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Identification of ureteral ligation during gynecologic operations
Identification
of ureteral ligation
during gynecologic operations ARTHUR RAY Louisville,
J. A.
DONOVAN,
GIBSON,
M.D. M.D.
Kentucky
The injection of intraureteral dye for the diagnosis of ureteral ligation or injury was studied in mongrel dogs and baboons. Intraureteral injection of phenolsulfonphthalein and indigo carmine proved to be a practical means of identifying complete unilateral ureteral ligation. The safety of this procedure in animals has now been proved, and, if work in progress at present proves as effective, the procedure should be added to the gynecologic armamentarium in selected cases.
U R E T E R A L I N J U R Y is a rare but serious complication of gynecologic operations. Statistics vary, according to Reisman and associates,l from 10 per cent in radical hysterectomies to 0.5 per cent in routine hysterectomies. These figures can be misleading because reporting usually involves cases with successful diagnosis and therapy. If ureteral injury could be identified at the time of a surgical procedure and appropriate corrective measures instituted, it is likely that the dire consequences could be markedly reduced. The purpose of this project is to develop an easy method of identifying ureteral injury during a surgical procedure. Harvard2 and Benson and Hinman3 mentioned the use of intraureteral dye injection but no results were presented. The objectives of this study are: ( 1) to determine if intravenous indigo carmine is a practical means of identifying ureteral
From the Department Gynecology, University School of Medicine. y;;;‘ved
for
publication
Accepted
]anuary
of Obstetrics of Louisville, January
injury, (2) to determine if injection of phenolsulfonphthaIein (PSP) and indigo carmine directly into the ureters is a practical means of identifying ureteral obstruction, (3) to observe the effects of injection of these dyes directly into the ureter. Material
and
methods
experimentation. Nine
mongrel dogs were anesthetized with pentobarbital and the ureters exposed by laparotomy. Intravenous injection of indigo carmine was carried out in all animals. A preoperative intravenous pyelogram was obtained in one dog, and postoperative studies were performed in all animals. At laparotomy the dog ureters were stabilized with an Allis clamp and a 25 gauge butterfly needle was used for dye injection. Indigo carmine (one ampule diluted with 50 ml. of normal saline solution) and PSP (4 ampules diluted with 50 ml. of normal saline solution) were the two dyes chosen for the study. These dyes were selected because both can be safely given intravenously; therefore, if inadvertent intravenous injection is performed into the lateral umbilical arteries or ovarian vein, no harm occurs to the patient. PSP must be used in a relatively concentrated form because of its light pink color in acid urine. Injection into the ureter was Dog
and
4,
16, 1973.
Reprint requests: Dr. Arthur J. Donovan, Dept, of Ob./Gyn., University of Louisville, Louisvtlle, Kentucky 40202. 793
794
Donovan
and
July 15, 1973 Am. J. Ohs*@. GynecoI.
Gibson
performed prior to and following ureteral ligation. The dogs were killed at periods frorn one week to two months postoperatively and the ureters observed for injury or stricture. Baboon experimentation. Three baboons were anesthetized with phencyclidine and pentobarbital. They were particularly selected because their ureteral anatomy and size were very similar to those in the human subject. PSP was first injected into one ureter and the results obtained. Indigo carmine was then injected into the other ureter. The techniques and observations were recorded on a 16 mm. movie film. Preoperative intravenous pyelograms and postoperative studies at one and 3 weeks were obtained. Results
and
comment
The intravenous injection of indigo carmine was not felt to be a practical means of identifying unilateral ureteral injury. In the mongrel dog one could observe the passage of the dye through the intact ureter. The observation of dye passage in the baboon was more difficult because of ureteral wall thickness. Following unilateral ureteral ligation in dogs and baboons, the dye would appear in the urine via the unligated ureter. Intravenous indigo carmine does have value in the diagnosis of bilateral ureteral ligation and leakage of urine into the operative site. Injection of dye into the ureter was difficult in the dog because of the small size of the ureter. This was improved somewhat by adequate preoperative hydration, PSP was used first because of its weak red color. Following injection, the urine immediately showed a red coloration. Indigo carmine was then injected into the opposite ureter and the urine immediately showed a blue color.
Ureteral ligation was then performed. Following this, no dye appeared in the urine through the ligated ureter. The end point for determining ureteral patency is the appearance of red and blue color in urine via the Foley catheter. The dogs were killed at periods of one week postoperatively. There was no gross appearance of ureteral damage in any dog. The ureters were sectioned, and at one week there was marked evidence of inflammatory reaction present; in subsequent animals this had cleared completely. Ureteral peristalsis was normal in all animals and there was no evidence of stricture on postoperative intravenous pyelograms. Intraureteral injection in the baboon was technically easier because of the larger ureteral size. The results were similar in the baboon studies, and injection of dye into the ureter immediately colored the urine. Following unilateral ligation, no dye appeared in the urine although vigorous ureteral peristalsis was present. This indicates that ureteral peristalsis alone does not rule out ureteral injury. Preoperative and postoperative intravenous pyelograms obtained on all baboons revealed no evidence of hydronephrosis or ureteral stricture. One must be very careful in identifying the ureter because inadvertent injection into the ovarian vessels may give fallacious results. One method found helpful is the use of negative pressure with the syringe which will readily identify a blood vessel. It is also conceivable that injuries such as crushing or partial ligation may not be identified by this procedure and might well result in urine coloration at the time of operation.
REFERENCES
1. Reisman, D. D., Kamholz, J. H., and Kantor, II. I.: J. Ural. 73: 363, 1957. ‘I
Harvard,
-’
‘711.
B. 1959.
M.:
Med.
Clin.
North
Am.
43:
3.
Benson, GYSECOL.
R. C., and Hinman, 70: 467, 1955.
F.: AM.
J. OBSTET.
of ureteral ligation
during gynecologic operations ARTHUR RAY Louisville,
J. A.
DONOVAN,
GIBSON,
M.D. M.D.
Kentucky
The injection of intraureteral dye for the diagnosis of ureteral ligation or injury was studied in mongrel dogs and baboons. Intraureteral injection of phenolsulfonphthalein and indigo carmine proved to be a practical means of identifying complete unilateral ureteral ligation. The safety of this procedure in animals has now been proved, and, if work in progress at present proves as effective, the procedure should be added to the gynecologic armamentarium in selected cases.
U R E T E R A L I N J U R Y is a rare but serious complication of gynecologic operations. Statistics vary, according to Reisman and associates,l from 10 per cent in radical hysterectomies to 0.5 per cent in routine hysterectomies. These figures can be misleading because reporting usually involves cases with successful diagnosis and therapy. If ureteral injury could be identified at the time of a surgical procedure and appropriate corrective measures instituted, it is likely that the dire consequences could be markedly reduced. The purpose of this project is to develop an easy method of identifying ureteral injury during a surgical procedure. Harvard2 and Benson and Hinman3 mentioned the use of intraureteral dye injection but no results were presented. The objectives of this study are: ( 1) to determine if intravenous indigo carmine is a practical means of identifying ureteral
From the Department Gynecology, University School of Medicine. y;;;‘ved
for
publication
Accepted
]anuary
of Obstetrics of Louisville, January
injury, (2) to determine if injection of phenolsulfonphthaIein (PSP) and indigo carmine directly into the ureters is a practical means of identifying ureteral obstruction, (3) to observe the effects of injection of these dyes directly into the ureter. Material
and
methods
experimentation. Nine
mongrel dogs were anesthetized with pentobarbital and the ureters exposed by laparotomy. Intravenous injection of indigo carmine was carried out in all animals. A preoperative intravenous pyelogram was obtained in one dog, and postoperative studies were performed in all animals. At laparotomy the dog ureters were stabilized with an Allis clamp and a 25 gauge butterfly needle was used for dye injection. Indigo carmine (one ampule diluted with 50 ml. of normal saline solution) and PSP (4 ampules diluted with 50 ml. of normal saline solution) were the two dyes chosen for the study. These dyes were selected because both can be safely given intravenously; therefore, if inadvertent intravenous injection is performed into the lateral umbilical arteries or ovarian vein, no harm occurs to the patient. PSP must be used in a relatively concentrated form because of its light pink color in acid urine. Injection into the ureter was Dog
and
4,
16, 1973.
Reprint requests: Dr. Arthur J. Donovan, Dept, of Ob./Gyn., University of Louisville, Louisvtlle, Kentucky 40202. 793
794
Donovan
and
July 15, 1973 Am. J. Ohs*@. GynecoI.
Gibson
performed prior to and following ureteral ligation. The dogs were killed at periods frorn one week to two months postoperatively and the ureters observed for injury or stricture. Baboon experimentation. Three baboons were anesthetized with phencyclidine and pentobarbital. They were particularly selected because their ureteral anatomy and size were very similar to those in the human subject. PSP was first injected into one ureter and the results obtained. Indigo carmine was then injected into the other ureter. The techniques and observations were recorded on a 16 mm. movie film. Preoperative intravenous pyelograms and postoperative studies at one and 3 weeks were obtained. Results
and
comment
The intravenous injection of indigo carmine was not felt to be a practical means of identifying unilateral ureteral injury. In the mongrel dog one could observe the passage of the dye through the intact ureter. The observation of dye passage in the baboon was more difficult because of ureteral wall thickness. Following unilateral ureteral ligation in dogs and baboons, the dye would appear in the urine via the unligated ureter. Intravenous indigo carmine does have value in the diagnosis of bilateral ureteral ligation and leakage of urine into the operative site. Injection of dye into the ureter was difficult in the dog because of the small size of the ureter. This was improved somewhat by adequate preoperative hydration, PSP was used first because of its weak red color. Following injection, the urine immediately showed a red coloration. Indigo carmine was then injected into the opposite ureter and the urine immediately showed a blue color.
Ureteral ligation was then performed. Following this, no dye appeared in the urine through the ligated ureter. The end point for determining ureteral patency is the appearance of red and blue color in urine via the Foley catheter. The dogs were killed at periods of one week postoperatively. There was no gross appearance of ureteral damage in any dog. The ureters were sectioned, and at one week there was marked evidence of inflammatory reaction present; in subsequent animals this had cleared completely. Ureteral peristalsis was normal in all animals and there was no evidence of stricture on postoperative intravenous pyelograms. Intraureteral injection in the baboon was technically easier because of the larger ureteral size. The results were similar in the baboon studies, and injection of dye into the ureter immediately colored the urine. Following unilateral ligation, no dye appeared in the urine although vigorous ureteral peristalsis was present. This indicates that ureteral peristalsis alone does not rule out ureteral injury. Preoperative and postoperative intravenous pyelograms obtained on all baboons revealed no evidence of hydronephrosis or ureteral stricture. One must be very careful in identifying the ureter because inadvertent injection into the ovarian vessels may give fallacious results. One method found helpful is the use of negative pressure with the syringe which will readily identify a blood vessel. It is also conceivable that injuries such as crushing or partial ligation may not be identified by this procedure and might well result in urine coloration at the time of operation.
REFERENCES
1. Reisman, D. D., Kamholz, J. H., and Kantor, II. I.: J. Ural. 73: 363, 1957. ‘I
Harvard,
-’
‘711.
B. 1959.
M.:
Med.
Clin.
North
Am.
43:
3.
Benson, GYSECOL.
R. C., and Hinman, 70: 467, 1955.
F.: AM.
J. OBSTET.