A 39-year-old woman is admitted to the hospital for a total abdominal hysterectomy for symptomatic uterine fibroids. The largest fibroid, measuring 8 cm, is located in the lower aspect of the uterus at the level of the cardinal ligament, compressing the bladder anteriorly. The patient has no other medical conditions and no prior surgeries. After the surgery, she develops right-sided back pain. The patient has been able to urinate without difficulty. Injury to which of the following structures is the most likely explanation for this patient's postoperative symptoms?

Question

A 39-year-old woman is admitted to the hospital for a total abdominal hysterectomy for symptomatic uterine fibroids.  The largest fibroid, measuring 8 cm, is located in the lower aspect of the uterus at the level of the cardinal ligament, compressing the bladder anteriorly.  The patient has no other medical conditions and no prior surgeries.  After the surgery, she develops right-sided back pain.  The patient has been able to urinate without difficulty.  Injury to which of the following structures is the most likely explanation for this patient's postoperative symptoms?

Quizplus · Accepted Answer

11ec160b_3578_72cb_9249_c30b198ce48c_MD0001_00 This patient has a right ureteral injury, a potential complication of pelvic surgery (particularly hysterectomy) due to the ureter's proximity to major pelvic ligaments and vessels. The most common sites of ureteral injury during hysterectomy include the following: Where the ureter enters the pelvis at the pelvic brim, posterior to the infundibulopelvic ligament (which contains the ovarian vessels) Along the pelvic sidewall as the ureter runs along the lateral aspect of the uterosacral ligament In the cardinal ligament (which contains the uterine vessels) as the ureter dives under the uterine artery ("water under the bridge") Along the anterolateral cervix and vaginal fornix as the ureter enters the bladder Hysterectomy requires suture ligation and transection of the main uterine blood supply, the uterine artery within the cardinal ligament. Large fibroids at the level of the cardinal ligament (as in this patient) can distort uterine anatomy, thereby increasing the risk of accidentally suturing the ureter and causing ureteral obstruction during a hysterectomy. A unilateral ureteral obstruction causes urine to accumulate proximally, leading to distension and dilation of the proximal ureter and kidney (ie, hydronephrosis) and back pain. Most patients with unilateral obstruction maintain normal urinary function and have a normal serum creatinine level because the contralateral kidney and ureter function normally and compensate for the affected kidney. (Choice A) The bladder can be injured during hysterectomy during its separation from the lower aspect of the uterus and cervix. However, bladder injuries typically present with abdominal pain/distension due to accumulation of urine within the abdomen. (Choices B, C, and E) Injury to the external iliac, ovarian, or uterine artery would not present with isolated back pain. Instead, an undiagnosed arterial injury would likely present postoperatively with an acute abdomen (due to hemoperitoneum) and hemodynamic instability (eg, hypotension). Educational objective: The ureter can be injured during pelvic surgery due to its proximity to major pelvic ligaments and vessels such as the uterine artery within the cardinal ligament. Unintentional suturing of the ureter can present postoperatively with unilateral back pain (ie, hydronephrosis) due to ureteral obstruction. __________ References: Prevention of ureteral injuries in gynecologic surgery. (http://www.ncbi.nlm.nih.gov/pubmed/12748497)

A 39-Year-Old Woman Is Admitted to the Hospital for a Total