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Study Objective: To demonstrate techniques of ureterolysis during complex laparoscopic hysterectomy., Design: Technical video demonstrating different approaches to ureterolysis for complex benign pathology during laparoscopic hysterectomy (Canadian Task Force classification III)., Setting: Benign gynecology department at a university hospital., Intervention: Performance of ureterolysis during laparoscopic hysterectomy for benign pathology., Conclusion: Ureteric injury has significant morbidity and is the most common reason for litigation following hysterectomy, with an estimated risk of 0.02% to 0.4%. [1,2]. Ureterolysis is infrequently practiced by benign gynecologists; however, it may be necessary during complex surgery. Benign pathology requiring hysterectomy, such as endometriosis, myomas, large uteri, and adnexal masses, are recognized risk factors for ureteric injury [3]. Most injuries occur during division of the uterine artery at the level of the internal cervical os. The average distance between the ureter and cervix is 2 cm, but it is only 0.5 cm in 3.2% of the population with a normal pelvis [4]. Preventive strategies, such as the use of a uterine manipulator, may increase this distance, although it still might not be sufficient to prevent injury in women with normal anatomic variants and complex pathology. Visualizing the ureter at the pelvic brim and side wall without retroperitoneal dissection may be inadequate because the segment of ureter between the intersection of the uterine artery and the bladder is not visible. The ureter can be safely dissected up to 15 cm without compromising its viability. In this educational video, we demonstrate various simple, quick, and reproducible techniques to perform ureterolysis for complex benign pathology. These techniques can be used by both expert and novice surgeons to perform and teach ureterolysis. Our method determines the course of the ureter throughout the pelvis and relation to the uterine artery to reduce intraoperative injury. We have performed more than 350 cases with no injuries., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the anatomic relationship between ureter and oblique lateral interbody fusion access by using contrast-enhanced computed tomographic urography., Methods: Contrast-enhanced computed tomographic urography data of 234 patients were retrospectively analyzed. The angle of inclination (∠α) of bilateral ureters, the angle between bilateral surgical accesses (∠β), the insertion angle of surgical access (∠γ), and the angle between ureter and outer margin of ipsilateral surgical access (∠ε) at L2/3, L3/4, and L4/5 levels were measured and analyzed., Results: ∠α gradually increased from L2/3 to L4/5. ∠β gradually decreased from L2/3 to L4/5, and at each level the left-sided ∠β was larger than right-sided ∠β. ∠ε were positive at L2/3 and left-sided L3/4. The right-sided ∠ε at L3/4 and the bilateral sided ∠ε at L4/5 were negative, and the right-sided ∠ε at L4/5 had the largest absolute value., Conclusions: The bilateral ureters gradually descents from the lateral margin to the anteromedial margin on the surface of psoas major muscle. The range of bilateral surgical accesses for oblique lateral interbody fusion gradually decreases from L2/3 to L4/5, and the left-sided access is larger than the right-sided when at the same level. Ureters at the right-sided L3/4 level and bilateral L4/5 levels are at high risk of being injured. In particular, the right ureter at the L4/5 level is most likely to be injured., (Copyright © 2018 Elsevier Inc. All rights reserved.)