Causes and prevention of laparoscopic ureter injuries: an analysis of 31 cases during laparoscopic hysterectomy in the Netherlands.
BACKGROUND
Ureter injuries are the most dreaded complication in gynecological surgery. Some risk factors for the occurrence of urinary tract injuries are known, but clear guidelines to prevent ureter injuries during laparoscopic hysterectomy (LH) are lacking. The aim of this study was to analyze all known ureter injuries that occurred during LH for a benign indication in the Netherlands, in order to identify patient- and surgeon-related risk factors.


METHODS
Ninety-five LH-performing gynecologists were asked to recall all cases of known ureter injuries during LH in their hospital. After identification of ureter injuries, a structured interview was performed with a questionnaire that focused on the identification of predisposing factors which could account for the cause of the injury.


RESULTS
Forty-one injuries were detected in 37 patients (4 bilateral ureter injuries) in a 20-year period. The questionnaire could be completed for 31 cases. Predisposing factors were retrospectively assessed and classified into categories: patient-related (i.e., deep infiltrating endometriosis, intraligamentary fibroids) (n = 18), surgeon-related (insufficient experience and/or technique) (n = 16), or both (insufficient experience and difficult case) (n = 8). According to earlier-mentioned recommendations in a Delphi study among experts, in 48.4 % of these ureter injury cases, more than one of the recommended techniques or predisposing conditions were not applied or available. Only one ureter injury was diagnosed during the LH; the mean time to diagnose the injury was 29 days.


CONCLUSIONS
Incomplete learning curve, insufficient applied technique such as coagulation of the uterine artery without the use of a uterine manipulator, and/or from the contralateral side and/or without previously performed ureterolysis in case of distorted anatomy may be considered as the main predisposing factors.
Department of Obstetrics and Gynecology, VU University Medical Center, De Boelelaan 1117, 1181 HV Amsterdam, The Netherlands. pf.janssen@vumc.nl
Petra F
PF
Janssen
Hans A M
HA
Brölmann
Judith A F
JA
Huirne
D002983:Clinical Competence / Q000592:standards; D005260:Female; D006176:Gynecology / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007044:Hysterectomy / Q000009:adverse effects* / Q000295:instrumentation / Q000706:statistics & numerical data; D007431:Intraoperative Complications / Q000175:diagnosis / Q000209:etiology; D010535:Laparoscopy / Q000009:adverse effects* / Q000295:instrumentation / Q000706:statistics & numerical data; D059032:Learning Curve; D008875:Middle Aged; D009426:Netherlands; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013525:Surgical Instruments / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D014513:Ureter / Q000293:injuries*