Ureter Injury During Pelvic Surgery: Proving Medical Negligence

What Are the Ureters and Why Are They Vulnerable?

The ureters are two thin, muscular tubes (approximately 25-30 cm long and 3-4 mm in diameter) that carry urine from the kidneys to the bladder. They pass through the retroperitoneum (behind the abdominal lining) and into the pelvis, where they course close to:

- The uterus and cervix (in women) - The ovaries and fallopian tubes (in women) - The bladder - The rectum and sigmoid colon - Major blood vessels (the iliac arteries and veins)

This proximity to the structures being operated on during pelvic surgery makes the ureters vulnerable to injury. The ureters are thin and can be difficult to see — particularly in patients with scarring from prior surgery, endometriosis, cancer, or inflammation.

The standard of care requires the surgeon to identify the ureters at the beginning of the procedure and to protect them throughout the surgery. Failure to do so can result in cutting, crushing, cauterizing, or ligating (tying off) a ureter — with potentially devastating consequences for the patient's kidney function.

How Ureter Injuries Occur

Ureter injuries during pelvic surgery can occur through several mechanisms:

• Transection: The ureter is accidentally cut during dissection — either partially or completely. This is one of the most serious injuries and requires immediate repair.
• Ligation: The ureter is accidentally tied off with a suture or clip, blocking the flow of urine. This can cause urine to back up into the kidney (hydronephrosis), potentially causing permanent kidney damage.
• Thermal injury: Cautery or energy devices (such as harmonic scalpels or bipolar devices) burn the ureter. The damage may not be immediately apparent — the ureter may necrose (die) days to weeks later, causing delayed leakage.
• Crush injury: A clamp, grasper, or other instrument crushes the ureter, causing tissue damage that may lead to stricture (narrowing) or leakage.
• Devitalization: The blood supply to the ureter is disrupted during dissection, causing the ureter to necrose days to weeks later.
• Stretching injury: Excessive traction or retraction stretches the ureter, potentially causing damage or stricture.
• Avulsion: The ureter is torn away from the bladder or kidney — a catastrophic injury.

Types of Ureter Injury

Ureter injuries are classified by the AAST (American Association for the Surgery of Trauma) grading scale:

• Grade I: Contusion or hematoma (bruising or bleeding) without devascularization.
• Grade II: Laceration involving less than 50% of the ureter circumference.
• Grade III: Laceration involving 50% or more of the ureter circumference.
• Grade IV: Complete transection of the ureter with less than 2 cm of devascularization.
• Grade V: Complete transection with more than 2 cm of devascularization, or avulsion of the ureter from the kidney or bladder.

High-Risk Procedures for Ureter Injury

Ureter injuries can occur during any pelvic surgery, but certain procedures carry higher risk:

• Hysterectomy (abdominal, vaginal, laparoscopic, or robotic) — the most common cause of iatrogenic ureter injury. The ureters pass close to the uterine vessels and cervix. [Link to: /medical-malpractice/hysterectomy-gynecological-malpractice]
• Oophorectomy (removal of ovaries) — the ureters are near the ovarian vessels.
• Cesarean section — particularly in emergency or repeat C-sections with scarring.
• Colorectal surgery — particularly low anterior resection, abdominoperineal resection, and colectomy, where the ureters are near the colon and rectum.
• Vascular surgery — aortic, iliac, or femoral artery surgery, where the ureters are near the major vessels.
• Pelvic floor reconstruction — surgery for prolapse or incontinence.
• Lymph node dissection — for gynecologic or urologic cancer.
• Endometriosis surgery — endometriosis can cause scarring that distorts anatomy.
• Laparoscopic/robotic surgery — these minimally invasive approaches have higher ureter injury rates than open surgery, partly due to limited visualization and the use of energy devices. [Link to: /surgical-errors/robotic-surgery-malpractice]

The Standard of Care for Ureter Protection

The standard of care for preventing ureter injury during pelvic surgery includes:

1. Preoperative identification of risk factors: The surgeon should identify factors that increase the risk of ureter injury — prior pelvic surgery, large tumors, endometriosis, pelvic inflammatory disease, obesity, or anatomical abnormalities.

2. Preoperative ureteral stents: For high-risk cases (large fibroids, severe endometriosis, prior pelvic surgery, cancer, known anatomical abnormalities), the standard of care may require placement of ureteral stents before surgery. Stents make the ureters easier to identify and feel during surgery — though they do not prevent all injuries.

3. Intraoperative identification: The surgeon must identify the ureters at the beginning of the procedure and throughout — either by direct visualization, palpation (feeling), or both.

4. Careful dissection: The surgeon must dissect carefully near the ureters — avoiding blind clamping, suturing, or cautery near the ureters.

5. Proper use of energy devices: Energy devices (cautery, harmonic scalpel, bipolar) must be used carefully — at a safe distance from the ureters to avoid thermal injury.

6. Intraoperative inspection: At the end of the procedure, the surgeon should inspect the ureters for signs of injury — discoloration, leakage, or abnormal appearance.

7. Intraoperative cystoscopy: After gynecological surgery (particularly hysterectomy), the standard of care may require cystoscopy — looking inside the bladder with a camera — to check for ureteral patency (whether urine is flowing from both ureters into the bladder). This allows immediate identification and repair of ureter injuries.

8. Immediate repair of recognized injuries: If a ureter injury is identified during surgery, it should be repaired immediately — either by the primary surgeon or by a urologist consulted intraoperatively.

Recognizing Ureter Injury Intraoperatively

When ureter injuries are recognized during surgery, they can be repaired immediately — with much better outcomes than injuries recognized post-operatively. Signs of intraoperative ureter injury include:

- Visible leakage of clear fluid from the ureter or surgical field (urine). - Discoloration or darkening of the ureter (indicating thermal injury or devascularization). - Abnormal appearance of the ureter — kinking, narrowing, or partial transection. - Absence of urine efflux from the ureteral orifice on cystoscopy (indicating possible ligation). - Hematuria (blood in urine) during surgery.

The standard of care requires the surgeon to be vigilant for these signs and to investigate any concerns. When an injury is identified, a urologist should be consulted for immediate repair.

Intraoperative cystoscopy — looking inside the bladder with a camera at the end of gynecological surgery — is increasingly considered the standard of care for detecting ureter injuries. Cystoscopy can identify ureteral ligation (no urine flowing from one side) or other injuries that might otherwise go unrecognized. Failure to perform cystoscopy after high-risk gynecological procedures may constitute negligence.

Post-Operative Presentation of Unrecognized Injury

When ureter injuries are not recognized during surgery, they may present days to weeks later with:

• Flank pain: Pain in the back/side (kidney area) — from urine backing up into the kidney (hydronephrosis).
• Fever: From infection or kidney damage.
• Abdominal distension: From urine leaking into the abdomen.
• Urinary leakage: Ureterovaginal fistula — urine leaking through the vagina after gynecological surgery.
• Low urine output: If both ureters are injured (rare) or if one kidney is not functioning.
• Sepsis: From infected urine in the abdomen or kidney infection.
• Nausea and vomiting.
• Incisional or drain output: Clear fluid from the incision or surgical drain (urine).
• Elevated creatinine: Blood tests showing reduced kidney function.

When Ureter Injury Constitutes Malpractice

Ureter injury is a known risk of pelvic surgery — occurring in approximately 1-2% of gynecological procedures. However, it constitutes malpractice when it results from a deviation from the standard of care:

- Failure to identify the ureters at the beginning and throughout the procedure. - Failure to use ureteral stents in high-risk cases where the standard of care would require them. - Blind clamping or suturing near the ureters without proper visualization. - Improper use of energy devices — using cautery too close to the ureters. - Failure to perform intraoperative cystoscopy after high-risk gynecological procedures (increasingly considered standard of care). - Failure to recognize the injury intraoperatively — despite signs that should have been appreciated. - Failure to consult a urologist when an injury is identified or suspected. - Failure to recognize and treat the injury post-operatively — dismissing patient complaints of flank pain, fever, or leakage.

The defense will argue that the ureter injury was a known risk that the patient consented to. Expert testimony is required to distinguish a preventable error from an unavoidable risk. [Link to: /surgical-errors/error-vs-known-risk]

Proving Negligence in Ureter Injury Cases

To prove that a ureter injury constitutes malpractice, we:

1. Obtain complete medical records: Pre-operative records, operative report, anesthesia records, nursing notes, post-operative records, imaging studies (CT scans, renal ultrasounds), and pathology reports.

2. Engage surgical experts: Board-certified gynecologic surgeons, urologists, or colorectal surgeons review the records and provide opinions on the standard of care — whether ureteral stents should have been placed, whether the ureters were properly identified, whether cystoscopy should have been performed, and whether the injury should have been recognized and repaired intraoperatively.

3. Analyze the operative report: The operative report should describe the identification of the ureters, the surgical technique, and any complications. Discrepancies or omissions may be evidence of substandard care.

4. Establish causation: Expert testimony linking the surgical technique to the ureter injury — distinguishing a preventable error from a known risk.

5. Document damages: Medical expenses (including additional surgeries, stent placement, nephrostomy, or kidney removal), lost wages, pain and suffering, and any permanent kidney damage or loss of the kidney.

New York Statute of Limitations

Under CPLR § 214-a, the statute of limitations is 2.5 years from the date of the surgery. The continuous treatment doctrine may extend the deadline if you continued receiving treatment from the same surgeon for the ureter injury. The foreign object exception may apply if a stent or clip was improperly left in place. [Link to: /surgical-errors/statute-of-limitations]

Frequently Asked Questions

The value of a medical malpractice case in New York depends on several factors, including the severity of the injury, the strength of liability evidence, and the economic and non-economic damages involved. New York is one of the few states with no caps on medical malpractice damages, meaning there is no artificial limit on what you can recover. Below are typical settlement ranges based on injury severity.