Laparoscopic Dissection of the Pelvic Ureter: Rules of Engagement

Abstract

This video shows the feasibility of laparoscopic ureteral dissection and provides safety rules to perform ureterolysis. Identification and dissection of the ureter should be part of all gynecologic surgeons' background to reduce the risk of complications [1]. Knowledge of anatomy plays a pivotal role, allowing the surgeon to keep the ureter at a distance and minimizing the need for ureterolysis. Unfortunately, the need for ureteral dissection is not always predictable preoperatively, and gynecologic surgeons need to master this technique, especially when approaching more complex procedures such as endometriosis [2]. An implicit risk of damage cannot be denied when performing ureterolysis; therefore, the ureter should be dissected only when strictly necessary and handled with care to minimize the use of energy [3].

Use of Indocyanine Green for Intraoperative Perfusion Assessment in Women with Ureteral Endometriosis: A Preliminary Study.

“…Vascular ureteral supply of the pelvic segment arises from gonadal, common internal iliac and uterine arteries. Ureteral dissection and excisional techniques can cause thermal or mechanic damage of the ureteral arteries and Waldeyer's sheath, leading to segmental ischemia and subsequent risk of ureteral fistula or stenosis [31].…”

Preoperative ureteral stenting in women with deep posterior endometriosis and ureteral involvement: Is it useful?

“…Regardless of the surgical technique, ureteral dissection and excisional procedures imply a consistent risk of urological complications 14 . Indeed, they can lead to mechanical or thermal damage of the ureteral arteries and Waldeyer's sheath and subsequent local ischemia and ureteral fistula or stenosis 24 …”

“…14 Indeed, they can lead to mechanical or thermal damage of the ureteral arteries and Waldeyer's sheath and subsequent local ischemia and ureteral fistula or stenosis. 24 The systematic positioning of preoperative ureteral stents in women with UI by DIE is still debated. According to the current literature evidence, a major indication for the insertion of preoperative ureteral stents is to recover form obstructive uropathy and to ease massive hydronephrosis.…”