Originally published March 2015
Injury to the ureter is a well-known but not always recognized complication of some surgical procedures. While it can happen in the course of any abdominal or pelvic surgery, ureteric injury is most often associated with certain gynecologic and urologic procedures. Recognizing such injury in the post-operative period is often challenging, as symptoms may be non-specific and attributed to the normal recovery process. Many cases are discovered only after discharge. Unfortunately, delayed diagnosis can result in serious complications including advanced infection and kidney loss.
The CMPA reviewed 54 medico-legal cases involving surgical ureteric injury that closed between 2009 and 2013. The most common procedures associated with such injury were hysterectomy (with or without ovary removal), ureteral stone removal, and removal of an ovary or ovarian cyst.
The reviewed cases indicate that the risk of injury may increase with patient characteristics such as obesity, adhesions from endometriosis or previous abdominal surgery, and variations in the anatomical location of the ureters. The identification of the ureters, in addition to prompt recognition and appropriate management of an injury, ensure optimal patient care. A proper consent discussion and documentation in the medical record also support patient care and, in addition, support the defence of care.
Ureteric injury is the most common cause of litigation in gynecologic surgery. Injuries involve either a laceration or the ligation with a suture or clip. Experts in some cases opined that it is difficult to defend not making reasonable efforts to identify and protect the ureters, especially in cases where pelvic anatomy may be distorted by, for example, extensive pelvic endometriosis or ovarian mass. Experts in some cases were also critical when recognition of a ureter injury was delayed, despite suggestive signs or symptoms.
In some cases, experts were also critical of the surgical management of a recognized injury, including not consulting a specialist when appropriate. Such was the case of a gynecologist in a tertiary centre who noted a small hole in the mid-portion of a ureter while performing a radical hysterectomy. He repaired the hole and placed a Jackson-Pratt drain. The patient later developed an infected urinoma. Experts in this case stated that the gynecologist should have consulted an urologist who was readily available to make the repair. A settlement was paid to the patient by the CMPA on behalf of the member gynecologist.
While most instances of surgical ureteric injury attracted criticism from experts, in some cases the experts noted that the injuries were a recognized risk of surgery and were unavoidable.
Case example: Injury occurs when the ureter cannot be safely visualized
A 38-year-old undergoes a laparoscopically assisted vaginal hysterectomy (LAVH) for uterine bleeding that is unresponsive to medical treatment. The patient’s post-operative lab results show an increase in serum creatinine. She complains of left lower abdominal pain but has no costovertebral (renal) angle tenderness. The obstetrician/gynecologist who performed the surgery suspects ureteric injury and orders an ultrasound, which shows a left ureteric dilatation. A contrast CT scan confirms a left ureteral transection near the bladder base. The patient is referred to urology, where she undergoes successful re-implantation.
The patient launches a legal action alleging the surgeon was negligent in not visualizing the ureter. At trial, the defence expert states that, although great care should be taken in identifying the ureter in its course through the retroperitoneum, it would be unwise to dissect the ureter at the level of the uterine artery and cardinal ligament, as the plaintiff’s expert suggests. The defense expert notes that dissection here could cause unwanted bleeding and increase the risk of ureteric injury, given that the ureter is usually located close to the lateral edge of the cervix. The judge agrees the injury occurred where the ureter could not be visualized, and confirms that an unfortunate outcome does not necessarily mean the care was negligent. The action is dismissed.
In the reviewed CMPA cases involving urologists, most of the ureteric injuries were recognized intra-operatively, hence delayed recognition was not an issue. Experts’ comments in these cases centred on the urologist’s clinical judgment or skill, such as improper choice of approach or technique, applying too much force, not using a safety guidewire, and not performing a retrograde pyelogram before a procedure. Issues with post-operative management were also noted in some cases, including inadequate communication with the patient and delays in referring the patient for consultation or follow-up treatment.
Consent considerations can arise when a surgery needs to be altered because of a complication. This was seen in cases, such as the following, where ureteric avulsion led to the need for nephrectomy.
Case example: A urologist proceeds to nephrectomy without consent
A middle-aged female presents to the emergency department with intermittent severe renal colic of 2 days duration. She is referred to urology for evaluation of a right obstructive 7mm stone located slightly below the uretero-pelvic junction. The urologist proposes an ureteroscopy with possible laser lithotripsy. He discusses with the patient the risks of the procedure including possible failure, residual stone, infection, and ureteric trauma. During surgery, the urologist is unable to pass a guidewire beyond the stone and proceeds to complete the ureteroscopy without it. The stone migrates back to the pelvis where the urologist fragments it with a laser probe. The larger fragment is caught with a wire basket and pulled back down the ureter, when it becomes stuck transiently just below the uretero-pelvic junction. Upon entering the bladder, the urologist notices a segment of intussuscepted ureter in the basket. He proceeds immediately to an open exploration of the ureter through an extended right flank incision. He is unable to find the ureter and assumes the injury is beyond repair. He then performs a right nephrectomy.
The patient launches a legal action against the urologist. Experts are critical of several aspects of the urologist’s care. They find that the initial consent discussion was incomplete and should have included the remote risk of ureteric loss and nephrectomy. They also state that a guidewire should have been inserted as soon as it was feasible; with the wire in place, the urologist could have attempted to realign the ureter. The most severe criticism concerns the urologist’s management of the injury. The experts state that, as this was a serious but not life-threatening situation, the patient should have been awoken and informed about the need to consider temporizing measures such as a percutaneous nephrostomy. This would have provided the opportunity to disclose the nature of the complication, to complete the investigation as needed, and to discuss treatment options with the patient to obtain her informed consent. By proceeding immediately to a nephrectomy in these circumstances, the experts state that the urologist deprived the patient of other treatment options.
In the absence of expert support, a settlement is paid to the patient by the CMPA on behalf of the member urologist.
Risk management considerations
Surgeons should consider the following suggestions, based on peer expert opinion in the cases reviewed:
Consider any relevant patient risk factors, including co-morbidities and surgical history, which could have an impact on the patient’s surgical management.
Inform the patient about reasonably available treatments, the related risks and benefits (including uncommon risks if they carry potentially serious consequences), and your recommendations.
Consider requesting the assistance of an urologist before attempting to repair a ureter.
In cases where surgery needs to be changed because of a complication, obtain informed consent before proceeding, except in cases of imminent threat to the life or health of the patient.
Include in the operative note details of the surgical technique (including steps taken to protect the ureters), anatomical findings and variants, and any difficulties encountered.
Provide the patient or caregivers, when appropriate, with clear verbal or written post-operative instructions that include steps and precautions they should take after the procedure (e.g. wound care, medications, follow-up), symptoms and signs that should alert them to seek further medical attention, and how urgently and where to seek further care if needed.
In the event of a complication, ensure it is disclosed to the patient in a timely manner, and the discussion is documented in the medical record.