75% of injuries to the bladder and ureters occur following gynecologic procedures with the most during uncomplicated cases. The incidence of ureteral injury ranges from 0.2% to 11% depending on the definition used. Management involves quick recognition, evaluation, and tailored management for resolution without prolonged morbidity. The aims of ureteric reconstruction are to preserve renal function and ensure urinary continuity. The immediate repair of ureteral injuries discovered intraoperatively has been reported with excellent results. The principles include a good vascular supply and a wide, spatulated, tension-free anastomosis of mucosa to mucosa followed by ureteral stenting. The advantage of this technique is maintaining bladder integrity and the endogenous anti-reflex mechanism and limiting morbidity and avoiding further surgery. We present a case series of three patients who have had a ureteral transection at time of vaginal reconstructive surgery who underwent transvaginal ureteral ureterostomy. The three cases involved three postmenopausal women with complete uterine procedentia. All three patients underwent a vaginal hysterectomy, bilateral salpingo-oophorectomy, maomacolocultoplasty, and anterior and posterior copal peroneorphy. In case one, the injury was noticed after no spill was seen out of the ureteral orifice and after failed attempts at stenting. The pedicles were explored and the transection was noticed in the uterus sacral pedicle. In the second case, in a similar fashion, the ureter had been entrapped by the uterus sacral pedicle suture and in releasing this, the ureter was transected. In the final case, which is represented by our video, the end of the transected ureter was noticed spilling urine in the operative field after the uterus was removed. The procedure begins by identifying the proximal and distal ends of the transected ureter. Since the ends appeared sufficiently patent, the ends were not spatulated in this case. During this, a double-J ureteral stent is placed in the proximal ureter until it reaches the renal pelvis. The anastomosis is performed using interrupted 4-O chromic sutures, starting in the posterior wall of the ureter, then moving to the lateral edges, then finally anteriorly. The sutures are tagged until the first layer is complete. It is important to start at the posterior wall of the ureter as this region will be difficult to assess once the sutures are tied and the stent is advanced in the distal ureter. The use of constant irrigation is helpful to maintain optimal visualization during the case. Once the posterior sutures have been placed, the stent is advanced in the distal ureter. A cystoscopy is performed to ensure a proper coil in the bladder. The posterior sutures are tied and an additional 2-3 sutures are placed to complete the first layer of the anastomosis. Care should be taken to place only the number of sutures needed to re-approximate the mucosal edges to avoid ischemic injury. The anterior sutures are tied while the most lateral sutures are tagged to stabilize the ureter during the remainder of the repair. A second layer re-approximating the ureteral adventitial layer using interrupted 3-ovicrel sutures is then performed. The lateral sutures that had been tagged earlier can be used to slightly rotate the ureter to gain access to the more posterior side. Once this layer is completed, the suture tags are cut and the third and final layer using the peritoneum is closed over the repair. This third layer hopefully improves vascularization of the anastomosis and decreases the risk of fistula formation. One ampule of indigo carmine is given intravenously and cystoscopy used to confirm ureteral patency. Postoperative management includes the use of an indwelling ureteral stent for 6-8 weeks. Following the removal of the stent, radiographic evaluation at 2 weeks is performed to evaluate for any abnormalities or stenosis at the anastomosis site. Subsequent evaluation at 3, 6, and 12 months is performed to assess for stricture at the anastomosis site. This radiograph represents a postoperative film to confirm correct placement of the double J stent. Two weeks following stent removal, an intravenous urogram is performed to assess adequate healing and drainage of the kidney. In summary, transvaginal ureteral ureterostomy is an option if ureteral injury is identified at the time of vaginal surgery. In a tension-free, multi-layer closure with spatulating the anastomotic ends as needed is performed. Postoperatively, ureteral stent placement for 6-8 weeks with timely assessment and follow-up to ensure patency without stricture formation is recommended. Thank you for your attention.

ureteral injuries

gynecologic procedures

ureteral transection

vaginal reconstructive surgery

transvaginal ureteral ureterostomy