Urologic injuries

Urologic injury during pelvic surgery is primarily a matter of prevention; should it occur, however, prompt recognition and appropriate management are essential. Basic principles are applicable, whether the operation has been performed via the abdominal or the vaginal route. Conditions such as endometriosis, infection, previous operation, and tumor distortion increase the likelihood of damage to the urinary tract. Difficult dissection may easily damage the urethra, bladder, or ureters. Preliminary information as to the position of the ureters and bladder will alert the surgeon. Exacting identification of the ureter and bladder is necessary prior to the use of clamps, sutures, or incision. The next most important factor is recognition of such injury. Whenever the possibility exists, it must be promptly and definitively delineated. Injury to the urethra, bladder, or ureters, when recognized and appropriately repaired, is unlikely to cause subsequent complications. Good surgical techniques, adequate and accurate hemostasis, prevention or treatment of infection, drainage of the operative site, and splinting and resting of the organ are necessary. It is the unrecognized and unrepaired urologic injury that increases the chances of immediate and delayed complications. Peritonitis, infection, stricture, fistula, hydronephrosis, and renal damage as well as death may occur even if the patient survives the immediate postoperative complications. It is important in such instances that the error not be compounded by rash attempts at additional surgical procedures at an operative site where there is maximal tissue reaction. General supportive measures with drainage of the urinary tract to preserve renal function are all that should be done. It is likewise important that the surgeon not be rushed into an early attempt to correct the resultant fistula. Adequate time must be allowed for the tissues to heal so that the subsequent repair may be carried out successfully and without further complications.