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A Review of Laparoscopic Ureteral Injury in Pelvic Surgery

A Review of Laparoscopic Ureteral Injury in Pelvic Surgery. Obstetrical and Gynecological survey Volume 58, Number 12. 2004 년 4 월 29 일 임 종 인. Abstract. Objective of this study laparoscopic surgeries 중 ureteral injury 가 발생한 문헌을 review Determine Reported rates of ureteral injury

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A Review of Laparoscopic Ureteral Injury in Pelvic Surgery

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  1. A Review of Laparoscopic Ureteral Injury in Pelvic Surgery Obstetrical and Gynecological survey Volume 58, Number 12 2004년 4월 29일 임 종 인

  2. Abstract • Objective of this study • laparoscopic surgeries중 ureteral injury가 발생한 문헌을 review • Determine • Reported rates of ureteral injury • Initial laparoscopic surgeries during which ureteral injury occurred • Time of injury recognition (intra- versus postoperative) • Type • Location • Mode of injury repair • Surgical laparoscopic instruments involved in ureteral injury.

  3. 적절한 medical subject heading(MSH) terms 선택 및 사용 • Medline computerized database 와 the online ACOG database 검색 • 1966 – 2003년 사이에 출간된 복강경수술 중 발생한 요관손상에 관한 영문 literature 검색

  4. A total of 70 reported instances in 2491 reported cases • Incidences of injury : <1% to 2% • 2491 cases • case reports, small series of studies, as well as longer, consecutive studies. • Total 70 case중 • The type of laparoscopic surgery • Not described or specified : 18(25.7%) cases • LAVH : 14 (20.0%) • Ureteral injury identification • Intraoperatively : 6(8.6%) cases • Postoperatively : 49(70.0%) cases • Not specified : 15(21.4%) cases • Type of injury • not specified or described : 36(51.4%) • Transection : most common, 14 (20.0%)

  5. Location of ureteral injury • Not specified : 46(65.7%) cases • At or above the pelvic brim : 10(14.3%) cases • Surgical laparoscopic instrument • Electrocautery : 17(24.3%) cases • Not reported : 34(48.6%) cases • Repair the ureteral injury • Laparotomy - 43(61.4%) cases • LAVH : the leading procedure in which injury occurred • Electrocoagulation : 대부분의 injury의 원인

  6. Target Audience • Obstericians & Gynecologists, Family physicians Learning Objectives • After completion of this article, the reader should be able to • Summarize the reported rates of ureteral injury • Identify the location of the more common laparoscopic ureteral injury • List the various types of laparoscopic ureteral injuries

  7. Materials and Methods • Laparoscopic surgeries중 발생한 ureteral injury에 대한 문헌의 분석 (1966-2003) • Appropriate MSH terms을 만들어 medline database 와 online ACOG database를 검색 • Bibliographies을 manual로 검색 • Key terms : “Laparoscopic complication” and “ureter”

  8. Results • Medline computerized database : 3344 articles • ACOG database : 3690 articles • Manual search of bibliographies • 30 articles discussed ureteral injury during laparoscopic surgery • 70 individual cases contained

  9. Rate of Injury and Initial Procedure • Incidence rates : <1% to 2% • Initial laparoscopic procedure • Not described : 18(25.7%) cases • LAVH : 14(20.0%) cases • Oophorectomy : 8 (11.4%) • Laparoscopic pelvic lymphadenectomy : 7 (10.0%) • Laparoscopic sterilization : 5 (7.1%) • Excision of endometriosis : 5 (7.1%), • Endometriosis ablation : 4 (5.7%) • Drainage of lymphoceles, electrocoagulation, and laparoscopic adhesiolysis : 각각 3 (4.3%)

  10. Time of Injury Recognition • Intraoperatively : 6 cases (8.6%) • Postoperatively : 49 (70.0%) cases • Not specified : 15 (21.4%) cases

  11. Type of Injury • Not described : 36 of the 70 (51.4%) cases • Transection : 14 cases (20.0%) • Laceration, obstruction, and stenosis : 각각 4 cases (5.71%) • Fistula formation, necrosis, and ligation : 각각 2 cases (2.9%) • Resection and burn injury : 각각 1 case (1.4%)

  12. Location of Injury • Not specified : 46 cases (65.7%) • At or above the pelvic brim : 10 of the 70 cases (14.3%) • At or above the uterine artery : 8 cases (11.4%) • At or above the bladder : 6 cases (8.6%)

  13. Mode of Approach to Injury Treatment • Laparotomy : 43 cases (61.4%) • Not described : 15 cases (21.4%) • Repair through laparoscopy : 8 cases (11.4%) • Conservative, nonsurgical management : 4 cases (5.7%).

  14. Instrumentation Involved in the Injury • Not specified :34 (48.6%) • Electrocautery : 17 (24.3%) • Endoscopic stapling : 12 (17.1%) • CO2laser : 4 (5.7%) • Forceps : 2 (2.9%) • Aspirating needle : 1 (1.4%).

  15. Discussion • Incidence of major complications in laparoscopic hysterectomy • 3.5% • Incidence of ureteral injuries • Between 0.3% and 2% • Rate of laparoscopic ureteral injury • Not comprehensively described and documented in the literature

  16. 최근 Laparoscopic hysterectomies 와 retroperitoneal laparoscopic procedures 의 증가로 인해 Ureteral injury 좀더 흔히 발생 • Härkki-Sirén et al. • Ureters : particularly vulnerable to injury during major operative laparoscopy

  17. Intraoperative diagnoses of ureteral injury • only 6(8.6%) cases • Papers on classic (nonlaparoscopic) gynecologic procedures • Injury diagnosis 시간보다는 ureteral injury를 detection하는 method에 대해 기술 • Hurt et al. : 5 methods 1) retrograde ureteral dye injection 2) intravenous dye injection 3) intraoperative ureteral catheterization 4) intravenous excretory urography 5) dissection of the ureter • 15(21.4%) cases가 diagnosis time을 보고 하지 않음

  18. Ureteral injury repair의 approach 방법 • Laparotomy : 43(61.4%) cases • 15(21.4%)cases did not report • Gordon and Lewis • Focal ureteral injuries • Double J-shaped catheter를 삽입하여, urine leakage를 막고 ureter를 지지하여 spontaneous healing을 유도하여 치료 가능 • More extensive damage • end-to-end anastomosis 나 ureteral implantation을 위한 laparotomy가 필요

  19. Preferred technique of ureteral injury repair • Dependent on the time of injury diagnosis • 59 cases • both time of ureteral injury diagnosis and mode of treatment were reported • Diagnosed postoperatively • Laparotomy : 술후 진단된 49 case중 38 cases (77.6%) • 5 cases of ureteral injury : not treated using laparotomy • 4 cases : conservative treatment • 1 case : laparoscopic approach • most often repaired using laparotomy • Diagnosed intraoperatively • laparoscopic repair 증가 • 6 cases • 2 cases : laparotomy • 4 cases : laparoscopy.

  20. The type and location of ureteral injuries • Type : not specifically described in 51.4% • Location : specified in even fewer cases • Potential locations for ureteral injury • Hurt et al. : classic, nonlaparoscopic pelvic surgeries • at the pelvic brim • Ureter가 uterine arteries 아래에서 cervix 외측으로 지나가는 부위 • Ureters가 bladder로 들어가는 vaginal fornix의 외측 부위 • Gordon and Lewis : laparoscopic surgeries • at the infundibulopelvic ligament • where the ureter passes deep to the ovarian fossa • at the ureteral canal • Our review • at or above the pelvic brim : the most common site

  21. Instruments involved in ureteral injuries • 34 cases (48.6%) : not defined or specified • LAVH and electrocautery • Identified as leading causes of laparoscopic ureteral injury (when data was available for analysis and review) • In more than 50% of the cases • Location and type of injury were also not specified • In this review (most common findings) • Electrocautery instrumentation • Transection injuries • At or above the pelvic brim

  22. Decrease the risk of this complication • Ostrzenski • laparoscopic suturing and tying method • Laparoscopic suturing technique and the tying of an intracorporeal or extracorporeal • staplers or electrocautery보다 좀더 안전한 method • Improved training in laparoscopic technique • Recognition of intra- and retroperitoneal gross and functional anatomy • Lower urinary tract의 integrity를 확인하기 위한 intraoperative protocols 확립 • 수술중에 urology consultation의 획득 • Decrease the delay in recognition of ureteral injury • Increase of their intraoperative repair.

  23. laparoscopic surgeries중 ureter injury에 대한 Data and discussion • Lacking in both breadth and depth • Much of the reviewed literature on existing information • Cursory and incomplete.

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