A 45-year-old woman is undergoing a complex total abdominal hysterectomy for severe, treatment-resistant endometriosis. During the dissection of the left infundibulopelvic ligament, the surgeon uses electrocautery to control unexpected bleeding near the pelvic sidewall. Shortly after, there is high clinical suspicion for a thermal injury to the left ureter. Arrange the following intraoperative steps in the most appropriate chronological order to evaluate and definitively manage this suspected complication.
- 1Administer an intravenous diagnostic agent (e.g., sodium fluorescein or indigo carmine).
- 2Perform intraoperative cystoscopy to observe for bilateral ureteral dye efflux.
- 3Attempt retrograde ureteral catheterization to localize the defect.
- 4Proceed with definitive surgical repair (e.g., ureteroureterostomy).
Answer
The correct sequence is to first administer intravenous dye, then perform cystoscopy to check for efflux, followed by attempting retrograde catheterization to localize the injury, and finally performing definitive surgical repair.
Intraoperative suspicion of a ureteral injury requires a systematic, stepwise diagnostic and therapeutic approach. First, an intravenous dye is administered so that urine can be easily visualized. Cystoscopy is then performed to evaluate if the dye is successfully effluxing from both ureteral orifices into the bladder. If efflux is absent on the suspected side, it indicates an obstruction or transection, and a retrograde ureteral catheter is passed to identify the exact anatomic level of the injury. Finally, once the injury is precisely localized and its severity is confirmed (e.g., severe thermal necrosis), a definitive surgical repair such as a ureteroureterostomy or ureteroneocystostomy is performed by the gynecologist or a consulting urologist.
Step-by-Step Solution
Key Concept
Intraoperative Management of Suspected Ureteral Injury
Estimated Time:1m 30s