URETERIC INJURY

Inadvertent surgical injury to the ureter is a relatively common cause of medical malpractice enquiry. The ureter, the narrow tube draining urine from the kidney, is vulnerable to injury during surgery, particularly near its entrance into the bladder. It is most commonly injured iatrogenically during gynecological surgery ¹, often when the surgeon is attempting to control bleeding ².

Inadvertent tying, clipping or cutting may cause leakage of urine into the abdominal or pelvic cavities, reversible or irreversible kidney damage, and subsequent liability to kidney infection³.

Practice Point

Surgical injury to a ureter is a recurring source of potentially viable medical malpractice enquiry

The first-line protection of the ureters during abdominal and pelvic surgery is anatomical. The surgeon traces and repeatedly rechecks the anatomical course by gentle pinching: the ureter is the only narrow tubular structure that responds with a wave of visible contraction that moves toward the bladder.

Ancillary strategies are sometimes used ⁴ such as lighted ureteric catheters introduced preoperatively through the bladder: not only are they not mandatory, but their routine use may cause more complication than benefit ⁵.

The position of the ureter may not be obvious. Not only is the natural course of the ureter variable, but scarring and adhesions from previous infections, other pathology and prior surgery may grossly distort the anatomy ^{6,
7, 8}.

Ureteric injury is a recognised and well-documented complication of pelvic and abdominal surgery, occurring in 4-25 out of every 1000 pelvic surgeries ⁹. However, a recent precedent¹⁰ has, for the first time, established in Canada the UK principle ¹¹ that the onus is on the injuring surgeon to show that s/he implemented a standard protective routine. Surgeons are wise to document explicitly such protection.

Practice Point

Look for explicit documentation that the ureters were visualised and protected during surgery

Circumstantial evidence may cast doubt on defence claims of reasonably conscientious protection of the ureters. As with other clinical and surgical components, the court may accept an assertion of habitual procedure, but plaintiff expert opinion about the findings at reparative surgery may cast doubt on the defendant surgeon's credibility in these circumstances.

Practice Point

Suspect defensive revision of the Operative Report if the dictation time is more than 24 hours after the surgery

It is not unknown for surgeons to later revise the Operative Record to document protection. Note that Canadian hospital regulations generally require that Operative Records be dictated within 24 hours.

Practice Point

Establish at the outset by medical screening how much of the adverse outcome will generate quantum of damages if liability can be proved

Prompt remediation may render the quantum of damages insufficient. If the injury to the ureter is promptly recognised and repaired ^{1,
12, 13,
14}, quantum of damages will frequently be insufficient for the financial risks of pursuing an action for medical malpractice. Rarely there will be such far-reaching complications and disability that the case will be worth taking to trial if settlement cannot be obtained.

Nephrectomy (surgical removal of the kidney) is rarely required.