Ureterolysis for Laparoscopic Hysterectomy

Study Objective To demonstrate techniques of ureterolysis during complex laparoscopic hysterectomy. Design Technical video demonstrating different approaches to ureterolysis for complex benign pathology during laparoscopic hysterectomy (Canadian Task Force classification III). Setting Benign gynecology department at a university hospital. Intervention Performance of ureterolysis during laparoscopic hysterectomy for benign pathology. Conclusion Ureteric injury has significant morbidity and is the most common reason for litigation following hysterectomy, with an estimated risk of 0.02% to 0.4%. [ 1 Jha S Rowland S Litigation in gynaecology. Obstet Gynaecol. 2014; 16: 51-57 Google Scholar , 2 Adelman MR Bardsley TR Sharp HT Urinary tract injuries in laparoscopic hysterectomy: a systematic review. J Minim Invasive Gynecol. 2014; 21: 558-566 Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar ]. Ureterolysis is infrequently practiced by benign gynecologists; however, it may be necessary during complex surgery. Benign pathology requiring hysterectomy, such as endometriosis, myomas, large uteri, and adnexal masses, are recognized risk factors for ureteric injury [ 3 Piscitelli JT Simel DL Addison A Who should have intravenous pyelograms before hysterectomy for benign disease?. Obstet Gynecol. 1978; 69: 541-545 Google Scholar ]. Most injuries occur during division of the uterine artery at the level of the internal cervical os. The average distance between the ureter and cervix is 2 cm, but it is only 0.5 cm in 3.2% of the population with a normal pelvis [ 4 Hurd WW Chee SS Gallagher KL Ohl DA Hurteau JA Location of the ureters in relation to the uterine cervix by computed tomography. Am J Obstet Gynecol. 2001; 184: 336-339 Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar ]. Preventive strategies, such as the use of a uterine manipulator, may increase this distance, although it still might not be sufficient to prevent injury in women with normal anatomic variants and complex pathology. Visualizing the ureter at the pelvic brim and side wall without retroperitoneal dissection may be inadequate because the segment of ureter between the intersection of the uterine artery and the bladder is not visible. The ureter can be safely dissected up to 15 cm without compromising its viability. In this educational video, we demonstrate various simple, quick, and reproducible techniques to perform ureterolysis for complex benign pathology. These techniques can be used by both expert and novice surgeons to perform and teach ureterolysis. Our method determines the course of the ureter throughout the pelvis and relation to the uterine artery to reduce intraoperative injury. We have performed more than 350 cases with no injuries.