Mobilization and protection of the ureter during laparoscopic total hysterectomy for cervical fibroids.

Abstract

Cervical fibroids (CFs) grow in the narrowest part of the uterus, which is adjacent to the ureter, uterine vessels and their branches. The ureter is at risk of being divided, thermally injured, and/or misligated when handling the vessels during total laparoscopic hysterectomy (TLH) to treat CFs We present a series of videos to detail the methods and skills required to perform blunt ureterolysis and handle the uterine vessels during TLH for CFs. This video contains three cases of CFs that underwent TLH. In Case 1, the surgeon did not separate the ureter in advance and mistook the ureter for a vessel during coagulating the vessels with bipolar forceps, which resulted in thermal injury to the ureter. Therefore, a ureteral stent was placed under cystoscopy, which was removed three months after the operation. In both Cases 2, 3, the surgeon used a curved vascular clamp to bluntly separate and fully expose the pelvic part of the ureter and then coagulated and divided the vessels. The separation started when the ureter traced the base of the posterior lobe of the broad ligament until it entered below the uterine artery. The uterine artery dissection site differed in Cases 2 and 3, with Case 2 being at the origin of the internal iliac artery and Case 3 in an area close to the CF, depending on the space between the CF and uterine artery. After six months of follow-up, all three patients were free of pyelonephrosis and ureteral dilatation, and no ureterovaginal fistulae occurred. Blunt ureterolysis procedure can effectively avoid ureter injury in TLH for CFs.