doi:10.1111/j.1447-0756.2007.00686.x

J. Obstet. Gynaecol. Res. Vol. 34, No. 1: 67–72, February 2008

Ureteral catheter placement for prevention of ureteral
injury during laparoscopic hysterectomy
Yudai Tanaka1, Hironori Asada2, Naoaki Kuji2 and Yasunori Yoshimura2
1
Department of Obstetrics and Gynecology, Yazaki Hospital, Kanagawa, and 2Department of Obstetrics and Gynecology, Keio
University School of Medicine, Tokyo, Japan

Abstract
Aim: Ureteral injury is among the most devastating complications of gynecologic surgery. Estimated incidenceof ureteral injury during laparoscopic hysterectomy is 2.6–35 times (0.2–6.0%) that in abdominal hysterectomy.
We investigated preoperative ureteral catheter (UC) placement as a way to prevent ureteral injury in laparoscopic hysterectomy.
Methods: Clinical records of 94 women who underwent laparoscopic hysterectomy between February 2006
and January 2007 in Yazaki Hospital, Kanagawa, Japan, were reviewed retrospectively. Thirty-four patients
between February and June 2006 underwent the surgery without ureteral catheterization and 60 patients
between July 2006 and January 2007 underwent surgery with ureteral catheterization. Clinical outcomes were
statistically compared between the two groups.
Results: The average time required for catheter insertion was 9.35 min. The ureter in which the catheter wasplaced was visualized clearly. In one patient, whose left ureter was deviated by a massive myoma, catheter
insertion was not possible. No complications arose from catheter placement except for minor complaints
including low back pain, urinary discomfort, and transient hamaturia. While one injury occurred in a patient
without ureteral catheterization (1/34), no ureteral injury occurred in any patient with ureteral catheterization(0/60). Operative time, total blood loss, and hospital stay were not signiﬁcantly different between the twogroups.
Conclusions: UC placement is simple, helping to prevent ureteral injury during laparoscopic hysterectomy
and enhancing safety of this procedure.
Key words: cystoscopy, laparoscopic hysterectomy, ureteral catheter, ureteral injury.

Introduction
The most commonly performed gynecologic operationworldwide is hysterectomy.1 In the US, 600 000 women
undergo some type of hysterectomy each year, with
37% of women 65 years old having had a hysterecotmy.2,3 Three approaches have been used to perform
hysterectomy: abdominal hysterectomy (AH), vaginal
hysterectomy (VH), and laparoscopic hysterectomy(LH). LH has been divided into three subtypes according to the method used to secure and divide the uterine

artery. In laparoscopically assisted hysterectomy(LAVH), the uterine vessels are secured vaginally,
while LH refers to laparoscopic division of the uterine
vessels. The procedure is termed total laparoscopic
hysterectomy (TLH) when surgery involves no transvaginal component and the vaginal vault is sutured
laparoscopically.4,5Although more than 70% of hysterectomies are performed by laparotomy, advances in endoscopic gynecologic surgery during the late 1980s and early 1990s
have led to a patient preference for LH over AH.6

Received: May 6 2007.
Accepted: July 13 2007.
Reprint request to: Dr Yudai Tanaka, Department of Obstetrics and Gynecology, Yazaki Hospital, 1-1-16 Kamitsuchidana-Naka Ayase,
Kanagawa 252-1113, Japan. Email: yudai_hello@yahoo.co.jp© 2007 The Authors
Journal compilation © 2007 Japan Society of Obstetrics and Gynecology

67

Y. Tanaka et al.

Advantages of LH over AH include less scarring, lesspostoperative pain, shorter hospital stay, and patients
return to normal activities sooner.7,8
However, as the new technology has been embraced,
increased risks of complication has been noted.9 Major
sites of potential injury during LH include the great
vessels, intestines, and urinary tract (bladder or
ureter). Among the latter, ureteral injuries are particularly troublesome.10 Urinary tract injury from gynecologic surgery can have major personal, ﬁnancial, andsocietal costs. In Canada, 17% of non-obstetric litigation in gynecologic surgery has been reported to
involve urinary tract injuries.11
Introduction of LH was followed by a number ofreports of ureteral injuries, with estimated incidence at
0.2–6.0%.12–15 In particular, several reports have compared incidence of urinary tract injuries between LH
and AH. Harkki-Siren et al.16 reported that in Finland
the rate of ureteral injuries associated with LH was 35
times that of AH. In a systematic review of 47 observational studies, Glimour et al.10 concluded that the rate ofurinary tract injury was up to 5 times greater in LH
than in AH. The Cochrane Database Systemic Review
in 200617 calculated from a meta-analysis of 27 trials
that the odds ratio of incidence in LH relative to AH
was 2.61 (95% CI 1.22–5.60). With any new technique,safety as well as clinical efﬁcacy is a highly importantconsideration.18 Accordingly, despite many advantagesof LH, excess occurrence of ureteral injury in LH has
impeded its worldwide acceptance.8,19
Thus, prevention of ureteral injury is of paramountimportance in LH. Since July 2006, we introduced preoperative ureteral catheterization (UC) under cystoscopic guidance in all patients who undergo LH at our
institution because the most important cause of highureteral injury risk during LH is due to the greater
difﬁculty with identifying the ureteral course. The
catheters straighten the ureters and offer clear visualization through the peritoneum without invasively
exploring the retroperitoneal area. We feel that UC hasenhanced safety and ease of all procedures performed
during LH. The present report describes UC in LH andpresents an evaluation of its usefulness.

Materials and Methods
We retrospectively studied 94 patients undergoing LH
between February 2006 and January 2007 in the Department of Gynecology at Yazaki Hospital, Kanagawa,Japan. The patients’ ages ranged from 36 to 74 years
with a mean of 50.1. Indications for LH were: uterine

68

myoma in 67% (weight range from 90 to 2410 g),
adenomyosis in 8%, and other conditions in 25% which
included atypical endometrial hyperplasia, dysfunctional uterine bleeding, and endometriosis. All LH
between February 2006 and June 2006 were performed
without UC (n = 34), and those between July 2006 andJanuary 2007 were done with UC (n = 60). Clinical outcomes (patients’ age, operative time, total blood loss,
uterine weight, hospital stay, and incidence of ureteral
injury) were assessed between cases with and without
UC using Student’s t-test. All patients and family
members gave consent for UC and LH after receiving
all pertinent information about the procedures.

Surgical technique
Ureteral catheterization
Patients were given endotracheal general anesthesia
and placed in the lithotomy position. A cystoscope(HOPKINS Telescope, 4 mm; angulation, 70° [model
K27005CA] together with a 22 Fr outer tube [model
K27026B]) (both from Karl Stortz, Tuttlingen,Germany) was inserted into the urinary bladder. After
ﬁlling the bladder with normal saline via the cystoscope, interureteric folds and the two ureteral openings were identiﬁed. After careful insertion of a guidewire into one opening, a Tigertail ﬂexible-tip UC
system (diameter, 6 F; length 70 cm) (C. R. Bard,
Murray Hill, New Jersey, USA) was advanced rostrally
along the guide wire for a length of 15 cm (Fig. 1). The
guide wire was then removed. Another guide wire andcatheter were inserted similarly into the contra lateral
opening. Each catheter was ﬁrmly ﬁxed to the thigh toprevent dislodgement from the ureter during theoperation. A 14 Fr Foley catheter was then placed in the
bladder.
A uterine manipulator (Ethicon, Division of Johnson& Johnson, Piscataway, NJ, USA) was inserted into theuterine cavity for effective control of the position of anenlarged uterus. A 10 mm laparoscope was inserted
within an umbilical trocar sleeve through a verticalintraumbilical incision. One 5 mm trocar sleeve wasthen placed in the supra-pubic area and two more laterally on each side to the rectus abdominalis muscle
and inferior epigastric vessels. The entire abdominal
cavity then was inspected.
Laparoscopic hysterectomy
LH was performed as described in textbooks.5,7,20,21 All
LH was carried out as TLH, which is associated withsigniﬁcantly less major morbidity, including ureteral© 2007 The Authors
Journal compilation © 2007 Japan Society of Obstetrics and Gynecology

Ureteral catheter in laparoscopic surgery

right

injury and bladder injury, and reduces the need toconvert to laparotomy rather than LAVH.5 The roundligaments were ﬁrstly dissected using bipolar forceps
and a cavity between anterior and posterior broad ligaments was opened. The infundibulopelvic ligaments(when oophorectomy was indicated) or the uteroovarian ligaments (when ovarian preservation was
possible and desired) were ligated with 2–0 silk or
coagulated with bipolar forceps. The vesico-uterine
peritoneal fold and the bladder were freed from theuterus and upper vagina. The ascending branch of theuterine artery was carefully identiﬁed and dissected
after ligation with 2–0 silk. After dissection of the cardinal ligament, a colpo probe vaginal fornix dLineator(Apple Mecidal, Marlborough, MA, USA) was placedin the vagina, and the anterior cervicovaginal junction
and lateral fornices were identiﬁed. Then the vaginalwall was dissected in a circular motion with a monopolar needle. The uterus was morcellated if necessary andremoved via the vagina. The vaginal vault and retroperitoneum were sutured with 0-Monoclyl (Ethicon,
Division of Johnson & Johnson, Piscataway, NJ, USA)vaginally. During procedures, full awareness of the ureteral course was maintained. A dilute indigo carmine
solution was then administered intravenously. Whendrainage of this blue dye appeared from both ureteralcatheters, the laparoscope and all trocars were
removed and all incisions were closed with 3–0 Vicryl(Ethicon). After abdominal radiography in the operating room to ensure correct insertion of both ureteralcatheters and absence of intraperitoneal foreign bodies,
the catheters were removed (Fig. 2).

Results
All procedures were successfully completed using thelaparoscopic approach. Bilateral UC required 5–14 min(mean 9.4). No ureteral injury occurred in any of theleft

Figure 1 Insertion of Tigertail
ﬂexible-tip catheters into bothureteral openings. Three blacklines on the catheter indicate a15-cm distance from the tip.

Figure 2 Postoperative abdominal radiograph. The
depth of insertion for each catheter is different since
the catheters were advanced and retracted during theoperation to conﬁrm the ureteral course.

cases. In one case, a catheter could not be advanced into
the left ureter due to a massive myoma, involving theleft broad ligament pressing upon the left ureter
causing a sharp angulation, which precluded advancement of the catheter. Apart from this unilateral placement failure, no major complications were associatedwith UC.
Postoperative asymptomatic hematuria was observed in 12 patients (20%) and all were cleared bypostoperative day (POD) three. Four patients (6.7%)
complained of urinary discomfort and pain after
surgery, with full resolution by POD seven. One patient(1.7%) complained of lower back pain on the left sidethat persisted for approximately 1 week postoperatively. It was unclear whether this pain was related
to UC.
The comparison of clinical outcomes between LH
cases with and without UC is shown in Table 1. While© 2007 The Authors
Journal compilation © 2007 Japan Society of Obstetrics and Gynecology

69

Y. Tanaka et al.

Table 1 Comparison of clinical outcomes between laparoscoptic hysterectomy
without ureteral catheter (from February 2006 to June 2006) and with ureteralcatheter (from July 2006 to January 2007)
Clinical characteristic

Without UC(n = 34)

With UC(n = 60)

Signiﬁcance*

Age (years)
Operative time (min)Total blood loss (ml)Uterine weight (g)Hospital stay† (days)
Ureteral injury (No.)

50 ⫾ 9.1
181 ⫾ 39360 ⫾ 279
255 ⫾ 162
4.7 ⫾ 2.0
149 ⫾ 8.0
168 ⫾ 51285 ⫾ 276
262 ⫾ 174
4.3 ⫾ 0.70

P = 0.913
P = 0.187
P = 0.208
P = 0.839
P = 0.133
P = 0.182*Student’s t test was used for calculating the P-value. †Hospital stay was calculated taking
day 1 as the ﬁrst day following the hysterectomy. All data given expect for number ofureteral injury are mean ⫾ standard deviation (95% CI). UC, ureteral catheterization.

no ureteral injury was observed in the group with UC,
there was one case of ureteral injury in the group
without UC, which required ureteroneocystostomy. In
all parameters, no signiﬁcant differences were noted
between the two groups.

Discussion
Lower urinary tract injury is always a risk during gynecologic surgery because of anatomic proximity andembryologic relationship between the reproductive
and lower urinary tracts.10,22 Undoubtedly, the greatest
likelihood of ureteral injury during laparoscopic gynecologic surgery occurs in patients undergoing LH.22,23
Overall, incidence of ureteral injury is estimated at
0.03–2.0% for AH, 0.02–0.5% for VH, and 0.2–6.0% for
LH.12–15 Although such ﬁgures for ureteral injury could
be interpreted as rather low, they translate into a substantial number of ureteral injuries given the large
numbers of hysterectomies performed annually.15
Uterine myomas or adhesions due to endometriosis
often distort the lower urinary tract and obscure its
relationships, causing difﬁculty for surgeons in identifying and isolating the ureter along its course. Even
without such pathology, anatomic variation involving
the urinary tract can increase injury risk. Thus, knowledge of the normal and variant anatomic courses of theureter through the pelvic wall, combined with surgicalskills, is a key to reducing risk of injury during
surgery.7
The safest way to secure the isolation of both ureters
is by exploring the retroperitoneal area, as performedin pelvic lymphadenectomy for malignant disease suchas cervical and ovarian cancer. However, such laparoscopic exploration requires particularly reﬁned surgical skill and in itself may lead to excessive bleeding,70

prolonged operating time, and even ureteral injury.
Alternatively, Koh et al.7 described a simple procedure
with creation of a ‘window’ overlying the anterior andposterior broad ligaments, used to inferolaterally displace the areolar tissue in which the ureter is embedded. However, such a window allows for visualizationof the ureteral course within a limited range only.
More than a decade ago, some authors advocatedroutine intraoperative cystoscopy as screening for
ureteral and bladder injuries.14,24 However, evidence
supporting this procedure has been considered insufﬁcient. While this examination should prevent sequelae
from undiagnosed lower urinary tract injuries, it is notconsidered sufﬁciently cost-effective for widespreaduse.10,15 Early postoperative ureteral jet ultrasonography, which has sensitivity of 100% and speciﬁcity of
90.9% for detecting complete ureteral obstruction,25,26
can provide early detection of urinary injuries, butcannot prevent ureteral injury.
Some reports concluded that increased surgical skill
decreased the complication rate.22,24,27 Indeed, Wattiez
et al.28 reported a signiﬁcant reduction in urinary tract
injury, with a 2.2% (n = 695) incidence during their ﬁrst
6 years of experience and only a 0.9% (n = 952) incidence in a later series, concluding that the most important factor in avoiding urinary tract injury in LH isexperience. However, immediately applicable measures are needed for prevention of ureteral injuries in
addition to accrual of experience. We have found preoperative UC to be a simple and effective solution.
The technique of UC does not require extensive
experience or speciﬁc skill and is easy for a surgeon tomaster. The Tigertail catheter possesses sufﬁcient elasticity to straighten the ureteral course and can correctmany deviations to ensure safety during each step in
LH. A ureter containing a UC bulges against the peri-© 2007 The Authors
Journal compilation © 2007 Japan Society of Obstetrics and Gynecology

Ureteral catheter in laparoscopic surgery

A

B

C

D

Figure 3 Intraoperative identiﬁcation of the ureteral course. (a,c) The ureteral catheter straightens the ureter (arrows) andcauses it to bulge from retroperitoneum. The catheter’s tiger-tail pattern is visualized through the ureteral wall. (b,d) Whenthe retroperitoneum is pushed upon by forceps, the elasticity of the ureteral catheter may be felt, clearly identifying thewhole ureteral course.

toneum, permitting identiﬁcation of the entire course(Fig. 3a,c). Even when the retroperitoneum is edematous and the ureteral course is not clearly visualized,
the elastic properties of the catheter help to determine
the ureteral course (Fig. 3b,d).
Permanent damage can usually be avoided if ureteral
injury is diagnosed at the time of surgery, but unfortunately most ureteral injuries are diagnosed postoperatively.13 Gilmour et al.10 reported that only 7% ofureteral injuries in LH were detected intraoperatively.
In a Taiwanese study, the mean postoperative delay todiagnosis and treatment of ureteral injuries was
11.3 days (range 0–44).22 We have avoided such injuries
to date with UC but, should they occur, the brightorange color of the catheter within the ureter should
be readily apparent, identifying the site of injury
immediately.
Since no patients with bilateral ureteral patency at
the time of operation were found to have a ureteral
injury later,15 the emergence of indigo carmine dyefrom ureteral oriﬁces provides conﬁrmation of ureteral

patency and assurance that injury has not occurred, UC
provides easier conﬁrmation than intraoperative cystoscopy because the operator does not need to setup
the instruments for cystoscopy during surgery andthen wait for the spill of the dye.
To avoid injury of renal pelvis and calices by theureteral catheter, the tip should remain inside theureter between ureteropelivic junction and renal
pelvis. For this reason, we think that depth of 15 cm
from the ureteral opening is adequate. Although notobserved in our series, potential complications of UC
include postoperative cystitis or pyelonephritis. Ureteral mucosal injury with hematuria has been transientand did not require treatment. In the single case inwhich the catheter could not be inserted into one
ureter, the left ureter proves to be displaced and kinked
by a massive myoma involving the broad ligament. In
such instances, effort at insertion must be terminated to
avoid ureteral perforation by forceful advancement.
While there was one ureteral injury in a patient
without UC (1/34), no injury occurred in patients with© 2007 The Authors
Journal compilation © 2007 Japan Society of Obstetrics and Gynecology

71

Y. Tanaka et al.

UC (0/60). Although there is no statistical signiﬁcancebetween these two groups, this result indicates efﬁcacy
of UC for prevention of ureteral injury. Furthermore,
the case of the injury led us to introduce UC afterwards. Both mean operative time including UC andmean total blood loss were also improved in groups
with UC (though not signiﬁcant). Less time was
required for identiﬁcation of the ureteral course incases with UC, probably resulting in shorter operative
time and less blood loss. The other possibility is thatthe operator’s surgical skill had been improved during
the period.22,24,27,28
The cost of UC, as with postoperative cystoscopy,
might be criticized.15,22 However, modestly increased
cost is of minimal concern considering the seriousnessof the injuries prevented. The operator’s comfort andtheir safety towards total awareness of the ureteralcourse during LH is a paramount concern.
In conclusion, UC is a simple and effective way to
avoid ureteral injury in LH. Placement is usually completed within 15 min and is easily mastered. The procedure causes no major complications and UC should
notably reduce the risk of LH-related injury.

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© 2007 The Authors
Journal compilation © 2007 Japan Society of Obstetrics and Gynecology