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Ureteral injury after laparoscopic surgery
August 1997, Vol. 4, No. 4
TheJournal of the American Association of Gynecologic Laparoscopists
Ureteral Injury after Laparoscopic Surgery Cheng-Hsien Liu, M.D., Peng-Hui Wang, M.D., Wei-Ming Liu, M.D., and Chiou-Chung Yuan, M.D.
Abstract
Ureteral injuries are uncommon but serious complications of laparoscopic pelvic surgery. When unrecognized, patients experience fever, abdominal pain, signs of peritonitis, and leukocytosis usually 48 to 72 hours after the surgical procedure. A 48-year-old woman underwent laparoscopic-assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and anterior and posterior colporrhapy due to a large, symptomatic uterine myoma. Postoperatively, she suffered from progressive left lower quadrant pain, with drainage of yellowish fluid from the subumbilical puncture wound 5 days after the operation. Significant urinary ascites was present. Intravenous pyelogram revealed injury to the lower third of the left ureter about 3 cm away from the ureterovesical junction. Leftsided percutaneous nephrostomy was performed after transurethral placement of a ureteral stent failed. Reanastomosis of the ureter was performed successfully 3 months later, and the patient fully recovered without compromise of the genitourinary tract. (J Am Assoc Gynecol Laparosc 4(4):503-506, 1997)
flow and dysmenorrhea. She was scheduled to undergo LAVH plus bilateral salpingo-oophorectomy.
Ureteral injury is a rare complication associated with laparoscopic-assisted vaginal hysterectomy (LAVH), and its true frequency is unknown. A MEDLINE search revealed few published reports of this complication?-" Because LAVH is relatively new, it may require more time for case studies to be compiled. Furthermore, investigators may be reluctant to report complications to avoid damage to personal reputations or for medicolegal considerations. This case report should encourage others to assist in establishing the relative complication rate of LAVH.
Operative Procedure The patient received general anesthesia and was placed in dorsolithotomy position. A Foley catheter was inserted into the urinary bladder and a sound was inserted into the uterus to mobilize the uterus. Pneumoperitoneum was established with a Veress needle. Three port sites were established, with a 12-ram cannula in the periumbilical area and two 5-mm cannulas in both lateral abdominal incisions. We used disposable cannulas, which are sharp and easy to insert, and have retractable safety shields to prevent abdominal injuries. The 5-mm lateral cannulas were placed under direct laparoscopic view.
Case Report A 48-year-old, gravida 3, para 2 woman was admitted because of a uterine myoma, with heavy menstrual
From the Department of Obstetrics and Gynecology Veterans General Hospital-Taipei, National Yang-Ming University School of Medicine, Taipei, Taiwan (all authors). Address reprint requests to Chiou-Chung Yuan, M.D., Department of Obstetrics and Gynecology, Veterans General Hospital-Taipei, 201, Section 2, Shih-Pai Road, Taipei 11217, Taiwan; fax 886 287 39571.
503
Ureteral Injury after Laparoscopic Surgery Liu et al
With laparoscope and video camera in place, the ovaries and fallopian tubes were grasped with Babcock clamps and pulled medially; the uterus was pushed to the opposite side to expose the operative field, and the ureter was identified. Kleppinger bipolar forceps (Richard Wolf) was used to desiccate the infundibulopelvic (IP) ligament and round ligament with highfrequency, low-voltage cutting current (20-50 W; Elmed LBC 50 generator). We routinely choose sites just below the ovaries to divide the IP ligaments because the ureters are more deeply embedded in retroperitoneum at this point. A plane was developed between the retroperitoneum and the ureter. The duration of each desiccation did not exceed 20 seconds. On average, two to three desiccations to 0.5 cm depth were necessary. The peritoneum was incised, and the incision was continued along the posterior leaf of the broad ligament toward the uterosacral ligament with dissecting scissors attached to a unipolar circuit (40 W; ValleyLab) with unmodulated (coagulation) current. The uterosacral ligaments were not divided laparoscopically. Usually the so-called congenital adhesions on the left side attach the sigmoid colon to the peritoneum laterally at the pelvic brim. Dissection of the left IP ligament was begun by separating these adhesions from the underlying peritoneum so that the redundant sigmoid colon could be moved freely to the fight side to avoid injury. The patient's bulky uterus obscured the operative field and interfered with delicate manipulation of the instruments. To separate this congenital adhesion thoroughly, the duration of desiccation exceeded 20 seconds, probably because of some difficulty encountered when developing the paravesical space on the left side. Oozing areola tissue was initially coagulated with unipolar scissors to seal tiny, hairlike vessels. The pararectal spaces were opened by blunt dissection lateral to the ureters at the uterosacral ligament area. The fight uterine artery was exposed easily between the paravesical and pararectal spaces. Adequate bipolar desiccation was applied to the right uterine artery before division. The left uterine artery was not adequately exposed due to oozing because of incomplete coagulation of tiny vessels. Bleeders were sealed by massive, blind unipolar desiccation, and the left uterine artery was desiccated as usual. The left ureter was dissected to check the patency of the ureter, with satisfactory results (normal peristalsis). When the laparoscopic phase was completed, vaginal hysterectomy was performed as usual. After clos-
ing the vaginal cuff, the abdomen was reinflated, and hemostasis and patency of both ureters were confirmed.
Postoperative Course Postoperatively, the patient experienced persistent low-grade fever associated with abdominal discomfort. Clear discharge from the subumbilical stab wound was noted 5 days after the procedure. Sonographic examination showed massive f u i d accumulation in the abdominal cavity. Because of possible urinary tract injury, intravenous pyelogram with postvoiding vesicography was done, showing localized irregular collection of contrast medium around the lower third of the left ureter. Computerized tomographic scan revealed the presence of ascites due to left ureteral injury. Left percutaneous nephrostomy was performed after we were unsuccessful in placing a double-J stent for internal urinary diversion. Subsequent antegrade pyelogram showed extravasation of radiopaque contrast medium in the lower third of the left ureter. An end-to-end anastomosis of the ureter with double-J stent in place was performed 3 months after the first operation. The stent was removed 3 months later and the patient recovered well. Discussion
Iatrogenic ureteral injuries may occur during open and endoscopic operations. Endometriosis, ovarian neoplasm, pelvic adhesions, an enlarged uterus, distorted pelvic anatomy, coexistent bladder injury, and massive intraoperative hemorrhage are all risk factors for such injury.~ Some investigators reported that during open gynecologic surgery the ureter is most commonly injured at the pelvic brim where the ovarian vessels cross the ureter in the IP ligament, whereas others found that the damage occurs distal to this region where the uterine artery crosses ventral to the ureter and at the angle of the vaginal fornix.l. 4.7Whether the injuries are recognized either immediately or later,2they mandate immediate therapy. The frequency of ureteral injuries was higher after adnexectomy compared with LAVH; 3 (3%) in 102 cases of the former and 1 (0.2%) in 489 cases of the latter.U Urinoma was the clinical manifestation in three women, one bladder injury and two ureteral injuries.ll In our patient, urinary ascites initially caused drainage from a stab wound, low-grade fever, and delayed recovery. Laboratory examination showed mild
504
August 1997, Vol. 4, No. 4
TheJournal of the American Association of Gynecologic Laparoscopists
leukocytosis. Radiologic studies showing leakage at the injured site confirmed the diagnosis. Depending on the severity of the injury, partial transection of the ureter may be managed with primary closure and stent placement if the tissues appear viable. Various open surgical reconstructive techniques have been performed with successful results. 3 Endoscopic placement of an internal ureteral stent may suffice if the ureter appears viable. Repair may be done laparoscopically,4.9 which avoids laparotomy in patients with viable ureters. In this woman, after failing to place an internal stent, percutaneous nephrostomy was performed due to delayed diagnosis during the active inflammatory stage of wound healing. Clinical manifestations improved soon after the procedure. The three common sites for ureteric injury are at the IP ligament where the ureter crosses the pelvic brim and the common iliac vessels, at the uterosacral ligament where the ureter passes, and at the ureteric canal where the ureter passes under the uterine artery. The last might have been the site in our patient, and the injury might have resulted in part from thermal damage during electrodesiccation, from minor lacerations while isolating the ureter, or from the combination of both during the laparoscopic phase of the operation. Indeed, this woman's uterosacral ligament was not divided in the laparoscopic phase, and radiologic examination confirmed the location of injury. The huge uterus caused distortion of both ureters, especially the left one, and so-called congenital adhesions on the left side caused difficulty in laparoscopic manipulation. Furthermore, bleeding from tiny vessels during dissection of the paravesical space obscured the operative field; blind as well as massive coagulation with unipolar scissors was associated with a long desiccation time, and blood stained the extraperitoneal areolar tissues. Although it is theoretically simple to develop areolar tissue on either side of the uterus, we faced some difficulty in this patient. Tiny vessels were injured while developing the paravesical space, resulting in thermal injury while trying to desiccate the bleeders. This thermal effect from the unipolar circuit attached to the dissecting scissors might have caused delayed necrosis of the left ureter with extravasation of urine. It was postulated that 7 days are required to create a ureteral fistula when the cause is propagation either of current or of heat.~2 Dissection of the left ureter was performed in this case to check patency, which might have intensified the thermal damage to the ureter. This
phenomenon was supported by literature reports. Thermal injury to the ureter, which occurs most commonly after fulguration or laser vaporization of endometriosis involving the uterosacral ligaments, usually causes a stricture hydroureter and hydronephrosis, and can ultimately lead to loss of the affected kidney. ~3 We conclude that the most likely cause of injury in our patient was the combination of thermal injury and minor laceration. To reduce the chance of such events during laparoscopic surgery, every operator must be careful not to injure tiny vessels, since the slightest amount of bleeding could stain extraperitoneal areolar tissues and obscure the view of underlying structures. Delicate manipulation and avoidance of unipolar electrodessication for massive and obscured operative tissue should be kept in mind. Furthermore, bipolar electrodesiccation for transection of uterine vessels must be performed carefully and avoided whenever the operative field is not clearly defined. There are conflicting reports on whether it is necessary to dissect the ureter when performing LAVH. 14 The ureter is easily identified when the IP ligament or utero-ovarian ligament is divided and traced along the retroperitoneum. Still, it might be necessary sometimes to dissect the ureter at the retroperitoneum for a short distance to aid in its identification. This is a crucial step when severe endometriosis and an enlarged uterus cause distortion of structures. It is also prudent to visualize the ureter when the uterine artery is desiccated with bipolar scissors. Although we performed dissection of the ureter, this procedure was followed by desiccation of the uterine vessel due to oozing and bleeding. If we had identified the left ureter before desiccating the uterine vessel in such a troublesome case, this complication could have been avoided. Furthermore, we emphasize the importance of continuous irrigation with cold normal saline to cool the operative site, and suction of excessive amount of fluid, since cleaning the operative field may decrease occurrence of such injury. In addition, we could have used four port sites instead of the traditional three in our patient. A suction-irrigation catheter could have then been placed through the suprapubic port. References
1. Meirow D, Moriel EZ, Zilberman M, et al: Evaluation and treatment of iatrogenic ureteral injuries during obstetric and gynecologic operations for nonmalignant conditions. J Am Coil Surg 178:144-148, 1994
505
Ureteral Injury after Laparoscopic Surgery Liu et at
8. Winslow PH, Kreger R, Ebbeson B, et al: Conservative management of electrical bum injury of the ureter secondary to laparoscopy. Urology 27:60-62, 1986
2. Grainger DA, Soderstrom RM, Schiff SF, et al: Ureteral injuries at laparoscopy: Insights into diagnosis, management, and prevention. Obstet Gyneco175:839-843, 1990
9. Nezhat C, Nezhat F, Green B: Laparoscopic treatment of obstructed ureter due to endometriosis by resection and ureteroureterostomy: A case report. J Urol 148:865-868, 1992
3. Blandy JP, Badenoch DE Fowler CG, et al: Early repair of iatrogenic injury to the ureter or bladder after gynecological surgery. J Urol 146:761-765, 1991
10. Schwartz RO: Complications of laparoscopic hysterectomy. Obstet Gynecol 81:1022-1024, 1993
4. Nezhat C, Nezhat F: Laparoscopic repair of ureter resected during operative laparoscopy. Obstet Gynecol 80:543-544, 1992
11. Saidi MH, Sadler RK, Vancaillie TG, et al: Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol 87:272-276, 1996
5. Assimos DG, Patterson LC, Taylor CL: Changing incidence and etiology of iatrogenic ureteral injuries. J Urol 152:2240-2246, 1994
12. Donnez J, Nisolle M: An Atlas of Laser Operative Laparoscopy and Hysteroscopy. New York, Parthenon Publishing Group, 1994
6. Gomel V, James C: Intraoperative management of ureteral injury during operative laparoscopy. Fertil Steril 55:416-419, 1991
13. Kadar N: Atlas of Laparoscopic Pelvic Surgery. London, Blackwell Science, 1995
7. Kadar N, Lemmerling L: Urinary tract injuries during laparoscopically assisted hysterectomy: Causes and prevention. Am J Obstet Gynecol 170:47-48, 1994
14. Lee CL, Soong YK: Laparoscopic hysterectomy: ls dissecting the ureter necessary? Int Surg 80:167-169, 1995
506
TheJournal of the American Association of Gynecologic Laparoscopists
Ureteral Injury after Laparoscopic Surgery Cheng-Hsien Liu, M.D., Peng-Hui Wang, M.D., Wei-Ming Liu, M.D., and Chiou-Chung Yuan, M.D.
Abstract
Ureteral injuries are uncommon but serious complications of laparoscopic pelvic surgery. When unrecognized, patients experience fever, abdominal pain, signs of peritonitis, and leukocytosis usually 48 to 72 hours after the surgical procedure. A 48-year-old woman underwent laparoscopic-assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and anterior and posterior colporrhapy due to a large, symptomatic uterine myoma. Postoperatively, she suffered from progressive left lower quadrant pain, with drainage of yellowish fluid from the subumbilical puncture wound 5 days after the operation. Significant urinary ascites was present. Intravenous pyelogram revealed injury to the lower third of the left ureter about 3 cm away from the ureterovesical junction. Leftsided percutaneous nephrostomy was performed after transurethral placement of a ureteral stent failed. Reanastomosis of the ureter was performed successfully 3 months later, and the patient fully recovered without compromise of the genitourinary tract. (J Am Assoc Gynecol Laparosc 4(4):503-506, 1997)
flow and dysmenorrhea. She was scheduled to undergo LAVH plus bilateral salpingo-oophorectomy.
Ureteral injury is a rare complication associated with laparoscopic-assisted vaginal hysterectomy (LAVH), and its true frequency is unknown. A MEDLINE search revealed few published reports of this complication?-" Because LAVH is relatively new, it may require more time for case studies to be compiled. Furthermore, investigators may be reluctant to report complications to avoid damage to personal reputations or for medicolegal considerations. This case report should encourage others to assist in establishing the relative complication rate of LAVH.
Operative Procedure The patient received general anesthesia and was placed in dorsolithotomy position. A Foley catheter was inserted into the urinary bladder and a sound was inserted into the uterus to mobilize the uterus. Pneumoperitoneum was established with a Veress needle. Three port sites were established, with a 12-ram cannula in the periumbilical area and two 5-mm cannulas in both lateral abdominal incisions. We used disposable cannulas, which are sharp and easy to insert, and have retractable safety shields to prevent abdominal injuries. The 5-mm lateral cannulas were placed under direct laparoscopic view.
Case Report A 48-year-old, gravida 3, para 2 woman was admitted because of a uterine myoma, with heavy menstrual
From the Department of Obstetrics and Gynecology Veterans General Hospital-Taipei, National Yang-Ming University School of Medicine, Taipei, Taiwan (all authors). Address reprint requests to Chiou-Chung Yuan, M.D., Department of Obstetrics and Gynecology, Veterans General Hospital-Taipei, 201, Section 2, Shih-Pai Road, Taipei 11217, Taiwan; fax 886 287 39571.
503
Ureteral Injury after Laparoscopic Surgery Liu et al
With laparoscope and video camera in place, the ovaries and fallopian tubes were grasped with Babcock clamps and pulled medially; the uterus was pushed to the opposite side to expose the operative field, and the ureter was identified. Kleppinger bipolar forceps (Richard Wolf) was used to desiccate the infundibulopelvic (IP) ligament and round ligament with highfrequency, low-voltage cutting current (20-50 W; Elmed LBC 50 generator). We routinely choose sites just below the ovaries to divide the IP ligaments because the ureters are more deeply embedded in retroperitoneum at this point. A plane was developed between the retroperitoneum and the ureter. The duration of each desiccation did not exceed 20 seconds. On average, two to three desiccations to 0.5 cm depth were necessary. The peritoneum was incised, and the incision was continued along the posterior leaf of the broad ligament toward the uterosacral ligament with dissecting scissors attached to a unipolar circuit (40 W; ValleyLab) with unmodulated (coagulation) current. The uterosacral ligaments were not divided laparoscopically. Usually the so-called congenital adhesions on the left side attach the sigmoid colon to the peritoneum laterally at the pelvic brim. Dissection of the left IP ligament was begun by separating these adhesions from the underlying peritoneum so that the redundant sigmoid colon could be moved freely to the fight side to avoid injury. The patient's bulky uterus obscured the operative field and interfered with delicate manipulation of the instruments. To separate this congenital adhesion thoroughly, the duration of desiccation exceeded 20 seconds, probably because of some difficulty encountered when developing the paravesical space on the left side. Oozing areola tissue was initially coagulated with unipolar scissors to seal tiny, hairlike vessels. The pararectal spaces were opened by blunt dissection lateral to the ureters at the uterosacral ligament area. The fight uterine artery was exposed easily between the paravesical and pararectal spaces. Adequate bipolar desiccation was applied to the right uterine artery before division. The left uterine artery was not adequately exposed due to oozing because of incomplete coagulation of tiny vessels. Bleeders were sealed by massive, blind unipolar desiccation, and the left uterine artery was desiccated as usual. The left ureter was dissected to check the patency of the ureter, with satisfactory results (normal peristalsis). When the laparoscopic phase was completed, vaginal hysterectomy was performed as usual. After clos-
ing the vaginal cuff, the abdomen was reinflated, and hemostasis and patency of both ureters were confirmed.
Postoperative Course Postoperatively, the patient experienced persistent low-grade fever associated with abdominal discomfort. Clear discharge from the subumbilical stab wound was noted 5 days after the procedure. Sonographic examination showed massive f u i d accumulation in the abdominal cavity. Because of possible urinary tract injury, intravenous pyelogram with postvoiding vesicography was done, showing localized irregular collection of contrast medium around the lower third of the left ureter. Computerized tomographic scan revealed the presence of ascites due to left ureteral injury. Left percutaneous nephrostomy was performed after we were unsuccessful in placing a double-J stent for internal urinary diversion. Subsequent antegrade pyelogram showed extravasation of radiopaque contrast medium in the lower third of the left ureter. An end-to-end anastomosis of the ureter with double-J stent in place was performed 3 months after the first operation. The stent was removed 3 months later and the patient recovered well. Discussion
Iatrogenic ureteral injuries may occur during open and endoscopic operations. Endometriosis, ovarian neoplasm, pelvic adhesions, an enlarged uterus, distorted pelvic anatomy, coexistent bladder injury, and massive intraoperative hemorrhage are all risk factors for such injury.~ Some investigators reported that during open gynecologic surgery the ureter is most commonly injured at the pelvic brim where the ovarian vessels cross the ureter in the IP ligament, whereas others found that the damage occurs distal to this region where the uterine artery crosses ventral to the ureter and at the angle of the vaginal fornix.l. 4.7Whether the injuries are recognized either immediately or later,2they mandate immediate therapy. The frequency of ureteral injuries was higher after adnexectomy compared with LAVH; 3 (3%) in 102 cases of the former and 1 (0.2%) in 489 cases of the latter.U Urinoma was the clinical manifestation in three women, one bladder injury and two ureteral injuries.ll In our patient, urinary ascites initially caused drainage from a stab wound, low-grade fever, and delayed recovery. Laboratory examination showed mild
504
August 1997, Vol. 4, No. 4
TheJournal of the American Association of Gynecologic Laparoscopists
leukocytosis. Radiologic studies showing leakage at the injured site confirmed the diagnosis. Depending on the severity of the injury, partial transection of the ureter may be managed with primary closure and stent placement if the tissues appear viable. Various open surgical reconstructive techniques have been performed with successful results. 3 Endoscopic placement of an internal ureteral stent may suffice if the ureter appears viable. Repair may be done laparoscopically,4.9 which avoids laparotomy in patients with viable ureters. In this woman, after failing to place an internal stent, percutaneous nephrostomy was performed due to delayed diagnosis during the active inflammatory stage of wound healing. Clinical manifestations improved soon after the procedure. The three common sites for ureteric injury are at the IP ligament where the ureter crosses the pelvic brim and the common iliac vessels, at the uterosacral ligament where the ureter passes, and at the ureteric canal where the ureter passes under the uterine artery. The last might have been the site in our patient, and the injury might have resulted in part from thermal damage during electrodesiccation, from minor lacerations while isolating the ureter, or from the combination of both during the laparoscopic phase of the operation. Indeed, this woman's uterosacral ligament was not divided in the laparoscopic phase, and radiologic examination confirmed the location of injury. The huge uterus caused distortion of both ureters, especially the left one, and so-called congenital adhesions on the left side caused difficulty in laparoscopic manipulation. Furthermore, bleeding from tiny vessels during dissection of the paravesical space obscured the operative field; blind as well as massive coagulation with unipolar scissors was associated with a long desiccation time, and blood stained the extraperitoneal areolar tissues. Although it is theoretically simple to develop areolar tissue on either side of the uterus, we faced some difficulty in this patient. Tiny vessels were injured while developing the paravesical space, resulting in thermal injury while trying to desiccate the bleeders. This thermal effect from the unipolar circuit attached to the dissecting scissors might have caused delayed necrosis of the left ureter with extravasation of urine. It was postulated that 7 days are required to create a ureteral fistula when the cause is propagation either of current or of heat.~2 Dissection of the left ureter was performed in this case to check patency, which might have intensified the thermal damage to the ureter. This
phenomenon was supported by literature reports. Thermal injury to the ureter, which occurs most commonly after fulguration or laser vaporization of endometriosis involving the uterosacral ligaments, usually causes a stricture hydroureter and hydronephrosis, and can ultimately lead to loss of the affected kidney. ~3 We conclude that the most likely cause of injury in our patient was the combination of thermal injury and minor laceration. To reduce the chance of such events during laparoscopic surgery, every operator must be careful not to injure tiny vessels, since the slightest amount of bleeding could stain extraperitoneal areolar tissues and obscure the view of underlying structures. Delicate manipulation and avoidance of unipolar electrodessication for massive and obscured operative tissue should be kept in mind. Furthermore, bipolar electrodesiccation for transection of uterine vessels must be performed carefully and avoided whenever the operative field is not clearly defined. There are conflicting reports on whether it is necessary to dissect the ureter when performing LAVH. 14 The ureter is easily identified when the IP ligament or utero-ovarian ligament is divided and traced along the retroperitoneum. Still, it might be necessary sometimes to dissect the ureter at the retroperitoneum for a short distance to aid in its identification. This is a crucial step when severe endometriosis and an enlarged uterus cause distortion of structures. It is also prudent to visualize the ureter when the uterine artery is desiccated with bipolar scissors. Although we performed dissection of the ureter, this procedure was followed by desiccation of the uterine vessel due to oozing and bleeding. If we had identified the left ureter before desiccating the uterine vessel in such a troublesome case, this complication could have been avoided. Furthermore, we emphasize the importance of continuous irrigation with cold normal saline to cool the operative site, and suction of excessive amount of fluid, since cleaning the operative field may decrease occurrence of such injury. In addition, we could have used four port sites instead of the traditional three in our patient. A suction-irrigation catheter could have then been placed through the suprapubic port. References
1. Meirow D, Moriel EZ, Zilberman M, et al: Evaluation and treatment of iatrogenic ureteral injuries during obstetric and gynecologic operations for nonmalignant conditions. J Am Coil Surg 178:144-148, 1994
505
Ureteral Injury after Laparoscopic Surgery Liu et at
8. Winslow PH, Kreger R, Ebbeson B, et al: Conservative management of electrical bum injury of the ureter secondary to laparoscopy. Urology 27:60-62, 1986
2. Grainger DA, Soderstrom RM, Schiff SF, et al: Ureteral injuries at laparoscopy: Insights into diagnosis, management, and prevention. Obstet Gyneco175:839-843, 1990
9. Nezhat C, Nezhat F, Green B: Laparoscopic treatment of obstructed ureter due to endometriosis by resection and ureteroureterostomy: A case report. J Urol 148:865-868, 1992
3. Blandy JP, Badenoch DE Fowler CG, et al: Early repair of iatrogenic injury to the ureter or bladder after gynecological surgery. J Urol 146:761-765, 1991
10. Schwartz RO: Complications of laparoscopic hysterectomy. Obstet Gynecol 81:1022-1024, 1993
4. Nezhat C, Nezhat F: Laparoscopic repair of ureter resected during operative laparoscopy. Obstet Gynecol 80:543-544, 1992
11. Saidi MH, Sadler RK, Vancaillie TG, et al: Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol 87:272-276, 1996
5. Assimos DG, Patterson LC, Taylor CL: Changing incidence and etiology of iatrogenic ureteral injuries. J Urol 152:2240-2246, 1994
12. Donnez J, Nisolle M: An Atlas of Laser Operative Laparoscopy and Hysteroscopy. New York, Parthenon Publishing Group, 1994
6. Gomel V, James C: Intraoperative management of ureteral injury during operative laparoscopy. Fertil Steril 55:416-419, 1991
13. Kadar N: Atlas of Laparoscopic Pelvic Surgery. London, Blackwell Science, 1995
7. Kadar N, Lemmerling L: Urinary tract injuries during laparoscopically assisted hysterectomy: Causes and prevention. Am J Obstet Gynecol 170:47-48, 1994
14. Lee CL, Soong YK: Laparoscopic hysterectomy: ls dissecting the ureter necessary? Int Surg 80:167-169, 1995
506