{"paper_id":"a58ac3c0-25ac-4fa8-9218-3bc8885d3ae3","body_text":"~ 409 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2020; 4(2): 409-412 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com  \n2020; 4(2): 409-412 \nReceived: 12-01-2020 \nAccepted: 14-02-2020 \n \nDr. Anju Kumari Rani \nSenior Consultant, Gynecological \nServices, SGPGIMS, Lucknow, \nUttar Pradesh, India \n \nDr. Brijesh Singh \nConsultant Surgeon, General \nHospital, SGPGIMS, Lucknow, \nUttar Pradesh, India \n \nShobhit Kumar \nMBBS Student, KGMU, Lucknow, \nUttar Pradesh, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr. Anju Kumari Rani \nSenior Consultant, Gynecological \nServices, SGPGIMS, Lucknow, \nUttar Pradesh, India \n \nUrological injuries in gynecological surgery: A review \n \nDr. Anju Kumari Rani, Dr. Brijesh Singh and Shobhit Kumar \n \nDOI: https://doi.org/10.33545/gynae.2020.v4.i2g.558  \n \nAbstract \nDue to close anatomical proximity of urogenital systems to female reproductive system, urological \ncomplications are common in gynecological surgeries. In fact most of iatrogenic urinary tract injuries are \ndue to gynecologic surgeries. Previous pelvic surgery, endometriosis, gynecological malignancy, pelvic \nradiation, abnormalities of ureter, and presence of ad hesion were found to be significant risk factors. \nUrinary bladder injury was the most common urinary tract injury during gynecologic surgery and usually \nrecognized and repaired immediately with minimal complications. However, ureteral injuries which mostly \nhappens in distal one third of the ureter usually are not recognized immediately and have the potential to be \nlife-threatening or to result in permanent kidney damage. The most reliable way for surgeons to avoid \nureteral injury is to clearly identify the ureter. Aim should be of early diagnosis and management of \nurological injury to avoid the life threatening complications. \n \nKeywords: Hysterectomy, ureteral injury, bladder injury, complications, vesicovaginal fistula \n \nIntroduction  \nThe reproductive and urinary tracts in women are closely related anatomically and \nembryologically. Hence operative injuries to the urinary tract are common in gynecological \nsurgery due to the proximity of the urogenital orga n systems. In fact 75% of iatrogenic urinary \ntract injuries are due to gynaecological surgeries; bladder injuries being the most common \nurologic injury. They are usually recognized during surgery and repaired immediately with \nminimal complications. However, ureteral injuries are typically not recognized immediately; \nhence they have the potential to be life-threatening or to result in permanent kidney damage. \n The primary objective of this study was to identify risk factors associated with urologic injuries \nand to review the management.  \n \nMaterial & methods \nIncidence: The overall rate of urinary tract injury associated with pelvic surgery in women \nranges from 0.3 to 1 percent \n[1, 2] . Bladder injury is approximately three times more common \nthan ureteral injury [1, 3] . Up to 2.4 percent of patients may require concomitant urological \nintervention after hysterectomy-related injury to the urinary tract [4]. In a large population based \nanalysis which included over 223,872 patients, ureteral injury occurred in 1,753 patients \n(0.78%) and was unrecognized in 1,094 patients (62%) [2]. While there was no significantly \nincreased risk of acute renal failure or death for recognized ureteral injuries compared with no \ninjuries, unrecognized injury was associated with significant increased risk of acute renal failure \nand death.  \n \nImpact of procedure route: The incidence of urinary tract injury at gynecologic surgery varies \nby the type of procedure and route of surgery: Of ureteral injuries from gynecologic surgery, \nroughly 50 percent are from radical hysterectomy (Laparoscopic assisted Radical hysterectomy \ndoes more injury followed by open Radical hysterectomy), 40 percent are from abdominal \nhysterectomy and less than 5 percent result from vaginal hysterectomy.  \n \nRisk factors: These are conditions that distort pelvic anatomy, obscure tissue planes, make \nvisualization of urinary tract structures difficult,  or make the urinary tract more vulnerable to \ninjury \n[4, 6] . These include prior pelvic surgery, endometriosis, urinary tract abnormalities (eg, \nduplicated ureter, pelvic kidney), history of pelvic irradiation, obesity, large pelvic mass, \nfibroids including in the cervix and broad ligament. Specific to pelvic surgery, prior laparotomy \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 410 ~ \nor cesarean delivery was associated with higher rates of bladder \nand/or ureteral injury in studies of hysterectomy with 1000 or \nmore women; the rates were compared with patients who had \nnot previously undergone these procedures [7]: Previous \nlaparotomy – 2.1 versus 0.5 percent, Previous cesarean delivery \n– 2.9 to 4.7 versus 0.7 to 1.1 percent. A large population-based \nstudy reported black race as a risk for bladder injury [6]. This is \nattributed to a greater incidence of large uteri and uterine \nfibroids among black women undergoing hysterectomy [6]. \n \nAnatomy: The ureters are retroperitoneal, 25 to 30 cm long \nstructures that run from the renal pelvis to the bladder and can \nbe injured during pelvic surgery at any point along their distal \ncourse. Most common sites of injuries are-1) infundibulopelvic \nligament where ureter runs just medial and inferior to the \novarian vessels. 2) at internal cervical os, the ureter passes under \nthe uterine arteries in the cardinal ligament through a tunnel of \nareolar tissue, 3) The ureters then pass close to the anterolateral \nfornix of the vagina and enter the posterior aspect of the bladder. \nBladder is positioned anterior to the vagina, cervix, and lower \nuterine segment. The base is opposed to the cervix and vagina \nwith the vesicocervical and vesicovaginal fascia. The bladder is \ndivided into the dome superiorly and the base inferiorly \n[8]. The \nbase contains the trigone, including the ureters, which enter \nposteriorly, and the urethra which exits at the most inferior \naspect of the bladder. \n \nMechanisms of injury:  Injuries with energy sources: Thermal \ndamage from electrosurgery, laser or harmonic scalpel, is \nbecoming a more frequent cause of injury to the urinary tract \n[9, \n10]. The expected thermal spread from devices ranges from 2 to \n22 mm. In a systematic review of 90 studies, electrosurgery was \nthe most common cause of ureteral injury (33 percent) while \nlysis of adhesions was the most common cause of bladder injury \n(23 percent) \n[4]. Other modes of intraoperative ureteral injury \ninclude: crushed with a clamp, kinked or ligated with a suture or \nstaple, lacerated or transected during sharp/blunt dissection or \nwhile using an energy source, devascularization or denervation. \nAdditional mechanisms of intraoperative bladder injury include: \nTrochar or Verris needle injury during laparoscopic surgery, \nlaceration of the bladder wall with or without breach in the \nbladder wall, devascularization or denervation, accidental \nplacement of an intravesical suture or staple. \n \nSequelae of injury:  Potential consequences of lower urinary \ntract injury include ureteral obstruction (resulting in \nhydronephrosis and possible irreversible injury which, if \nbilateral, can lead to renal failure), genitourinary fistula and \nurinoma \n[11]. Any of these consequences can lead to readmission, \nsepsis, and death [2]. When bladder injuries present \npostoperatively, genitourinary fistulas appear to be the most \ncommon presentation (74 of 76 in one series). Fistulas are more \noften associated with hysterectomy, particularly radical \nhysterectomy. \n \nDiagnosis & management  \nPeroperative: When a bladder injury is found during pelvic \nsurgery, it should be repaired in 2 layers with prolong indwelling \ncatheter, and it is wise also to investigate the possibility of an \naccompanying ureteral injury. If the patient had received prior \npelvic irradiation, the bladder repair should be covered with \nomentum or peritoneum (two types of abdominal membrane), if \navailable, to prevent possible formation of a fistula. A suction \ndrain is placed until the drainage is minimal. If drainage output \nremains high, the drainage fluid should be sent for creatinine \nlevel test. Creatinine levels higher than normal serum levels \nindicate a urine leak; whereas levels equal to serum indicate \nperitoneal or lymphatic fluid. Persistent urinary leakage \ntypically resolves with an additional two to four weeks of \nbladder drainage \n[16]. In laparoscopic surgeries bladder may get \npenetrated by placement of the Veress needle or trocar. Trocar \ninjuries are typically to the bladder dome and have an entry and \nexit wound. Bladder injuries occur most often with midline and \nlower abdominal trocar placement. A full bladder or one with \ndistorted anatomy from previous pelvic surgery, endometriosis \nor adhesions is more likely to be injured laparoscopically \n[17]. \nDuring the operation, the diagnosis of bladder injury is \nsuggested by the presence of gas filling up the Foley bag or \nvisibly bloody urine in the Foley bag. Veress needle injuries and \nother small injuries to the bladder can be successfully managed \nconservatively by catheter drainage for seven to 14 days \nfollowed by cystography. Large bladder injuries, such as from 5 \nor 10 mm trocar or surgical dissection, often require suturing the \ninjuries closed (either laparoscopically or by open repair) with \nprolonged catheter drainage. \n If injury to the ureter is suspected during the operation, the \nureter must be meticulously examined as direct exploration and \nvisual inspection are the most common and accurate methods for \ndiagnosis. If no obvious urine leak is noted at the suspected \ninjury site then to help identify the ureteral injury, indigo \ncarmine can be injected into the ureteral opening or injected \ndirectly into the ureter. The injection of indigo carmine into a \nvein coupled with Lasix diuretic, which colors the urine blue, is \nalso helpful. The blue-tinged urine helps confirm injury. A \nureter with a bruised appearance can have significant trauma \nfrom either a crush or ischemic injury. To determine whether a \nureter has lost blood supply are to note wall discoloration and \nabsence of refill of the capillaries. A ureter that visibly can \ncontract, unfortunately, is not a clear indication of normal \nureteral function or of adequate blood supply. The method of \nureteral repair is determined by many factors, including the \nlocation and length of ureteral injury or type of injury. Partial \nureteral lacerations or thermal injuries that are diagnosed during \nthe operation can be managed by endoscopic placement of a \nstent. When the ureter has been cut completely, an immediate, \nopen surgical approach is typically needed. \n \nDelayed bladder & ureter injury/diagnosis \nUndiagnosed injuries to the bladder that occur during surgery \ntypically become evident days to weeks after surgery. In patients \nwith previous pelvic irradiation, fistulas can occur months to \neven years after hysterectomy. Typical delayed bladder \ncomplications are various forms of fistulas. Cystography with a \npost-drainage X-ray will enable the surgeon to assess injury \ninside and/or outside the abdominal membrane. Injuries inside \nthe abdominal membrane require surgical closure and drainage, \nwhereas injuries outside the abdominal membrane can be \nsuccessfully managed through prolonged Foley catheter \ndrainage. Decreased urine output, absent or defective urine \nexcretion, an excess of urine, elevated blood urea nitrogen, the \npresence of blood in the urine, bruising and abdominal swelling \nsuggest a bladder injury has been missed. \nInitially, a ureter that is cut produces no symptoms until a cyst \ncollecting urine causes abdominal swelling, bowel obstruction, \ninfection, fever or low back, or abdominal pain. Persistent blood \nin the urine, increase in white blood cells and/or urinary (fluid) \nleakage from the vagina are other reliable signs of injury. \nAbsorption of the urine by the abdominal membrane will often \ncause a rise in the serum urea nitrogen. Such injuries have been \nmanaged successfully by a variety of methods, from ureteral \nstent placement for minor injuries to open surgical repairs. \nWhen the injury is not detected  for more than two to three \nweeks, the patient requires proximal urinary diversion (PCNL \nand, if possible, ureteral stenting), as well as drain placement \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 411 ~ \ninto the urine-containing cyst. The discharged urine also may \ncause fibrosis severe enough to cause ureteral obstruction. At \ntwo to three weeks after surgery, re-exploration is typically \ndifficult and fraught with danger because of inflammation, \nfibrosis, adhesions, blood clotting and distorted anatomy.  \nIntravenous urography findings suggestive of ureteral injury are \ndelayed visualization or the inability to visualize the involved \nkidney, hydronephrosis, or incomplete visualization of the entire \nureter. Retrograde urography is typically the most sensitive \nradiographic method to evaluate the integrity of the ureter, and \nto determine if it has been damaged. CECT can identify a \nhematoma (clotted blood), a cyst containing urine or \nhydronephrosis, ureteral leak, all suggestive of ureteral injury. \nDefinitive repair is performed in a delayed/staged fashion. \n \nDiscussion \nMost ureteral injuries (80 to 90 percent) occur in the part of the \nureter that is in the pelvis, the segment of ureter closest to the \nbladder. In fact, more than 75 percent of ureteral injuries due to \ngynecologic surgeries occur during uncomplicated and routine \nprocedure where pelvic anatomy is normal \n[10]. Hemorrhage \n(extensive bleeding) during the operation is a clear and main risk \nfactor for ureteral injury. Sudden hemorrhage should never be \ntreated with blind cautery (searing of tissue) or suturing, but \nrather direct pressure, sharp dissection and exposure of the \nbleeding vessels followed by accurate and precise suturing \n[2, 10]. \nAbdominal hysterectomy is the most common cause of ureteral \ninjury inadvertently caused by a surgeon. Here, the potential for \nureteral injury is greatest during the ligation and division of the \nuterine arteries, followed by division of the ovarian vessels in \ninfundibulopelvic ligament. In radical hysterectomy, the ureter \ncan be skeletonized when removing an adjacent tumor, and this \ncan result in a lack of blood supply and delayed death of tissue. \nRadical hysterectomy also may require en-bloc resection \n(removal as a unit) of a ureteral segment (in order to achieve a \ntumor-free margin). Prio r irradiation can co mpromise ureteral \nblood supply, make wounds heal poorly and increase the risk of \nureter injury during pelvic surgery (after hysterectomy by three \nto fourfold). Cancers can directly invade and can fix the ureter \nor distort its course. Severe pelvic prolapse also can increase the \nrisk of ureteral injury. Infected or inflamed tissues are other \nimportant contributing factors for ureteral injury \n[14].  \nThe method of ureteral repair is determined by many factors, \nincluding the location and length of ureteral injury, the time of \ndiagnosis (during the operation, early postoperative or delayed), \nthe type of injury and the presence of associated medical or \nsurgical illnesses. Clearly, the optimal time for repair of a \nureteral injury is during the operation, when it initially occurs. \nImmediate recognition and repair allow for better results and \nfewer complications compared with that in a delayed fashion. \nUnfortunately, most ureteral injuries from gynecologic surgery \n(more than 80 percent) are discovered in a delayed fashion. \nInjuries that are detected after an operation tend to be more \ncomplex, require more complex repairs and multiple procedures, \nand have more complications than those detected and repaired \nduring the operation. Rates for surgical removal of the kidney \nresulting from delayed diagnosis, overall, are seven times as \ncommon as when the ureter injury is diagnosed during surgery. \nUrine leakage also can cause abscess formation and scarring of \nthe ureter, leading to obstruction and formation of abnormal \npassages.  \n \nPreventive measures \nInformed consent - Counseling about the risk of urinary tract \ninjury is part of the informed consent process prior to pelvic \nsurgery. Medical history - Important history are prior pelvic \nsurgery, radiation, or infection and known or suspected \nendometriosis. Congenital anomalies of the urinary tract (eg, \nduplicated ureters, pelvic kidney) may be suspected if there is a \npersonal or family history of congenital anomalies of the urinary \ntract or reproductive tract, since these abnormalities often \ncoexist. Imaging studies - Contrast studies of the ureters may be \nuseful in patients with known or suspected urinary tract \nanomalies. Preoperative imaging with computed tomography or \nurography can be helpful in demonstrating structural \nabnormalities in the urinary tract \n[12]. Magnetic resonance \nimaging can be helpful in confirming the presence of cervical \nfibroid, broad ligament fibroid, and/or retroperitoneal cysts or \nmasses that increase the risks of urinary tract injury.  \n \nOperative setup \nPatient positioning - Patient positioning in the dorsal lithotomy \nrather than supine position for pelvic surgery provides better \naccess for evaluation of the urinary tract with cystoscopy or \nother methods that require access to the urethra. This setup \nallows a second surgical assistant to stand between the patient's \nlegs, which improves their ability to assist. Bladder catheter -\nPlacement of a Foley catheter may be helpful in procedures in \nwhich there is a potential for urinary tract injury. If there is an \nincreased risk of injury, a triple lumen (three-way) catheter can \nbe used, which will allow instillation of contrast material if \nbladder injury is suspected. Persistent blood-tinged urine in the \ncatheter output should prompt evaluation for urinary tract injury. \nProphylactic ureteral catheters - Universal use of prophylactic \nureteral catheters is not recommended \n[13, 14]. A randomized trial \nthat assigned 3,141 women with no prior pelvic surgery who \nwere undergoing major gynecologic surgery to bilateral ureteral \ncatheters versus no stents reported similar incidences of ureteral \ninjury in the groups (1.2 versus 1.1 percent) \n[14]. Ureteral \ncatheters are potentially helpful for selected women with known \nor suspected periureteral fibrosis or scarring, such as those with \nsevere endometriosis, large cervical fibroids, or prior pelvic \nirradiation. Surgical Technique - The most important principle \nfor prevention of urinary tract injury is to develop and divide \ntissue planes to identify and isolate the structures of the lower \nurinary tract before operating on other pelvic structures. \nAnatomic variation and pelvic pathology may obscure tissue \nplanes, thereby increasing the risks of an injury \n[1]. Avoiding \nureteral injury  - Identification of the ureter at each step in a \nprocedure avoids injury [12]. The highest risk of denervation \nand/or devascularization is during ureterolysis; therefore, \nremoval of all tissue surrounding the ureter should be avoided \nduring gynecologic surgery performed for benign indications. \nDuring gynecologic surgeries the steps of the procedure in \nwhich the ureter is most likely to be injured are:  Ligation of the \novarian vessels  - To avoid ureteral injury when the ovarian \nvessels are ligated during oophorectomy, there are several \nmethods of identifying the ureter; however, opening the \nretroperitoneum and visualizing and/or palpating the ureter prior \nto isolating, clamping, and ligating the ovarian vessels is the \nmethod that best ensures accurate identification and protection \nof the ureter. Ligation of the uterine vessels  - At the level of the \nuterine arteries, the uterine vessels are skeletonized before \nligation to visualize the ureter. If the vessels have been isolated, \nit is not required to completely dissect out the ureter. When \nplacing a clamp prior to ligating the vessels, care must be taken \nthat only the vessels are included in the clamp. Mobilizing the \nbladder from the anterior cervix and displacing it inferiorly will \nalso shift the ureters inferior to the uterine arteries prior to \nclamping. The ureters pass below the uterine vessels, and once \nthese vessels are ligated, the ureter will pass just inferior and \nlateral to this pedicle. Thus, to protect the ureter during \nsubsequent dissection of the cardinal ligament, the clamp is \nplaced medial to the uterine artery pedicle. Vaginal cuff closure \nThe ureters enter the bladder posteriorly, along its interface with \nthe anterior vaginal wall. As the bladder is dissected off the \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 412 ~ \nsurface of the vagina or cervix and displaced inferiorly, the \nureters will descend with the bladder to a level safely below the \nsuperior aspect of the cuff but care must be taken during closure \nof the vaginal cuff to avoid both the ureters and bladder injury. \nAvoiding bladder injury - Injury to the bl adder may occur while \ndissecting the bladder away from the lower uterus, cervix, and \nupper vagina during hysterectomy. This tissue plane is usually \neasy to find and dissect, whether a hysterectomy is being \nperformed from a laparoscopic, abdominal, or vaginal approach. \nHowever, one or more previous cesarean deliveries may cause \nfibrosis and scarring. In this setting, there is increased difficulty \nin dissecting the tissue plane with a higher risk of bladder injury. \nUse sharp dissection, with or without electrosurgery, whether \nthe dissection is easy or difficult, do not perform blunt dissection \nwhen developing this tissue plane. Blunt dissection may result in \nincreased bleeding or tearing of the bladder. Bladder injury that \noccurs with sharp, rather than blunt, dissection can often be \neasier to repair. In laparoscopic surgery, injury to the bladder \nusually occurs during secondary trocar insertion. Bladder injury \ncan be avoided by placement of the secondary trocar under \ndirect visualization and by making certain that the bladder is \nemptied before trocar placement. Intraoperative maneuvers - At \nabdominal hysterectomy, having the first assistant constantly \npulling the uterus up, while the surgeon mobilizes the bladder \nand ligates the uterine arteries and the cardinal/uterosacral \nligaments, facilitates descent of the bladder and ureters away \nfrom these structures, decreasing the risk of injury. During \nlaparoscopic hysterectomy, having the second assistant \nconstantly pushing the uterus up accomplishes the same \nmaneuver. At vaginal hysterectomy, placing clamps and suturing \npedicles as close as possible to the cervix and uterus decreases \nthe risk of ureteric injury. Identifying a pelvic kidney  - A pelvic \nkidney, which occurs in from 1 in 500 to 1 in 3000 individuals, \nmay be encountered during gynecologic surgery. They are \nusually unilateral, retroperitoneal, irregular in shape, and may \noccur anywhere below the pelvic brim. The blood supply is \ninvariably anomalous, often with branches coming from the \naorta, common, external or internal iliac vessels, and vessels \nmay come from both sides of the pelvis. During laparotomy, \nidentification of a pelvic kidney can be made by palpating the \nabdominal retroperitoneum to confirm that there is no abdominal \nkidney, and then by identifying the ureter which exits the pelvic \nkidney \n[15]. Intraoperative sonography may also be used to \nidentify a pelvic kidney.  \n \nConclusion \nStatistically urological injuries are rare, but are responsible for \nsignificant morbidity. Bladder injuries are more common than \nureteric injuries but causes less morbidity due to early detection \nand repair. Ureteral injuries are, however, less frequent but \nassociated with high morbidity. Early diagnosis and intervention \nare necessary to prevent the occurrence of life-threatening \nurological complications in gynecological surgery. \n \nReferences  \n1. 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