Ureteric injury at laparoscopic hysterectomy — structured oral station (12 minutes)

Opening prompt — "Tell me what you do from the moment you see no left jet."

Model response — say it in this order: [1][4]

• "An absent ureteric jet after a difficult dissection near the ureteric tunnel is an injury until proven otherwise. I would stop the dissection, call my consultant and a urologist, and tell the anaesthetist."
• "I would re-confirm with an intravenous dye — indigo carmine, or methylene blue after checking she is not on an SSRI or MAOI, or 10 percent sodium fluorescein 0.25 to 1.0 mL — and watch for a jet within minutes. If there is still no jet, I would pass an open-ended ureteric catheter and do a retrograde pyelogram to define obstruction, transection or extravasation."
• "That tells me the level, the mechanism — transection, ligation, crush or thermal — and the length of any devitalised segment, which decides whether I debride and reconstruct."[8][9]

Examiner is listening for: immediate pause and call for help, a named dye agent with the SSRI caveat, the definitive retrograde pyelogram, and characterisation of the injury before any repair. [4]

Probe 1 — "Where exactly is the ureter at risk in this operation?"

• Name the four points: infundibulopelvic ligament at the brim, ovarian fossa, uterine artery crossover, and the ureteric tunnel of the cardinal ligament.[3]
• "The classic point is the uterine artery crossover — 'water under the bridge' — where the uterine artery runs above and anterior to the ureter at the level of the internal os. In this case, sealing the cardinal ligament puts the ureteric tunnel at risk."[3]

Probe 2 — "It is a complete distal transection from the bipolar device. How do you repair it?"

• "Because it is a thermal injury, I would debride generously beyond the visible burn — thermal spread extends further than the eye sees, and late perforation happens in that zone. Then I would reconstruct over a double-J stent, tension-free, with a retroperitoneal drain, and test the repair."[13][16]
• "For a distal injury the standard reconstruction is ureteroneocystostomy — reimplantation into the bladder; if length is short I would add a psoas hitch, and if still short a Boari flap. Wang's work shows ureteroureterostomy is also a feasible, antireflux-preserving option for distal injuries in experienced hands, with less reflux than reimplantation."[9]

Probe 3 — "Some units stent the ureters prophylactically before a case like this. Does that prevent the injury?"

• "No. The Gurumurthy systematic review found prophylactic ureteric catheterisation is not associated with a lower risk of ureteric injury — the risk ratio was 0.9 with a confidence interval crossing one — and it increased the risk of urinary tract infection. A catheter aids identification, it does not prevent injury, and I would not be falsely reassured by one being in situ."[6]

Probe 4 — "What is the cystoscopy actually buying you here?"

• "Detection, not avoidance. Routine intraoperative cystoscopy markedly increases the intraoperative detection of urinary tract injury, with a published sensitivity of 80 to 90 percent for ureteral trauma. The AAGL report is explicit that some injuries missed even at cystoscopy are the thermal ones from energy devices — which is exactly why I debride generously. FINHYST found only 10 percent of ureter injuries were recognised intraoperatively; cystoscopy is what changes that."[1][4]

Probe 5 — "She is waking up and her partner is in recovery. What do you say?"

This is a scored domain, not a courtesy. Demonstrate it out loud: [1]

• Move to her eye level, use her name, and speak plainly: "During your operation we found that a tube carrying urine from the kidney to the bladder — the ureter — was injured. We have called in a urology surgeon and repaired it. You will have a small internal tube called a stent for a while, and we will watch your kidney function closely. I want to be honest with you about what happened and what happens next."
• Acknowledge her fear, keep the partner informed with her consent, avoid jargon and avoid minimising. Commit to a follow-up plan, a named contact, and a debrief.
• "I would also complete an accurate operative note and an incident report, because honest documentation and disclosure are part of safe care."

Probe 6 — "What is her prognosis?"

• "An injury recognised and repaired intraoperatively carries the success of elective reconstructive surgery — the EAU systematic review reports an 87 percent pooled clinical success rate, higher with reconstruction than endoscopic treatment, with renal unit loss in only 2.3 percent. She will need the stent removed and imaging afterwards to exclude a late stricture, and long-term follow-up of her renal function."[15]