Ureteral injuries are one of the major complications following gynecologic surgeries. They are serious, troublesome, often associated with significant morbidity, and are one of the most common causes for legal action against gynecologic surgeons. The reported rates of injury depend on the vigilance of diagnosis, type of surgery and other risk factors. We present a case of a 48 year old obese Caucasian female with no significant past medical history who came in with back pain and progressive abdominal swelling for the past three months and was found to have a very large pelvic mass. After preoperative evaluation, including: medical history, physical exam, and imaging studies showing a heterogenous mass 24.6 × 33.0 × 43.1, we predicted that the risk of urinary tract injuries was very high. We used preoperative prophylactic bilateral ureteral catheters to prevent injury. A surgical oncologist was consulted and an exploratory laparotomy was performed with removal of the large multi-lobulated pelvic mass + total abdominal hysterectomy, bilateral salpingo-oophorectomy, and appendectomy all performed at the same time. Patient had an incidental cystotomy during the procedure, which was repaired intra-operatively. The ureters remained intact with no injuries. The importance of thorough preoperative identification, evaluation and anticipation of ureteral injuries will be discussed in detail.
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