Hysterectomy is one of the most commonly performed gynecologic surgeries worldwide, indicated for conditions such as uterine fibroids, adenomyosis, abnormal uterine bleeding, endometriosis, and malignancy. Laparoscopic hysterectomy has emerged as a minimally invasive alternative to open surgery, offering smaller incisions, faster recovery, less postoperative pain, and better cosmetic outcomes.

In selected cases, especially complex pelvic surgeries, concomitant ureteral stent placement is employed to prevent ureteral injury. Ureteral stents provide intraoperative ureteral identification, facilitate dissection, and allow early recognition of ureteral compromise, enhancing surgical safety.

Indications for Ureteral Stent Placement

Ureteral stent placement is considered in patients undergoing laparoscopic hysterectomy when there is:

Distorted pelvic anatomy due to adhesions, endometriosis, or large fibroids.

Previous pelvic or abdominal surgeries, increasing the risk of ureteral injury.

Malignancy or radical hysterectomy where ureteral dissection is extensive.

Pelvic organ prolapse repair or concomitant procedures like sacrocolpopexy.

The primary goal is prevention and early detection of ureteral injury, which is a rare but serious complication of hysterectomy.

Preoperative Evaluation

Clinical Assessment:

Detailed gynecologic history including prior surgeries, urinary symptoms, and comorbidities.

Physical examination with evaluation of uterine size and pelvic anatomy.

Imaging:

Ultrasound or MRI to assess uterine size, fibroid location, or endometriotic lesions.

CT urography may be used in selected cases to evaluate ureteral anatomy.

Laboratory Tests:

Complete blood count, renal function tests, coagulation profile, and urinalysis.

Patient Counseling:

Discuss the rationale for ureteral stent placement.

Explain potential complications such as hematuria, infection, or stent discomfort.

Anesthesia and Patient Positioning

General anesthesia with endotracheal intubation is required.

Patient placed in dorsal lithotomy position with arms tucked.

Trendelenburg tilt of 15–30 degrees allows bowel displacement and better pelvic visualization.

Foley catheter inserted to decompress the bladder during surgery.

Ureteral Stent Placement

Cystoscopy:

Performed at the beginning of surgery using a rigid or flexible cystoscope.

Bladder is filled with sterile saline for visualization of ureteral orifices.

Guidewire Placement:

A guidewire is introduced into each ureter under direct vision.

Stent Insertion:

Ureteral stents (typically 6–8 Fr) are advanced over the guidewire into the ureter up to the renal pelvis.

Proper positioning is confirmed by observing the distal coil in the bladder.

Securing the Stents:

Stents remain in place during the hysterectomy to allow visual and tactile identification of ureters.

Laparoscopic Hysterectomy Procedure

Port Placement:

Umbilical 10–12 mm camera port.

Two 5 mm lateral working ports.

Optional 5 mm suprapubic port for uterine manipulation.

Surgical Steps:

Diagnostic Laparoscopy: Survey abdomen and pelvis for adhesions or pathology.

Adhesiolysis: Carefully release adhesions around the uterus, bladder, and ureters.

Dissection:

Round ligaments coagulated and transected.

Broad ligament opened; ureters identified and protected, facilitated by stents.

Uterine arteries ligated near their origin.

Colpotomy: Circumferential incision around the cervix for uterine removal.

Vaginal Cuff Closure: Laparoscopic closure using absorbable sutures.

Role of Ureteral Stents During Surgery

Enhanced ureteral visualization: Stents help delineate the ureter path.

Tactile feedback: Surgeons can feel the stent when dissecting near ureters.

Early recognition of injury: Intraoperative ureteral compromise is identified by urine leakage around stents or change in stent position.

Prevention of ligation or thermal injury during coagulation and transection of vessels.

Postoperative Care

Early ambulation and oral intake encouraged.

Pain managed with NSAIDs; opioids if needed.

Foley catheter typically removed within 24 hours.

Ureteral stents may be removed 1–2 weeks postoperatively depending on the surgeon’s preference.

Monitor for hematuria, flank pain, urinary tract infection, or urinary obstruction.

Advantages

Minimally invasive approach reduces postoperative pain and recovery time.

Reduced risk of ureteral injury in complex pelvic surgeries.

Enhanced safety in patients with distorted pelvic anatomy.

Early identification and management of intraoperative ureteral injury.

Better cosmetic outcome compared to open hysterectomy.

Complications

Ureteral stent-related: Hematuria, infection, dysuria, stent migration.

Surgical: Bleeding, bladder or bowel injury, vaginal cuff dehiscence.

Prevention: Careful cystoscopic technique, meticulous dissection, proper stent placement.

Conclusion

Laparoscopic hysterectomy with ureteral stent placement is a safe and effective approach for women undergoing complex pelvic surgery. Stents provide critical guidance for ureter identification, reducing the risk of injury and improving surgical outcomes.

In elderly or high-risk patients, this combined technique offers minimal invasiveness, faster recovery, enhanced safety, and reliable uterine removal, representing a modern standard in advanced gynecologic surgery.