1. A Review of Laparoscopic Ureteral Injury in Pelvic Surgery Obstetrical and Gynecological survey Volume 58, Number 12 2004 년 4 월 29 일 임 종 인

2. Abstract Objective of this study – laparoscopic surgeries 중 ureteral injury 가 발생한 문헌을 review – Determine Reported rates of ureteral injury Initial laparoscopic surgeries during which ureteral injury occurred Time of injury recognition (intra- versus postoperative) Type Location Mode of injury repair Surgical laparoscopic instruments involved in ureteral injury.

3. 적절한 medical subject heading(MSH) terms 선택 및 사용 – Medline computerized database 와 the online ACOG database 검색 – 1966 – 2003 년 사이에 출간된 복강경수술 중 발생한 요관손상에 관 한 영문 literature 검색

4. A total of 70 reported instances in 2491 reported cases Incidences of injury : <1% to 2% 2491 cases – case reports, small series of studies, as well as longer, consecutive studies. Total 70 case 중 – The type of laparoscopic surgery Not described or specified : 18(25.7%) cases LAVH : 14 (20.0%) – Ureteral injury identification Intraoperatively : 6(8.6%) cases Postoperatively : 49(70.0%) cases Not specified : 15(21.4%) cases – Type of injury not specified or described : 36(51.4%) Transection : most common, 14 (20.0%)

5. – Location of ureteral injury Not specified : 46(65.7%) cases At or above the pelvic brim : 10(14.3%) cases – Surgical laparoscopic instrument Electrocautery : 17(24.3%) cases Not reported : 34(48.6%) cases – Repair the ureteral injury Laparotomy - 43(61.4%) cases LAVH : the leading procedure in which injury occurred Electrocoagulation : 대부분의 injury 의 원인

6. Target Audience Obstericians & Gynecologists, Family physicians Learning Objectives After completion of this article, the reader should be able to  Summarize the reported rates of ureteral injury  Identify the location of the more common laparoscopic ureteral injury  List the various types of laparoscopic ureteral injuries

7. Materials and Methods Laparoscopic surgeries 중 발생한 ureteral injury 에 대한 문헌의 분석 (1966-2003) – Appropriate MSH terms 을 만들어 medline database 와 online ACOG database 를 검색 – Bibliographies 을 manual 로 검색 Key terms : “ Laparoscopic complication ” and “ ureter ”

8. Results Medline computerized database : 3344 articles ACOG database : 3690 articles Manual search of bibliographies  30 articles discussed ureteral injury during laparoscopic surgery  70 individual cases contained

9. Rate of Injury and Initial Procedure Incidence rates : <1% to 2% Initial laparoscopic procedure – Not described : 18(25.7%) cases – LAVH : 14(20.0%) cases – Oophorectomy : 8 (11.4%) – Laparoscopic pelvic lymphadenectomy : 7 (10.0%) – Laparoscopic sterilization : 5 (7.1%) – Excision of endometriosis : 5 (7.1%), – Endometriosis ablation : 4 (5.7%) – Drainage of lymphoceles, electrocoagulation, and laparoscopic adhesiolysis : 각각 3 (4.3%)

10. Time of Injury Recognition Intraoperatively : 6 cases (8.6%) Postoperatively : 49 (70.0%) cases Not specified : 15 (21.4%) cases

11. Type of Injury Not described : 36 of the 70 (51.4%) cases Transection : 14 cases (20.0%) Laceration, obstruction, and stenosis : 각각 4 cases (5.71%) Fistula formation, necrosis, and ligation : 각각 2 cases (2.9%) Resection and burn injury : 각각 1 case (1.4%)

12. Location of Injury Not specified : 46 cases (65.7%) At or above the pelvic brim : 10 of the 70 cases (14.3%) At or above the uterine artery : 8 cases (11.4%) At or above the bladder : 6 cases (8.6%)

13. Mode of Approach to Injury Treatment Laparotomy : 43 cases (61.4%) Not described : 15 cases (21.4%) Repair through laparoscopy : 8 cases (11.4%) Conservative, nonsurgical management : 4 cases (5.7%).

14. Instrumentation Involved in the Injury Not specified :34 (48.6%) Electrocautery : 17 (24.3%) Endoscopic stapling : 12 (17.1%) CO2 laser : 4 (5.7%) Forceps : 2 (2.9%) Aspirating needle : 1 (1.4%).

16. Discussion Incidence of major complications in laparoscopic hysterectomy – 3.5% – Incidence of ureteral injuries Between 0.3% and 2% Rate of laparoscopic ureteral injury – Not comprehensively described and documented in the literature

17. 최근 Laparoscopic hysterectomies 와 retroperitoneal laparoscopic procedures 의 증가로 인해 Ureteral injury 좀더 흔 히 발생 H ä rkki-Sir é n et al. – Ureters : particularly vulnerable to injury during major operative laparoscopy

18. Intraoperative diagnoses of ureteral injury – only 6(8.6%) cases Papers on classic (nonlaparoscopic) gynecologic procedures – Injury diagnosis 시간보다는 ureteral injury 를 detection 하는 method 에 대해 기술 – Hurt et al. : 5 methods 1) retrograde ureteral dye injection 2) intravenous dye injection 3) intraoperative ureteral catheterization 4) intravenous excretory urography 5) dissection of the ureter 15(21.4%) cases 가 diagnosis time 을 보고 하지 않음

19. Ureteral injury repair 의 approach 방법 – Laparotomy : 43(61.4%) cases – 15(21.4%)cases did not report Gordon and Lewis – Focal ureteral injuries Double J-shaped catheter 를 삽입하여, urine leakage 를 막고 ureter 를 지지하여 spontaneous healing 을 유도하여 치료 가능 – More extensive damage end-to-end anastomosis 나 ureteral implantation 을 위한 laparotomy 가 필요

20. Preferred technique of ureteral injury repair – Dependent on the time of injury diagnosis 59 cases – both time of ureteral injury diagnosis and mode of treatment were reported – Diagnosed postoperatively Laparotomy : 술후 진단된 49 case 중 38 cases (77.6%) 5 cases of ureteral injury : not treated using laparotomy –4 cases : conservative treatment –1 case : laparoscopic approach most often repaired using laparotomy – Diagnosed intraoperatively laparoscopic repair 증가 6 cases –2 cases : laparotomy –4 cases : laparoscopy.

21. The type and location of ureteral injuries – Type : not specifically described in 51.4% – Location : specified in even fewer cases – Potential locations for ureteral injury Hurt et al. : classic, nonlaparoscopic pelvic surgeries 1) at the pelvic brim 2) Ureter 가 uterine arteries 아래에서 cervix 외측으로 지나가는 부위 3) Ureters 가 bladder 로 들어가는 vaginal fornix 의 외측 부위 Gordon and Lewis : laparoscopic surgeries  at the infundibulopelvic ligament  where the ureter passes deep to the ovarian fossa  at the ureteral canal Our review – at or above the pelvic brim : the most common site

22. Instruments involved in ureteral injuries – 34 cases (48.6%) : not defined or specified – LAVH and electrocautery Identified as leading causes of laparoscopic ureteral injury (when data was available for analysis and review) In more than 50% of the cases – Location and type of injury were also not specified – In this review (most common findings) Electrocautery instrumentation Transection injuries At or above the pelvic brim

23. Decrease the risk of this complication – Ostrzenski laparoscopic suturing and tying method – Laparoscopic suturing technique and the tying of an intracorporeal or extracorporeal staplers or electrocautery 보다 좀더 안전한 method – Improved training in laparoscopic technique Recognition of intra- and retroperitoneal gross and functional anatomy – Lower urinary tract 의 integrity 를 확인하기 위한 intraoperative protocols 확립 – 수술중에 urology consultation 의 획득 Decrease the delay in recognition of ureteral injury Increase of their intraoperative repair.

24. laparoscopic surgeries 중 ureter injury 에 대한 Data and discussion – Lacking in both breadth and depth Much of the reviewed literature on existing information – Cursory and incomplete.