral ligament. When necessary, a second or third suture was used in the same fashion through the uterosacral ligaments to avoid any peritoneal gap, which might result in a future enterocele formation.
At this point, 5 ml of indigo carmine dye was administered to the patient. A transurethral cystoscopy was routinely done after cuff closure to verify ureteral permeability and bladder integrity. If a cystoscope was not available, a 30° hysteroscope was used. At the close of each operation, an underwater examination was used to detect bleeding from vessels and viscera tamponaded during the procedure by the increased intraperitoneal pressure of the CO2 pneumoperitoneum. At least 2 l of lactated Ringer's solution was left in the peritoneal cavity. The umbilical incision was closed with a single 40 Vicryl suture opposing deep fascia and skin dermis, with the knot buried beneath the fascia. The lower quadrant incisions were loosely approximated with a Javid vascular clamp (V. Mueller, McGraw Park, IL, USA) and covered with collodion to allow drainage of excess lactated Ringer's solution.
The types of laparoscopic technique carried out on the 118 patients were simply modifications of the more extensive procedure described above. All types of procedures done are presented in Table II. If laparoscopic lymphadenectomy was indicated, it was performed at the beginning of the surgery and the technique was essentially the same used for pelvic lymphadenectomy carried out by laparotomy. The detailed description of that technique may be found elsewhere (Neuman et al., 1991
).
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Results |
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Discussion |
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As far as we know, this study is the first one to consider the usefulness of detection of ureteral damage after laparoscopic hysterectomy using intra-operative cystoscopy to assess ureteral permeability in a large series. A misplaced suture during the uterine artery ligature was responsible for three cases of ureteral occlusion in this group. One patient had a fibrotic band. All these patients had a distortion of the anatomy caused by severe uterosacral endometriosis and a large uterus (Table III). The intra-operative cystoscopy enabled the recognition of all cases of ureteral occlusion, avoiding the delay of 221 days in recognition. We agree with other authors that it is best to find out about ureteral obstruction at the time of the initial surgery (Grainger et al., 1990
). The early intra-operative diagnosis and repair of these complications explain the absence of postoperative ureteral complications in our series.
Some authors have observed that endo-urological techniques are highly successful in treating ureterovaginal fistulae (Selzman et al., 1995). In a series of seven ureterovaginal fistulae treated with a ureteral stent for 48 weeks, six healed completely without stricture. One stricture developed after 2 months after the stent was removed but conservative management with endo-urological techniques by cutting, dilating and stenting the ureter for 6 weeks resulted in complete resolution of the stricture.
The incidence of intra-operative ureteral obstruction found in our selected group of patients (3.4%) was similar to that found by others (4%; Harris et al., 1997) suggesting a comparable incidence of ureteral injuries at the time of either major operative laparoscopic or traditional open gynaecological surgeries. Intra-operative cystoscopy allows early recognition and treatment of all obstructive ureteral injuries and may reduce the postoperative rate of complications during advanced laparoscopic procedures.
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Notes |
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References |
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Submitted on October 16, 1998; accepted on March 16, 1999.