When there is no efflux from one or both sides, it is important to have a clear plan and algorithm in place for diagnosis and management (Fig. 7.3). First, consider the patient scenario. Reevaluate the patient’s history to consider if she has had a prior nephrectomy or ureteral reimplant; in the latter case, the ureter may efflux from a different position. If the patient has had any previous abdominal imaging, it can be helpful in identifying the occasional case of a prior nephrectomy or congenital absence of the ipsilateral kidney. In addition, confirm the time of administration of sodium fluoroscein with the anesthesiologist or nurse, as early delivery may mean that all dye has been excreted. Many different maneuvers have been attempted to promote more rapid excretion of the dye. Most commonly, ensuring adequate hydration by the anesthetist and/or administrating a diuretic such as furosemide may promote more rapid renal excretion of sodium fluoroscein. Resuming a level position or reverse Trendelenburg to encourage gravitational drainage has also been performed although these reports are anecdotal. Once sufficient time has passed to confirm a lack of excretion from one or both sides, there are a few ways to proceed. One option is to cut the more distal (i.e., more lateral) uterosacral plication suture (the uterosacral ligament is closest to the ureter distally) out of the vaginal cuff, and observe if efflux then occurs. With an assistant, it is possible to cut this suture while the cystoscope is still in place. If this suture was the cause, brisk efflux will usually immediately ensue and most pelvic reconstructive surgeons would not attempt to replace the suture in this situation because replacing or not replacing those sutures does not seem to affect the rate of prolapse recurrence [1]. If efflux does not ensue, remove the remaining sutures on that side, one at a time, proceeding from the most lateral and caudad to the most medial and cranial. It is important to remember, however, that if a concomitant anterior colporrhaphy was performed, that procedure also carries a risk of ureteral obstruction, and it may be prudent to remove those sutures although the rate of ureteral kinking with USVVS is higher than from anterior colporrhaphy [5].

Occasionally, there will still be a lack of efflux even after removal of all potentially offending sutures. If the patient lacks preoperative upper urinary tract imaging or sufficient historical reason to explain the lack of efflux, urologic consultation is indicated. The most common obstacle to performing retrograde ureterography in such cases is that these patients are often not positioned appropriately on the bed or on an appropriate operative table for pelvic fluoroscopy. Therefore, many urologists will attempt blind passage of a wire or ureteral catheter into the ureter to assure patency. If this is done, a flexible tipped, soft hydrophilic wire should be used, and even then there is risk of converting a ureteral kink or obstruction into a ureteral perforation. Making the extra effort to obtain a C-arm and repositioning the patient can significantly improve patient safety . With retrograde ureteropyelography, the urologist can accurately assess the patency of the ureter and make a decision whether or not a stent should be placed. If there is a suspicion of injury and a stent can be passed, it should be left in place for a minimum of 4–6 weeks [11].

Ureteral injury is a potential complication of uterosacral colpopexy even when intraoperative cystoscopy reveals bilateral ureteral efflux. The so-called delayed obstruction may occur due to excessive scarring between the uterosacral plication and the distal ureter, due to compromise of the ureteral blood supply or perhaps because of inadequate intraoperative examination for efflux. Ureteral obstruction presents in the acute postoperative period with flank pain, nausea, and vomiting, and potentially fever. The diagnosis should be confirmed with imaging, and the study of choice in patients with normal renal function is CT Urography (CTU, see Fig. 7.4c). The severity of hydronephrosis, site of ureteral obstruction, presence and location of any extravasation, presence or size of a potential urinoma, and the status of the contralateral kidney can all be assessed with a CTU. Once identified, in the acute postoperative period (up to 7 days), cutting the offending colpopexy sutures may be sufficient to relieve the obstruction. It is usually ideal to perform this in the operating room for several reasons. Aside from patient comfort, under anesthesia cystoscopy and retrograde ureteropyelography can be performed at the same time to confirm patency of the ureter following removal of the suture(s). In addition, given the potential for ureteral edema and the severity of the obstruction, many urologists would choose to place an indwelling ureteral stent after relief of the obstruction. With further delay in presentation or failure to unobstruct in this manner, open abdominal or laparoscopic ureterolysis and reimplant are often necessary although transvaginal ureterolysis and retrograde stenting has also been reported [12]. In a meta-analysis of USVVS , there was a 1.8% rate of ureteral obstruction, of which 2/3 resolved with suture removal, and the remainder required ureteral reimplantation [2].

Despite the intraperitoneal nature of the operation, bowel injury is rare with USVVS and is reported in less than 1% of cases [1, 2]. Small bowel obstruction (SBO) is very rare and was first reported in a series in 2007 [13]. Three patients presented with significant nausea and vomiting on postoperative days 1–14 and were found to have possible SBO [13]. After failing conservative management, all subsequently underwent laparoscopy, and the source of the obstruction was adhesions in two of the patients, and a polypropylene suture in the third. One of the patients requiring significant adhesiolysis and underwent small bowel resection and enteroenterostomy due to enterotomies during dissection. SBO is more likely with known abdominal and pelvic adhesions or history of endometriosis [1]. Careful attention to surgical technique helps maintain a very low rate of SBO or bowel low. When exposing the uterosacral ligaments, packing of the bowel with tagged, counted laparotomy sponges is usually necessary. The peritoneum should be carefully inspected for abdominal adhesions, the sponges advanced slowly and gently to avoid enterotomies, and gentle retraction on the sponges to minimize trauma. Similarly, these packs should be removed slowly and carefully, and counted, after placing suspension sutures. If performing culdoplasty, care in closing the peritoneum can avoid capturing bowel in the closure and keeping the patient in the Trendelenberg position during this maneuver.