Sara Schaenzer Grand Rounds January 24 th, 2018
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1 Sara Schaenzer Grand Rounds January 24 th, 2018
2 Bladder Anatomy
3 Ureter Anatomy
4 Areas of Injury Bladder: Posterior bladder wall above trigone Ureter Crosses beneath uterine vessels At pelvic brim when ligating ovarian vessels At UVJ while dissecting bladder from upper vagina while closing vaginal cuff
5 Risk Factors for Urinary Tract Injuries 0.3 to 1 percent risk of urinary tract injury with gynecologic surgery, bladder injury 3x more common than ureter Risk factors for injury: Prior pelvic or abdominal surgery Endometriosis Urinary tract abnormalities History of pelvic irradiation Obesity Adhesions Large pelvic mass, fibroids, or uterus > 250 grams Low volume surgeons (less than 10 hysterectomy per year)
6 Prevention of Injury General techniques: Knowing anatomy, understanding common injury mechanisms, consideration of prior surgeries, good surgical techniques Preventing bladder injuries: sharp dissection to establish tissue planes, fill with fluid if borders are unclear, palpate Foley catheter to identify bladder location Preventing ureter injuries: Selective dissection only, place ureteral stents with distorted anatomy, maintain 5 mm margin between heat and viscera
7 Consequences of Undiagnosed Injuries Undiagnosed bladder injuries: fistula formation, altered urinary patterns Undiagnosed ureter injuries: Fistula formation, stricture, obstruction. Unrecognized obstruction can lead to renal failure
8 Techniques for Intraoperative Recognition Bladder: Test integrity by filling with methylene blue, sterile milk, saline, CO2 gas Ureters: Visualizing jets on cystoscopy
9 Role of Cystoscopy Consider routine use with prolapse or incontinence procedures Surgeon dependent with hysterectomy Routine cystoscopy: Increases detection rate of urinary tract injury 5-fold but difficult to evaluate clinical significant due to low rate of injuries Immediate feedback for individual surgeon to use in future cases Low complication rates of cystoscopy Risks: identifying clinically insignificant injuries, false positive findings, increased cost/time/training
10 Post operative Injury Recognition Signs of injury: leakage of urine from vagina or abdominal incision, flank pain, hematuria, oliguria/anuria, abdominal pain/distention, nausea, fever With post-op diagnosis: Relieve renal obstruction, treat infection, stop urine leakage
11 Treatment of Bladder Injuries Dome Injuries Less than 2 mm: do not require repair or prolonged catheterization 2 mm to 1 cm: single layer delayed absorbable suture, 5-14 days catheterization 2 cm or greater: two-layered running closure with delayed absorbable suture, 5-14 days catheterization Trigone Injuries Need to assess ureter and urethra integrity, often requires stents Typically requires urologist to assess
12 Treatment of Ureter Injuries Mechanisms of Injury Kinking: removal suture Ligation or crush: Ureteral stent or resection depending on damage Thermal: Minor: stent Extensive: resection and reparative surgery Lacerations: Less than ½ diameter of ureter: repair over stent with delayed absorbable suture More than ½ diameter of ureter: anastomosis or reimplantation Complete transection: Distal 1/3: reimplantation (ureteroneocystotomy) Middle or Upper 1/3: Primary anastomosis (ureteroureterostomy) or reimplantation with Boari flap
13 Follow-up of Ureter Injuries Following reimplantation: Foley in place for 1-2 weeks Following anastomosis or reimplantation: Stent in place for 1-2 months At 3-6 months and 12 months: assessment for stricture and kidney function with pyelography, renal US, and serum creatinine
14 References Gilmour, Donna. (2017). Urinary tract injury in gynecologic surgery: Epidemiology and prevention. Uptodate. Gilmour, Donna. (2017). Urinary tract injury in gynecologic surgery: Identification and management. Uptodate. Sharp, H. T., & Adelman, M.R. (2016). Prevention, Recognition, and Management of Urological Injuries During Gynecologic Surgery. Clinical Expert Series, Obstetrics & Gynecology, 127(6),
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