Ureteral Injury During Gynecologic Surgery Workup

Updated: Nov 12, 2020
  • Author: Sandip P Vasavada, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Laboratory Studies

If the ureteral injury is noted intraoperatively, additional laboratory tests are rarely, if ever, needed. Imaging studies are of greater benefit.

If ureteral injury is suspected postoperatively, laboratory tests, including a complete blood cell count (CBC) with manual differential and an electrolyte panel with blood urea nitrogen (BUN) and serum creatinine level, are needed to assess for possible infection and kidney dysfunction.

In the event that a CT-guided aspiration of an abdominal or pelvic fluid collection has been performed or if pelvic drain output is high through a surgically placed drain, a creatinine measurement of the fluid may be helpful in distinguishing whether the fluid is urine (as would be indicated by an elevated creatinine level).


Imaging Studies

If the ureteral injury is noted intraoperatively and an imaging study is necessary to localize the lesion, the best choice is retrograde ureteropyelography. After placement of a cystoscope in the bladder and cannulation of the affected ureteral orifice with a ureteral catheter, dilute diatrizoate (eg, Cystografin) is injected into the ureter under fluoroscopy or while taking a kidneys, ureters, bladder (KUB) image. If the dye is seen in the renal pelvis without any ureteral extravasation or significant narrowing along the ureter, the ureter is in continuity and the case may be managed conservatively, with either observation or stent placement.

If ureteral injury is suspected postoperatively, imaging studies evaluating for hydronephrosis, ipsilateral renal function, and continuity of the ureter are necessary. These imaging studies may include intravenous urography (IVU), abdominal and pelvic computed tomography (CT) scan with intravenous contrast, renal ultrasonography, and/or retrograde ureteropyelography.

While IVU largely has fallen out of favor in the evaluation of stone disease, many urologists believe that an IVU is the best imaging study to evaluate for continuity of the ureter in cases of ureteral injury. Unlike renal ultrasonography and a retrograde ureteropyelography, IVU is used to assess for function of the ipsilateral kidney and the drainage of the ureter in a series of sagittal images. Hydronephrosis, ureteral integrity, and any extravasation can usually be seen readily with IVU.

A CT scan can also be used to assess for both function of the ipsilateral kidney and drainage of the ureter. Because CT images are a series of cross sections, visualizing ureteral integrity and continuity is often more difficult with CT scanning than with IVU. However, CT scanning has the advantage of imaging for concomitant conditions at the same time.

Renal ultrasonography is perhaps the best noninvasive method to visualize the kidney and shows hydronephrosis with great sensitivity. Renal ultrasonography cannot be used to assess kidney function or the continuity of the ureter. Therefore, if renal ultrasonography is performed, retrograde ureteropyelography is often necessary to evaluate the course of the ureter.


Other Tests

If one is unsure whether a ureteral injury has occurred intraoperatively, intravenous administration of 10 mL of indigo carmine or methylene blue with 20 mg of furosemide may help to localize a ureteral injury. Extravasation of blue dye indicates ureteral discontinuity.

Postoperatively, if any drainage is noted from the vagina, an attempt should be made to diagnose a ureterovaginal or vesicovaginal fistula. This may be accomplished with a bedside test. In this test, a tablet of oral phenazopyridine (eg, Pyridium) is administered. The bladder is instilled via a catheter with saline that is colored with methylene blue. A vaginal tampon is inserted. Since phenazopyridine turns the urine orange, if an orange liquid is observed on the end of the tampon, a presumptive diagnosis of a ureterovaginal fistula can be made. Alternatively, if the tampon absorbs a blue liquid, the diagnosis of vesicovaginal fistula can be made. However, since both types of fistulas may be present simultaneously, this test may not be completely reliable.


Diagnostic Procedures

If the patient is unsuitable for surgery because of sepsis or hemodynamic instability, urinary diversion in the form of a percutaneous nephrostomy tube placement should be performed. This allows decompression of an enclosed and potentially infected space and helps to treat a urinary source of sepsis.


Histologic Findings

In very rare cases, ureteral injuries are first diagnosed based on identification of the ureter histologically in the pathologic specimen.