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Unroofing of the Ureter for Radical Hysterectomy
Eugenio Volpi M.D.
Chair of Gynecologic Oncology. Ospedale Mauriziano
"Umberto I" Largo Turati 67 - 10128 Torino, Italy.
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Reprinted with kind permission from TheTrocar.com
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| Article Information |
| Publication Date: 04/08/2003 |
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| Practical Tip |
| Unroofing the ureter in the cardinal ligament is the most
important step during radical hysterectomy. At our institution we
developed a modified laparoscopic technique to free the ureter from its
roof through the cardinal ligament. The technique is based on the
advantages of laparoscopic surgery which mainly are: more accurate
haemostasis, magnification of the anatomical structures and positioning
of the scope parallel to the ureteral course instead of perpendicular
like in open surgery. Even if many authors have reported about
techniques for carry out radical laparoscopic hysterectomy, this method
for unroofing the ureter has not been previously described.
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We start hysterectomy dissecting the ureter up
to the crossing with the uterine artery in the broad ligament.
When the artery is visible and isolated , it is coagulated at
its origin from the hypogastric artery. Then the anterior
parametrium is entered by blunt dissection working on the ureter.
The uterine artery is not severed but kept in place and used as
a guide to the ureteral tunnel. Blunt dissection is continued as
far as possible in the anterior parametrium and only at this
moment the uterine artery is cut as well as the tissue
surrounding the ureter. This technique allows isolation of the
ureter before starting the dissection of the bladder on the
plane of the vesico-vaginal septum, since it is performed
from the posterior aspect of the parametrium. |
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According with our modification, the first step of
the radical hysterectomy
is opening the broad ligament to the level of where the uterine
artery crosses the ureter which lies underneath. The clip shows
the relationship between the ureter and the uterine artery. The
ureter is freed from the uterine artery, which at this point is
coagulated. Coagulation of the uterine artery reduces the
bleeding from the parametrium. |
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(Download QuickTime here
to view the videos.)
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As second step, it is easier to unroof the ureter
following its course into the anterior parametrium, working
directly on its adventitial sheath along its lateral and
superior aspect. The uterine artery is left in place and not cut
since it is easier to enter the space below the vessel when it
is intact. We generally dissect the ureter as far as possible by
blunt dissection. |
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Progressively the ureter is totally freed.
Sometimes it is possible to isolate and directly coagulate the
deep uterine vein as shown in the video clip. |
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Only after the ureter has been freed along its
lateral side, the uterine artery is cautiously severed. |
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The picture and video clip show the dissection of
the ureter from the anterior parametrium. The ureter is followed
almost to the bladder. |
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Final result of dissection. The ureter enters the
bladder. |
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| References |
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