If the course of the ureter is not readily identified by direct transperitoneal visualization, a peritoneal incision can be made below and parallel to the infundibulopelvic ligament, which allows entry into the retroperitoneum and, typically, easy visualization of the ureter throughout its course.
Alternatively, the retroperitoneum can be entered lateral to the infundibulopelvic ligament, and the ureter can be identified in the same manner as in abdominal hysterectomy.
If laparoscopically assisted hysterectomy is planned, I prefer to dissect the bladder flap vaginally rather than laparoscopically, as the risk of bladder injury is considerably lower from a vaginal approach than it is laparoscopically. Obviously, if a total laparoscopic hysterectomy is necessary because of poor vaginal access, laparoscopic bladder flap dissection is necessary. In this case, I again favor sharp dissection and minimal use of cautery to avoid bladder injury.
How can a surgeon prevent bladder or ureteral injury during vaginal hysterectomy?
BENT: Traditional methods in which each clamp is rolled off the cervix or uterus until the procedure is completed help keep unsuspecting surgeons out of the bladder and away from the ureter. The only risk involves bladder mobilization (ie, creation of the bladder flap), which should always be done sharply to prevent bladder perforation. Avoid blunt finger or sponge-stick dissection! Knowing how to sharply dissect the bladder flap is vital—then even cases of prior cesarean section are manageable.
Salpingo-oophorectomy can also proceed under direct vision. Avoid the ureter by making sure the clamp closes only over the pedicles of the tube and ovary, with no intervening tissues in the clamp. If space is very tight, divide the round ligament and take the pedicle in a smaller bite. Traction on the cervix during the procedure, and mobilization of the bladder, allow the ureters to slide upward, well out of harm’s way, as the procedure progresses.
The importance of sharp dissection
BARBER: During vaginal hysterectomy, I usually have the operative assistant hold the cervical tenaculum so that there is tension on the uterus. I then use forceps to elevate the bladder directly vertically in order to place the bladder fibers on tension. Next, I dissect the bladder off the cervix and lower uterine segment using sharp dissection, and identify the peritoneum by direct finger palpation. Almost always, it is smooth and slippery.
After identifying the peritoneum, I grasp it with a tonsil clamp and elevate it so that it can be entered easily with scissors. I always confirm peritoneal entry by visualizing and identifying intraperitoneal structures such as bowel fat, the uterine serosal surface, or adnexae.
Some people advocate palpating the ureter during vaginal cases.
CUNDIFF: The most common time of injury during vaginal hysterectomy is during dissection of the vesicovaginal space; and suture ligation of the infundibulopelvic ligaments and uterine arteries carries the greatest potential for ureteral injury.
During vaginal hysterectomy, I try to dissect the vesicovaginal space early. I use a Deever retractor to retract the bladder anteriorly, maximizing my ability to sharply dissect close to the cervix until entering the peritoneal cavity. Once I’m in the peritoneal cavity, I advance the Deever retractor to protect the bladder through the rest of the procedure. I maximize protection of the ureters by applying downward traction on the cervix during vaginal clamp placement.
KARRAM: I agree. Never try to enter the anterior cul-de-sac until the vesicouterine space has been identified and is easily palpated. Rushing to enter the anterior cul-de-sac will only lead to inadvertent cystotomy.
Assessing ureteral patency
After what pelvic surgeries do you think ureteral patency should be assessed, and how should it be accomplished?
CUNDIFF: The literature contains several studies10-13 that involved universal endoscopy of the lower urinary tract. These studies demonstrate that most injuries are not recognized by the surgeon prior to endoscopy. In fact, the vast majority of injuries occur after straightforward hysterectomies. This may be due in part to the sheer volume of hysterectomies, compared with other pelvic surgeries. However, it also shows that, when lower urinary tract evaluation is performed solely when the surgeon suspects an injury, a substantial proportion of injuries are missed.
KARRAM: When do you assess ureteral patency?
CUNDIFF: My personal practice is to evaluate it in all cases that carry the potential for injury to the ureter. The complexity of the evaluation is proportional to the probability of ureteral injury.
For all laparotomies and laparoscopies, I identify the course of the ureter and confirm peristalsis. In the simplest of cases, this can be done by identifying the ureter beneath the peritoneum as it crosses the pelvic brim and courses across the pelvic sidewall. More frequently, it involves opening the pararectal space to identify the course of the ureter. In the most complex cases, it requires ureterolysis.