QuizMe 14

Pelvic Floor Anatomy

A 51-year-old woman has a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy due to abnormal uterine bleeding. The uterus is found to be uniformly swollen at 10-weeks of gestation size, with grossly normal-appearing ovaries. With the exception of some cauterized bleeding at the vaginal cuff, the procedure is uncomplicated. On the second postoperative day, the patient complains of right flank pain, US did not show any collection. Decision to perform CT scan due to persistent pain which revealed hydroureter.

  • Total laparoscopic hysterectomy
  • Cauterization
  •  Ligation of the infundibulopelvic ligament
  • Opening the broad ligament
  • Coagulation of the uterine vessels
  •  Transection of the uterosacral ligament
  •  Incision for colpotomy

Coagulation of the uterine vessels

Ureteric injury is a devastating complication of pelvic surgery, with confirmed rates ranging from 0.02 % to 0.78 % for hysterectomies.  Ureteral injuries are associated with all types of hysterectomy, regardless of technique (abdominal, vaginal, or laparoscopic).

In laparoscopic surgery, the most common sites of ureteric injury are at the pelvic brim (where the ureter meets the infundibulo-pelvic ligament, which comprises the ovarian vessels) and lateral to the cervix (during division or coagulation of the uterine artery or the uterosacral and cardinal uterine ligaments). Up to one-quarter of ureteric injuries can be induced by electrocautery.

Risk Factors for ureteric injury include distorted anatomy due to endometriosis or adhesions, obesity, genital organ prolapse, and pregnant uterus.


  • Detailed knowledge of the anatomy
  • Safe electrosurgery and meticulous technique
  • MRI may help in planning complex procedures
  • Identify ureteric peristalsis to localize and follow the course of the ureter.
  • Perform ureterolysis in complex cases (extensive pelvic endometriosis, large ovarian cysts, pelvic adhesions, cervical fibroids)

Check  videos for detailed steps to isolate the ureter in both open and laparoscopic approaches on GynaeFellow App.

  • Baggish, M. S., & Karram, M. M. (2015). Atlas of pelvic anatomy and gynecologic surgery. Elsevier Health Sciences.
  • Brummer, T. H., Jalkanen, J., Fraser, J., Heikkinen, A. M., Kauko, M., Mäkinen, J., Seppälä, T., Sjöberg, J., Tomás, E., & Härkki, P. (2011). FINHYST, a prospective study of 5279 hysterectomies: complications and their risk factors. Human reproduction (Oxford, England), 26(7), 1741–1751. https://doi.org/10.1093/humrep/der116
  • Gilmour, D. T., Das, S., & Flowerdew, G. (2006). Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstetrics and gynecology, 107(6), 1366–1372. https://doi.org/10.1097/01.AOG.0000220500.83528.6e  
  • Minas, V., Gul, N., Aust, T., Doyle, M., & Rowlands, D. (2014). Urinary tract injuries in laparoscopic gynaecological surgery; prevention, recognition and management. The Obstetrician & Gynaecologist, 16(1), 19-28.

 Dr Nouf Khalifeh & Dr Aya Al-Shati