Ureteric injury at laparoscopic hysterectomy — structured SAQ (15 marks)

(a) Immediate intraoperative management — confirm and characterise (5 marks)

One mark per point, maximum five. ^[1][4]

• Stop and call for help — pause the dissection, call your consultant and a urologist, and tell the anaesthetist; do not close and hope.^[1]
• Re-confirm with a dye agent — give indigo carmine (or methylene blue, after checking for SSRIs or MAOIs) intravenously, or 10 percent sodium fluorescein 0.25 to 1.0 mL intravenously, and observe for a jet within minutes; an absent jet after several minutes is an injury until proven otherwise.^[8]
• Direct visualisation / intraureteral ICG — trace the whole pelvic ureter; where available, intraureteral indocyanine green with near-infrared imaging confirms its course and integrity.^[7]
• Retrograde pyelogram — if jets remain absent, pass an open-ended ureteric catheter at cystoscopy and image up the ureter to define obstruction, transection and extravasation; this is the definitive intraoperative test.^[9]
• Define the level, mechanism and devitalised length — distal versus mid versus proximal; transection versus ligation versus crush versus thermal; and the length of any thermally damaged segment, which dictates whether debridement and reconstruction are needed.^[4]

(b) Points of ureteric risk and the uterine artery relationship (4 marks)

One mark per point (up to four), with the relationship named for full marks. ^[3]

• Infundibulopelvic (IP / suspensory) ligament at the pelvic brim, where the ureter crosses the common iliac bifurcation lateral to the ovarian vessels.^[3]
• Ovarian fossa — the ureter lies posterior and lateral to the ovary and is dragged up with an adherent ovary or mass.^[3]
• Uterine artery crossover ("water under the bridge") — the uterine artery runs above and anterior to the ureter at the level of the internal cervical os; this is the classic point of injury when clamping or suturing the uterine vessels, and the relationship examiners never retire.^[3]
• Ureteric tunnel of the cardinal (Mackenrodt) ligament — where the ureter passes medially and inferiorly to enter the bladder; the territory of radical hysterectomy and the site of the classic postoperative ureterovaginal fistula.^[3]

(c) Definitive repair principles for a distal thermal transection (4 marks)

One mark per principle; name the distal reconstruction options for full marks. ^[9][13]

• Debride generously to viable margins — a thermal injury extends beyond the visible burn, so resect the damaged segment before any anastomosis; repair must be tension-free over a double-J stent with a retroperitoneal drain, and the repair tested (dye or imaging).^[4][16]
• Distal injury → ureteroneocystostomy (reimplantation) into a tension-free bladder anastomosis; if length is inadequate, add a psoas hitch and, if still short, a Boari flap.^[9][13]
• Mid-segment alternative — ureteroureterostomy — Wang showed laparoscopic ureteroureterostomy is a feasible, safe, antireflux-preserving option for distal gynaecological injury, with less blood loss and less reflux than reimplantation in experienced hands.^[9]
• Stent, drain, test, and follow up — double-J stent until the anastomosis heals, drain the field, confirm the repair, and image after stent removal to exclude a late stricture; the EAU review reports 87 percent pooled success and 2.3 percent renal unit loss overall.^[15]

(d) Evidence on prophylactic catheters and cystoscopy detection (2 marks)

One mark per correct statement. ^[1][6]

• Prophylactic ureteric catheterisation does not reduce ureteric injury — the Gurumurthy systematic review found no association with lower injury risk (RCT risk ratio 0.9, 95 percent CI 0.49 to 1.65) and an increased risk of urinary tract infection; catheters aid identification only.^[6]
• Cystoscopy is the detection lever — routine intraoperative cystoscopy markedly increases the intraoperative detection of urinary tract injury, with a published sensitivity of 80 to 90 percent for ureteral trauma (AAGL); FINHYST found only 10 percent of ureter injuries were recognised intraoperatively without such vigilance.^[1][4]