Human Reproduction, Vol. 15, No. 3, 733,
March 2000
© 2000 European Society of Human Reproduction and Embryology
Letters to the editor |
Ureteral injuries after laparoscopic hysterectomy
Service de Chirurgie Gynécologique, Clinique Universitaire Baudelocque, CHU Cochin Saint Vincent de Paul, Paris, France
Dear Sir,
The excellent article by Ribeiro et al. (1999) concerning the value of intraoperative cystoscopy at the time of laparoscopic hysterectomy prompts us to make the following comments.
We entirely agree with the fact that it is necessary to use all possible means to ensure the most accurate diagnosis possible for ureteral lesion (Grainger et al., 1990
; Ribeiro et al., 1999) during hysterectomy, but the main comment we wish to make concerns the rate of these ureteral complications. The rate in question, at 3.4% (four out of 118), seems to us to be far higher than those reported elsewhere whether for laparotomy, the vaginal route (Dicker et al., 1982) or for laparoscopic surgery (Nezhat et al., 1995; Chapron et al., 1996).
Given that there is no question as to the surgeons' skill, two other parameters, i.e. the operative indication and the laparoscopic surgery technique, could perhaps be the explanation for a rate which, in our eyes, is abnormally high.
Concerning the operative indication, all these patients had a distortion of the anatomy caused by severe utero–sacral endometriosis. In addition two of the patients presented a very voluminous uterus (830 and 900 g). These observations clearly show that although laparoscopic hysterectomy is a feasible operation (Reich et al., 1989), the indications must be perfect. In certain difficult situations hysterectomy via laparotomy may be preferable or indeed indicated, rather than expose the patients to such a great risk of ureteral complications. Even highly experienced laparoscopic surgeons, must not consider that carrying out a hysterectomy via laparotomy is something to be ashamed of. Constantly attempting to push back the limits for laparoscopic surgery will lead to discredit for a technique which has so many advantages both for the patients and for society. Opponents of this surgery will thus be able to find all the arguments they need to limit the indications, diffusion and teaching of the techniques.
Concerning the operative technique, all the haemostasis in this study was achieved by ligatures and in all the cases a High McCall culdoplasty was performed. This technique raises the following two problems: (i) is the ureteral risk greater when haemostasis is ensured by laparoscopic ligatures rather than bipolar coagulation? and (ii) is it really necessary to make the vaginal suture by laparoscopic surgery and then systematically perform a High McCall culdoplasty?
Although laparoscopic hysterectomy is a feasible technique, these results underline the absolute necessity for the indications to be perfect, and for rules to be established for a simple and safe technique so that it can be reproduced, which is the sine qua non for its diffusion.
Notes
1 To whom correspondence should be addressed 
References
Chapron, C.; Dubuisson, J.B. and Ansquer, Y. (1996) Is total laparoscopic hysterectomy a safe surgical procedure? Hum. Reprod., 11, 2422–2424.
Dicker, R.C., Greenspan J.R., Strauss L.T. et al. (1982) Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am. J. Obstet. Gynecol., 144, 841–848.[Web of Science][Medline]
Grainger, D.A., Soderstrom, R.M., Diamond, M.P. et al. (1990) Ureteral injuries at laparoscopy: insights into diagnosis, management and prevention. Obstet. Gynecol., 75, 838–843.
Nezhat, F., Nezhat, C.H., Admon, D. et al. (1995) Complications and results of 361 hysterectomies performed at laparoscopy. J. Am. Coll. Surg., 180, 307–316.[Web of Science][Medline]
Reich, H., DeCaprio, J., McGlynn, F. et al. (1989) Laparoscopic hysterectomy. J. Gynecol. Surg., 5, 213–216.
Ribeiro, S., Reich, H., Rosenberg, J. et al. (1999) The value of intra-operative cystoscopy at the time of laparoscopic hysterectomy. Hum. Reprod., 14, 1727–1729.
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