[Management of iatrogenic gynecologic injuries with urologic relevance. Causes and prevention of complications: the gynecologist's opinion]

OBJECTIVE: To detect and prevent urinary tract injuries in gynecological surgery. METHODS: A brief review of the literature about recognition and prevention of ureteral and bladder injuries. RESULTS: It is well known that factors as intra-operative bleeding, pelvic adhesions and infections, pelvic masses, endometriosis and obesity can make surgery difficult. For these reasons the study of the urinary tract and the use of ureteral catheters may be helpful when alterations of the urinary tract anatomy is suspected. However the surgeon should always operate under direct vision of the ureters with a judicious use of diathermy and taking care when separating bladder from the uterus where the blunt dissection is blind and dangerous. When there are some doubts about the integrity of ureters, the control with i.v. infusion of indigo-carmine or with ureteral catheters should be performed. The same applies for the bladder: the cystoscopy should be in the armamentarium of gynecological surgeons to control the ureteral efflux and the bladder integrity. To fill the bladder with methylene blue at the end of the surgery is also helpful in revealing, under the pressure, even very small lesions as well as partial thickness of the bladder that can cause a delayed fistula. CONCLUSIONS: Surgeons' training is the most important factor in avoiding and detecting urinary tract injuries. This is important not only for the technique but also in the selection of patients, and then in planning the more appropriate pre-operative study and in recognizing the presence of injuries during surgery.