Safeguarding the Ureter: Strategies to Prevent Intraoperative Ureteric Injury in Gynaecological Surgery.

Iatrogenic ureteric injury is an uncommon but serious complication of gynaecological surgery, with significant potential for renal impairment, fistula formation, prolonged hospitalisation, and medico-legal consequences. The ureter is at risk not only in complex pelvic procedures but also during apparently straightforward operations, and injuries may go unrecognised at the time of surgery, contributing to delayed diagnosis and worse clinical outcomes. We present a case series of five female patients aged 33, 59, 45, 46, and 47 years, respectively, who underwent complex gynaecological surgery for large fibroids at the Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences (AIIMS), Rajkot, Gujarat, India. Each case illustrates a distinct clinical challenge and a tailored ureteric safeguarding strategy. Preoperative magnetic resonance imaging (MRI) fibroid mapping was employed. In one case with a large cervical fibroid and documented bilateral ureteric dilatation, contrast-enhanced computed tomography (CT) with three-dimensional ureteric reconstruction provided an informed surgical roadmap and guided the decision for bilateral prophylactic double-J (DJ) ureteric stenting. In another case, attempted left-sided preoperative stenting failed due to fibroid-related ureteric obstruction - a finding that was reinterpreted as a diagnostically valuable signal of significant ureteric compromise rather than a procedural failure, directly heightening intraoperative vigilance. Across all five cases, systematic retroperitoneal dissection with early identification and tracing of the ureter at the pelvic brim served as the consistent intraoperative safeguard. In a further case, despite preparedness and awareness, inadvertent left ureteric transection occurred during haemostasis from an extremely vascular broad ligament fibroid mass; the injury was recognised immediately, urological assistance was summoned intraoperatively, and successful ureteroureterostomy with DJ stent insertion was performed, with complete patient recovery. Based on this experience, we propose a structured six-step protocol for ureteric safeguarding in complex gynaecological surgery: (1) preoperative risk stratification, (2) targeted imaging, (3) selective prophylactic ureteric stenting in cases with hydronephrosis or significant ureteric displacement, (4) systematic retroperitoneal dissection with early ureteric identification, (5) adjunctive intraoperative cystoscopy, and (6) preparedness for immediate surgical repair. This series demonstrates that a multimodal, anatomy-guided approach can substantially reduce the risk of ureteric injury in high-complexity cases, and that when injury occurs despite precautions, immediate intraoperative recognition and definitive repair are the most critical determinants of outcome.