Sara Schaenzer Grand Rounds January 24 th, 2018
Bladder Anatomy
Ureter Anatomy
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
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)
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
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
Techniques for Intraoperative Recognition Bladder: Test integrity by filling with methylene blue, sterile milk, saline, CO2 gas Ureters: Visualizing jets on cystoscopy
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
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
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
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
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
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), 1085-1095.
Questions?