**7.1 Primary prevention**

Prevention of injury before it occurs. As most injuries can be diagnosed intraoperatively, systematic assessment of urinary tract integrity should be part of the surgical plan.

Never cut/clamp /suture/apply energy before proper identification of ureter. always remember to preserve the blood supply of ureter. inadverent injury if suspected though not confirmed (blunt trauma/devascularization/ lateral damage due to thermal energy), ureteric stenting/catheterisation is to be done. always be proactive to involve the urogynaecologist at the earliest stage before, during or after surgery.

	- Place the lowest clamp first.

*Ureteric Injury in Gynecology Surgery DOI: http://dx.doi.org/10.5772/intechopen.99649*

#### **Figure 6.**

*Double pigtail stent placed in the ureter for management of crush injury or after repair of transection. Taken from [1].*

	- vesico-uterine space must be dissected adequately to allow displacement of ureters away from the clamp by downward traction on cervix and countertraction upward beneath the bladder.
	- Small-small bits of paracervical and parametrial tissues should be clamped, cut, and ligated.
	- If ureters are not visualized, retroperitoneal dissection should be done to decrease the incidence of complications (**Figure 4**). Visualization under Invisible near infrared (NIR) light after intravenous. or retrograde injection of ICG (Indigo carmine) dye is very useful if needed but it is expensive.
	- In tubal sterilization Fallopian tubes should be taken away from pelvic wall before electrocoagulation.
	- In LAVH if stapler application in cardinal and uterosacral ligament is not safe, then this part of operation should be done vaginally.

Note: Kinking is functionally similar to obstruction till it is undone. Be careful when clamping or suturing the uterosacral ligament and during reperitonisation.

## **7.2 Secondary prevention**

Recognition of injury during operation so that immediate repair can be done. (**Figure 6**–**12**)

Intraoperative cystoscopy using either flexible or rigid instruments can aid in the diagnosis or exclusion of urinary tract injury. Identification of the mechanism of injury and its location guides immediate or delayed repair.

Evaluation of ureter should be done before operative procedure is terminated by:


#### **Figure 7.**

*Management of transection of the ureter depends on the level at which ureter is transected, that is, in the upper third, middle third or lower third. Taken from [1].*

#### **Figure 8.**

*Diagrammatic representation of ureteroureterostomy. The ends are spatulated and sutured. Taken from [1].*


Note: if peristalsis seen, most probably injury is not there. but it cannot rule out ischaemic injury which will manifest postoperatibely only and may manifest after

*Urinary Tract Infection and Nephropathy - Insights into Potential Relationship*

#### **Figure 9.**

*Transposition of the ileum is performed when the lower segment is not long enough to implant into the bladder without tension. A distal segment of the ileum is cut and attached to the ureter at the upper end and implanted into the bladder at the lower end. Taken from [1].*

#### **Figure 10.**

*Transureteroureterostomy—when the length of the lower segment of the ureter is not adequate, the cut end is anastomosed to the ureter on the opposite side. Taken from [1].*

*Ureteric Injury in Gynecology Surgery DOI: http://dx.doi.org/10.5772/intechopen.99649*

#### **Figure 11.**

*A bladder flap (boari flap) shaped into a tube and the lower end of the ureter is attached to this to provide extra length and prevent tension. Taken from [1].*

*Psoas hitch procedure. the bladder is pulled up and stiched to the psoas muscle to prevent tension after ureteroneocystostomy. Taken from [1].*

7-10 days. so, if inadverent injury if suspected though not confirmed, ureteric stenting/catheterisation is to be done, to prevent further complications.

• Surgical procedures as per need are to be done as given under tertiary prevention depending on individual factors like site of injury, extent of damage and integrity of opposite ureter provided patient's condition allows. If unfit, temporary measures like closed drainage/PCN are taken till general condition is fit i.e., within 48-72hours or later after 6-8 weeks.
