Risk Factors for Urological Complications Associated with Caesarean Section-A Case-Control Study.

Background and Objectives: Acute urologic complications, including bladder and/or ureteric injury, are rare but known events occurring at the time of caesarean section (CS). Delayed or inadequate management is associated with increased morbidity and poor long-term outcomes. We conducted this study to identify the risk factors for urologic injuries at CS in order to inform obstetricians and patients of the risks and allow management planning to mitigate these risks. Materials and Methods: We reviewed all cases of urological injuries that occurred at CS surgeries in a tertiary university centre over a period of four years, from January 2016 to December 2019. To assess the risk factors of urologic injuries, a case-control study of women undergoing caesarean delivery was designed, matched 1:3 to randomly selected women who had an uncomplicated CS. Electronic medical records and operative reports were reviewed for socio-demographic and clinical information. Descriptive and univariate analyses were used to characterize the study population and identify the risk factors for urologic complications. Results: There were 36 patients with urologic complications out of 14,340 CS patients, with an incidence of 0.25%. The patients in the case group were older, had a lower gestational age at time of delivery and their newborns had a lower birth weight. Prior CS was more prevalent among the study group (88.2 vs. 66.7%), as was the incidence of placenta accreta and central praevia. In comparison with the control group, the intraoperative blood loss was higher in the case group, although there was no difference among the two groups regarding the type of surgery (emergency vs. elective), uterine rupture, or other obstetrical indications for CS. Prior CS and caesarean hysterectomy were risk factors for urologic injuries at CS. Conclusions: The major risk factor for urological injuries at the time of CS surgery is prior CS. Among patients with previous CS, those who undergo caesarean hysterectomy for placenta previa central and placenta accreta are at higher risk of surgical haemostasis and complex urologic injuries involving the bladder and the ureters.

[Urological problems related to coloproctology. Part 1].

The aim of this review was to characterize the possible urological manifestations of rectal disorders in case of the involvement of the genitourinary system, as well as the symptoms of urological diseases involving the distal part of the large bowel. In urological and coloproctological practice, the anatomical and physiological proximity of the distal part of the intestine and the urogenital organs is of importance (for example, the common innervation of the pelvic organs, the synergy of the pelvic floor muscles, etc.), since it results in similar clinical manifestations, making it difficult to make a diagnosis. The most relevant and common urological and proctological diseases, including prostatitis, intestinovesical and rectourethral fistulas, damage to the ureter and bladder during colorectal surgery are discussed in the article. Particular attention is paid to the interdisciplinary cooperation of urologists and proctologists and the frequent need for their joint participation in the diagnosis and treatment of the pelvic organs disorders.

Urinary System Iatrogenic Injuries: Problem Review.

INTRODUCTION: From May to December 2019, a literature review of the urinary system iatrogenic injury problem was performed. The most cited, representative articles in PubMed, Scopus, and WoS databases dedicated to this problem were selected. Urinary system iatrogenic injuries include ureter, bladder, urethra, and kidney traumas. It is widely thought that the main causes of such injuries are urological, obstetric, gynecological, and surgical operations on the retroperitoneal space, pelvis, or perineum. METHODS: The purpose of the study is to describe all aspects of the iatrogenic injure problem, under the established scheme and for each of the most damaged organs: the urethra, bladder, kidney, and ureter. The treatment of confirmed iatrogenic injuries largely depends on the period of its detection. Modern medical procedures provide conservative or minimally invasive treatment. An untimely diagnosis worsens the treatment prognosis. "Overlooked" urinary system trauma is a serious threat to society and a particular patient. Thus, incorrect or traumatic catheterization can lead to infection (RR 95%) and urethral stricture (RR ≥11-36%), and percutaneous puncture nephrostomy can cause the risk of functional renal parenchyma loss (median 5%), urinary congestion (7%), or sepsis (0.6-1.5%). RESULTS: Lost gain, profits, long-term and expensive, possibly multistage treatment, stress and depression, and the risks of suicide put a heavy financial, moral, and ethical burden on a person and society. Also, iatrogenic injury might have legal consequences. DISCUSSION/CONCLUSION: Thus, the significant problem of urinary tract iatrogenic injuries is still difficult to solve. There is a need to implement mandatory examining algorithms for patients at risk, as well as the multidisciplinary principle for all pelvic surgery.

Ureterolysis for Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To demonstrate techniques of ureterolysis during complex laparoscopic hysterectomy. DESIGN: Technical video demonstrating different approaches to ureterolysis for complex benign pathology during laparoscopic hysterectomy (Canadian Task Force classification III). SETTING: Benign gynecology department at a university hospital. INTERVENTION: Performance of ureterolysis during laparoscopic hysterectomy for benign pathology. CONCLUSION: Ureteric injury has significant morbidity and is the most common reason for litigation following hysterectomy, with an estimated risk of 0.02% to 0.4%. [1,2]. Ureterolysis is infrequently practiced by benign gynecologists; however, it may be necessary during complex surgery. Benign pathology requiring hysterectomy, such as endometriosis, myomas, large uteri, and adnexal masses, are recognized risk factors for ureteric injury [3]. Most injuries occur during division of the uterine artery at the level of the internal cervical os. The average distance between the ureter and cervix is 2 cm, but it is only 0.5 cm in 3.2% of the population with a normal pelvis [4]. Preventive strategies, such as the use of a uterine manipulator, may increase this distance, although it still might not be sufficient to prevent injury in women with normal anatomic variants and complex pathology. Visualizing the ureter at the pelvic brim and side wall without retroperitoneal dissection may be inadequate because the segment of ureter between the intersection of the uterine artery and the bladder is not visible. The ureter can be safely dissected up to 15 cm without compromising its viability. In this educational video, we demonstrate various simple, quick, and reproducible techniques to perform ureterolysis for complex benign pathology. These techniques can be used by both expert and novice surgeons to perform and teach ureterolysis. Our method determines the course of the ureter throughout the pelvis and relation to the uterine artery to reduce intraoperative injury. We have performed more than 350 cases with no injuries.

Incidence, type and management of ureteric injury associated with vesicovaginal fistulas: Report of a series from a specialized center.

OBJECTIVES: To report a large series of vesicovaginal fistula, and to assess the incidence of ureteric injury in association with vesicovaginal fistula. METHODS: We retrospectively reviewed a prospective database of patients with vesicovaginal fistula referred to our center between 2004 and 2016. Data on patient demographics, fistula etiology, mode of repair, and any associated ureteric injury and its treatment were noted. RESULTS: Overall, 116 patients (median age 49 years, range 23-88 years) were referred for management of vesicovaginal fistula during the study period. Four of these patients (3.4%) had associated ureteric injury, one of whom had bilateral injury. Ureteric obstruction alone was noted in two patients, ureterovaginal fistula alone in one patient, and bilateral ureteric obstruction and ureterovaginal fistula in one patient. All ureteric injuries were managed with simultaneous reimplantation into the bladder at the time of vesicovaginal fistula repair. Five patients had post-radiotherapy vesicovaginal fistula, and the remainder were post-surgical. Three patients with post-radiotherapy vesicovaginal fistula proceeded to primary diversion. CONCLUSIONS: Ureteric injury is far less common than previously reported, occurring in <5% of patients presenting with vesicovaginal fistula. It can be successfully managed, and it remains the major indication for abdominal repair of vesicovaginal fistula.

Minimally invasive surgical treatment on delayed uretero-vaginal fistula.

OBJECTIVE: To evaluate the procedure of endoscopic surgery for ureterovaginal fistula (UVF) and its clinical efficacy. MATERIALS AND METHODS: A retrospective analysis of 46 patients needing treatment for UVF with endourology technology was conducted (all patients had unilateral ureteric injury, 27 left and 19 right). Transurethral retrograde ureteric stenting or realignment retrograde/antegrade approach stenting was used to treat the fistula, and the relation between treatment and prognosis was analyzed. RESULTS: One case failed, the patient undergoing percutaneous nephrostomy instead. Success was achieved in 45 cases, and urinary leakage was stopped 48 h after surgery. Of the 45 patients operated on, 16 had their double-J stents removed after 3-6 months, and 29 needed replacement every 6-12 months. In a postoperative follow-up of 6-36 months, 10 patients had recurrent stenosis needing ureteroscopic endoureterotomy or reexpansion with a balloon. No other complications occurred. CONCLUSIONS: Endoscopic surgery is an effective technology in the treatment of UVF, with the advantages of being effective, reliable, less invasive, and readily accepted by patients.

An Augmented Reality Endoscope System for Ureter Position Detection.

Iatrogenic injury of ureter in the clinical operation may cause the serious complication and kidney damage. To avoid such a medical accident, it is necessary to provide the ureter position information to the doctor. For the detection of ureter position, an ureter position detection and display system with the augmented ris proposed to detect the ureter that is covered by human tissue. There are two key issues which should be considered in this new system. One is how to detect the covered ureter that cannot be captured by the electronic endoscope and the other is how to display the ureter position that provides stable and high-quality images. Simultaneously, any delayed processing of the system should disturb the surgery. The aided hardware detection method and target detection algorithms are proposed in this system. To mark the ureter position, a surface-lighting plastic optical fiber (POF) with the encoded light-emitting diode (LED) light is used to indicate the ureter position. The monochrome channel filtering algorithm (MCFA) is proposed to locate the ureter region more precisely. The ureter position is extracted using the proposed automatic region growing algorithm (ARGA) that utilizes the statistical information of the monochrome channel for the selection of growing seed point. In addition, according to the pulse signal of encoded light, the recognition of bright and dark frames based on the aided hardware (BDAH) is proposed to expedite the processing speed. Experimental results demonstrate that the proposed endoscope system can identify 92.04% ureter region in average.

A Novel Endoscope System for Position Detection and Depth Estimation of the Ureter.

Iatrogenic injury of ureter occurs occasionally in the clinical laparoscopic surgery. The ureter injury may cause the serious complications and kidney damage. To avoid such an injury, it is necessary to detect the ureter position in real-time. Currently, the endoscope cannot perform this type of function in detecting the ureter position in real-time. In order to have the real-time display of ureter position during the surgical operation, we propose a novel endoscope system which consists of a modified endoscope light and a new lumiontron tube with the LED light. The endoscope light is modified to detect the position of ureter by using our proposed dim target detection algorithm (DTDA). To make this new system functioning, two algorithmic approaches are proposed for the display of ureter position. The horizontal position of ureter is detected by the center line extraction method and the depth of ureter is estimated by the depth estimation method. Experimental results demonstrate that the proposed endoscope system can extract the position and depth information of ureter and exhibit superior performance in terms of accuracy and stabilization.

Internal Herniation Causing Double Obstruction of the Small Bowel and Urinary Tract: A Rare Case Presentation.

Small bowel obstruction is one of the most common urgent surgical conditions, caused by a variety of factors, with adhesions, malignancies, and hernias, internal and external, being the most common. Many types of internal hernias have been described in the literature; however, internal hernia caused by the ureter as a secondary complication of ureteroplasty is rare and only a few cases have been reported worldwide. This presentation discusses an interesting case of small bowel obstruction accompanied by obstruction of the urinary tract due to an internal hernia caused by the ureter. A 58-year-old female presented to the emergency department (ED) with acute pain in the abdominal and right lumbar region. Her surgical history includes hysterectomy, right ureter injury, and ureteroplasty performed 10 years ago. Clinical examination showed tenderness in the lower abdomen, positive Giordano's sign on the right, and metallic bowel sounds. A computer tomography scan revealed right-sided hydronephrosis, absence of excretion in the right urinary tract, and dilated loops of the small intestine. An exploratory laparoscopy revealed a small bowel loop strangulated by the ureter, followed by laparotomy, resection of a segment of the ileum, oblique anastomosis, and reimplantation of the right ureter. The patient was discharged eight days postoperatively without any complications. This case underscores the significance of surgical history in order to recognize even rarer causes of small bowel obstruction.

Ureteral Ligation During Robotic-Assisted Laparoscopic Prostatectomy.

Robotic-assisted laparoscopic prostatectomy (RALP) is the surgical standard of care for patients with localized prostate cancer. Although uncommon, the procedure involves a potential risk of injury to adjacent anatomical structures. We report on a unique case of iatrogenic ureteral injury during RALP that required subsequent robotic-assisted laparoscopic ureteral reimplantation for definitive repair. A 57-year-old male underwent RALP using the Da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA). The procedure was unremarkable and a 20 French Foley catheter was placed with plans for removal after one week following a negative cystogram. On postoperative day two, his creatinine level elevated to 2.69 mg/dL from a baseline of 1.40 mg/dL, left-sided flank pain increased, and non-contrast CT imaging revealed moderate left proximal hydroureteronephrosis and no other abnormalities. Aside from mild nausea on postoperative day one, he had no other symptoms. An integrated stent was unable to be placed by urology at this time. Subsequently, a left percutaneous nephrostomy tube was placed under fluoroscopic guidance. After this intervention, the patient's symptoms improved and the decision was made not to proceed with operative re-exploration at this time to attempt identification of the obstruction. Three weeks later, the patient underwent cystoscopy with attempted left retrograde ureteropyelography and left ureteroscopy due to suspected distal obstruction. This revealed complete obstruction of the intramural portion of the ureter, presumed to be secondary to suture ligation at the time of the vesicourethral anastomosis. Seven weeks postoperatively, the patient underwent robotic-assisted laparoscopic left ureteral reimplantation. Thereafter, the patient had a resolution of his left hydroureteronephrosis and acute kidney injury. This case describes an intravesical ureteral ligation during RALP. An iatrogenic intravesical ureteral ligation has far less guiding literature than a more common ureteral transection. Additionally, ureteral transection is often identified and managed intraoperatively, while the ureteral ligation presented in this case is far less likely to be apparent during surgery. Early identification will allow for rapid reoperation to manage the injury. We hypothesize that during the vesicourethral anastomosis, the left intramural ureter was ligated. Importantly, with the use of a 3-0 V-Loc stitch for the vesicourethral anastomosis, its barbed nature would not facilitate simple surgical removal. In conclusion, when performing RALP, the depth of the bladder-sided vesicourethral anastomotic stitch should be carefully considered to avoid a similar injury.

Conservative Management of Postoperative Urinary Leak and Intra-Abdominal Abscess.

Ureteral injury is a rare occurrence in medical practice. Most cases encountered stem from blunt trauma or are iatrogenic, occurring during open abdominal or pelvic surgery and laparoscopic procedures. Prompt diagnosis of ureteral injury allows clinicians to avoid complications including ureteral strictures, abscess, renal failure, sepsis, and loss of the ipsilateral kidney. Treatment depends on whether the ureteral injury was discovered intraoperatively or if it was a delayed diagnosis. Several procedures can be used, including ureteroureterostomy, ureteroileal interposition, and nephrectomy. Stenting can also be a viable option as it can reestablish urinary drainage. Herein, we present the case of a 43-year-old male who presented with complaints of progressive abdominal pain that was subsequently diagnosed as a left ureteral injury and how the use of a ureteral stent allowed him to have a full recovery with optimized normal ureteral function.

Heterotopic Kidney Autotransplantation for Recurrent Iatrogenic Distal Ureteral Injury: A Case Report.

Iatrogenic ureteral injuries are a significant complication during pelvic surgery, requiring a multidisciplinary approach for optimal repair. When a ureteral injury is suspected postoperatively, abdominal imaging is essential to determine the type of injury and thus the timing and method of reconstruction. That can be performed either by a CT pyelogram or by an ureterography-cystography with or without ureter stenting. Although technological advancements and minimally invasive surgery have been gaining ground over open complex surgeries, renal autotransplantation is a well-established technique of proximal ureter repair and should be highly considered when dealing with a severe injury. We hereby report the case of a patient with a recurrent ureter injury and multiple laparotomies treated with autotransplantation, without any major morbidities or change in their quality of life. In every case, a personalized approach for each patient and consultation with experienced transplant experts (surgeons, urologists, and nephrologists) is advised.

Iatrogenic Thermal Energy-Induced Distal Ureteric Injury and Its Management by Laparoscopy Ureteroureterostomy.

Background and Objectives: Most thermal energy-induced distal ureter injuries are missed intraoperatively as they are caused by delayed ischemia-induced necrosis of the affected part leading to fistula, and a delayed presentation. The injuries of the distal ureter are commonly managed by ureteroneocystostomy, which has long-term complications related to vesico-ureteric reflux (VUR). We present our experience of management of distal ureter injury due to thermal energy by laparoscopy ureteroureterostomy and the role of various methodologies for its diagnosis. Methods: It is a retrospective, single-center study that was conducted from January 1, 2020 - December, 31 2022. Results: A total of 8 cases were enrolled in the study. All cases had an uterovaginal fistula (UVF) post-laparoscopic gynecology surgery. The bilateral ureteric injury was observed in 2 cases. The median post-surgery time to diagnose UVF in the study was 10 days. All cases were managed by laparoscopy ureteroureterostomy (LUUS). Six cases underwent immediate surgery after the diagnosis; whereas 2 cases had initial double-J stent placement as treatment, which subsequently failed following which the LUUS was performed. There were not any immediate or long-term complications such as leakage, stenosis, fistula, or any requirement for revision surgery. Conclusion: The management of thermal energy-induced ureteric injury is exceptional as compared to other types of ureteric injury. Our approach should be toward immediate surgical management rather than a conservative one to avoid long-term complications and sequelae. Iatrogenic lower ureteral injury can be managed successfully by LUUS, maintaining the normal anatomy and physiology of VUR.

Urinary tract injuries during cesarean delivery: long-term outcome and management.

OBJECTIVE: Urinary tract injury during cesarean delivery is a rare but severe complication. Due to the high prevalence of cesarean delivery, this injury may pose a high burden of morbidity. We reviewed the cases of lower urinary tract injuries identified during cesarean delivery in a tertiary medical center and identified diagnosis and treatment methods, as well as short and long-term outcomes, to establish a protocol of care for such cases. METHODS: We included women with urinary tract injury during cesarean delivery between 2004 and 2018. The cases were identified according to ICD-9 codes, as well as free text in the medical report and discharge letter. Data were collected retrospectively. Telephone interviews were conducted to obtain additional data regarding long-term outcomes. RESULTS: In14 years, a total of 17,794 cesarean deliveries were performed at our institution (17.5% of all deliveries), 14 cases of bladder injury, and 11 cases of ureteral injury were identified featuring an incidence of 0.08 and 0.06%, respectively. All bladder injuries were diagnosed and repaired intra-operatively. Six (55%) cases of ureteral injury were diagnosed in the post-operative period, and 3 of these patients required further surgery for definitive treatment. None of the patients suffered long-term adverse effects. Most bladder injuries occurred in women with previous cesarean delivery in the presence of abdominal adhesions. In contrast, most ureteral injuries occurred in women with emergency cesarean delivery during the second stage of labor, and were accompanied by an extension of the uterine incision. All women had normal kidney function in follow up and did not suffer from long term sequelae. CONCLUSION: Urinary tract injury is an uncommon complication of cesarean delivery. A high index of suspicion is recommended to avoid late diagnosis and complications. We propose a comprehensive protocol for the management of these injuries.

Association of intraoperative gross hematuria with acute kidney injury after cytoreductive surgery.

Objectives: Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has been established in the management of peritoneal carcinomatosis. Although it is still necessary to take adequate measures against major postoperative complications including acute kidney injury (AKI), consensus is lacking on how to assess and stratify risk for patients with postoperative AKI after CRS-HIPEC. The aim of this retrospective cohort study was to investigate the association of intraoperative gross hematuria as a surrogate marker of ureter injury with postoperative AKI incidence. Methods: This retrospective cohort study investigated patients without impaired preoperative kidney function who underwent CRS-HIPEC at a single referral center, and evaluated the relationship between intraoperative gross hematuria and incidence of postoperative AKI as defined by the Kidney Disease Improving Global Outcomes practice guidelines. Logistic regression analysis was performed to calculate the odds ratio of intraoperative gross hematuria for AKI, adjusting for confounding factors and other risk factors for AKI. Results: We enrolled 185 patients (males, 37%). Twenty-five patients developed intraoperative gross hematuria. Postoperative AKI occurred in 10 (40%) of 25 patients with hematuria and 28 (17.5%) of 160 patients without hematuria. The crude odds ratio for exposure to hematuria was 3.14 (95% confidence interval, 1.30-7.60; p=0.020) for postoperative AKI. Adjusted odds ratio as estimated by multivariate logistic regression was 4.57 (95% confidence interval, 1.55-13.45; p=0.006). Conclusions: Intraoperative gross hematuria is significantly associated with postoperative AKI incidence after CRS-HIPEC.

In Situ and Intraoperative Detection of the Ureter Injury Using a Highly Sensitive Piezoresistive Sensor with a Tunable Porous Structure.

Iatrogenic ureteral injury, as a commonly encountered problem in gynecologic, colorectal, and pelvic surgeries, is known to be difficult to detect in situ and in real-time. Consequently, this injury may be left untreated, thereby leading to serious complications such as infections, renal failure, or even death. Here, high-performance tubular porous pressure sensors were proposed to identify the ureter in situ intraoperatively. The electrical conductivity, mechanical compressibility, and sensor sensitivity can be tuned by changing the pore structure of porous conductive composites. A low percolation threshold of 0.33 vol % was achieved due to the segregated conductive network by pores. Pores also lead to a low effective Young's modulus and high compressibility of the composites and thus result in a high sensitivity of 448.2 kPa-1 of sensors, which is consistent with the results of COMSOL simulation. Self-mounted on the tip of forceps, the sensors can monitor tube pressures with different frequencies and amplitudes, as demonstrated using an artificial pump system. The sensors can also differentiate ureter pulses from aorta pulses of a Bama minipig in situ and in real-time. This work provides a facile, cost-effective, and nondestructive method to identify the ureter intraoperatively, which cannot be effectively achieved by traditional methods.

Ureter injury in obstetric hysterectomy with placenta accreta spectrum: Case report.

INTRODUCTION AND IMPORTANCE: Placenta accreta spectrum (PAS) is a state of abnormal attachment of the placenta, including placenta accreta, placenta increta, and placenta percreta. This condition can be life-threatening due to the placenta cannot spontaneously separated, resulting in continuous bleeding. Cesarean section followed by hysterectomy is one of the treatment options for PAS. There was a great liability for urinary tract injuries during the operation of PAS patient. CASE PRESENTATION: We present the case of ureter injury during subtotal hysterectomy in patient with PAS. A 30-years-old female patient was diagnosed with recurrent antepartum hemorrhage due to placenta previa accreta spectrum on G2P1 33 weeks of gestational age, singleton live breech presentation, previous c-section 1×. After uterine transverse incision, the baby was delivered. We decided to perform subtotal hysterectomy. There was severe adhesion. On the exploration after subtotal hysterectomy was performed, we found ruptured of the right ureter. CLINICAL DISCUSSION: Hysterectomy peripartum is one of the treatment of PAS, either to prevent or to control postpartum hemorrhage. In pregnant women with morbid placental adherence, there was a great liability for urinary tract injuries. Distal ureters are the most commonly injured while hysterectomy. Injuries to the ureters in this patient occurred due to severe adhesions and unclear visual organ. CONCLUSION: Although it is rare, ureter injury may occur during subtotal hysterectomy in patient with placenta accreta spectrum. To prevent that condition, inserting ureter stent can be perform before the operation. Multidisciplinary approach is carried out so that patient outcomes are good.

Two Cases of Isolated Ureteral Injury Secondary to Blunt Force Trauma.

Ureteral injuries although rare can cause serious issues. The mechanism of injury is most commonly penetrating but in some rare cases blunt forces can contribute. It is important to diagnose ureteral injuries as soon as possible because they can have significant morbidity and mortality. Here we present two cases of isolated ureteral injury secondary to blunt force trauma. Both patients had the ureteral injury diagnosed by computed tomography (CT) scan and confirmed by a ureterogram with extravasation of contrast. Both patients also had peripelvic cyst, which could have been a contributing risk factor for injury. In both cases, the ureteral injury was repaired using a stent and both patients had no complications. We present these cases along with presentation, diagnostic work-up, and treatment.

Total laparoscopic hysterectomy without uterine manipulator. A retrospective study of 1023 cases.

OBJECTIVE: The aim of this study was to evaluate the feasibility and safety of a total laparoscopic hysterectomy (TLH) without the use of a uterine manipulator in women with benign indications for hysterectomy. STUDY DESIGN: Between January 2011 and January 2020, 1023 patients underwent a TLH without the use of any type of uterine manipulator. The indications for hysterectomy were all benign conditions. The patients' details were obtained from the hospital medical records and the indications for hysterectomy, the surgical data and the intra and postoperative complications were evaluated. All operations were performed by the same surgical team. RESULTS: The median age was 48.2 years, while the BMI ranged from between 26.2 kg/m2 and 47.8 kg/m2. A small percentage of the women were menopausal (278, 27 %) and, following a detailed consultation with 563 (55 %) of the patients, we performed a TLH with adnexectomy. The mean operative time was 78 min (43-168 min), while the estimated blood loss was 59 mL (20-260 ml) and the mean uterine weight was 255 g (40-1510 g). There was no case of conversion to laparotomy. A blood transfusion was required for 14 patients (1.4 %), while there was one case of ureteral injury and three cases where the bladder was opened and fixed laparoscopically. The average hospital stay was 1.1 days, with only 38 patients staying for two or more days. In the long term, we had five cases (0.5 %) of vaginal vault dehiscence and one case of vaginal vault hematoma. CONCLUSION: A TLH without the use of a uterine manipulator is a feasible and safe procedure. While it is perhaps a more demanding procedure for young doctors, when performed by well-trained and experienced laparoscopic surgeons, the procedure entails a short operative time and a low complications rate. As such, it should be the first step in the training of young doctors for performing laparoscopic radical hysterectomies.

Transection of Duplex Ureter During Vaginal Hysterectomy.

Duplex ureter, an embryological developmental anomaly, can lead to intra-operative injuries, even by surgeons with a stronghold on normal ureteric anatomy. We describe the first case of an ectopic ureter transected during vaginal hysterectomy performed for pelvic organ proplase, due to its abnormally low implantation into the bladder, worsened by cystocoele. The injury was recognised, and the duplex ureter was diagnosed with cystoscopy and retrograde pyelography. A post-operative computed tomography urogram allowed us to map the exact course. In this case, there was injury to the ectopic, non-functional ureter, thus averting any further intervention. However, lower urinary tract injuries are serious complications with high morbidity, especially during delayed diagnosis. Knowledge of the ureter variants, meticulous tracing of the course, and use of post-operative cystoscopy could reduce these complications, particularly in face of increasing minimally invasive approaches.