Management of Urinary Tract Injuries by Laparoscopy: Our Experience

Urinary tract injuries are the most common serious complication of laparoscopic pelvic surgery with variable frequency depending on the procedure (reported incidence between 0.2 and 15 per 1000 procedures). The risk factors include adhesions secondary to endometriosis, previous surgeries, pelvic inflammatory diseases (PIDs) and distorted tissue planes associated with malignancy, presence of pelvic masses which needs extensive retroperitoneal space dissection.[ 1 ] Again, due to anatomical close proximity, gynecologic surgery carries an inherent risk of injury to the urinary tract. Additional factor may be with surgeons with low volume surgical practices or surgical technique and instrument used.[ 2 ] Injury can occur even in the best experienced hands; The meticulous and proper dissection can minimize it.[ 3 ] Excessive bleeding sometimes hampers the view and found to be associated with a risk of urinary tract injuries.[ 4 ] Majority of iatrogenic urinary tract injuries are due to procedures performed by obstetricians, gynecologists, general surgeons, and urologic surgeons. Thus, sound knowledge of pelvic anatomy, awareness about such injuries and recognition in time is of utmost importance for these specialists.[ 5 ] The intraoperative diagnosis of urinary tract injuries remains a challenge. Urinary bladder injuries are more likely diagnosed intra-operatively whereas most of (55%–70%) of the ureteric injuries diagnosed postoperatively. Early postoperative diagnosis of ureteric injury typically occurs in 7–10 days after surgery.[ 6 ] Any delay in recognition of these injuries associated with an increased morbidity including fistula formation, infections, and renal failure. Furthermore, there is a high risk of reoperation following injuries to the urogenital system. These injuries also affect the length of hospitalization and quality of life.[ 7 ] Thus, prompt intra-operative identification, investigation, and treatment of suspected iatrogenic injury is crucial to lessen the occurrence of subsequent complications.[ 8 ] The combination of creatinine change, total leukocyte count, or C-reactive protein may be helpful for detecting urologic complications after total laparoscopic hysterectomy (TLH).[ 9 ]

There were 25 cases of the urinary tract injuries included in the study. The distribution according to the demographic factors is shown in Table 1 . The median age and parity of them was 43 years, respectively. All cases were managed by laparoscopic route. Demographic factors in urinary tract injuries The total 25 cases of urinary tract injuries include bladder injury,[ 10 ] ureteric injury,[ 4 ] ureterovaginal fistula (UVF),[ 6 ] and vesico-vaginal fistula.[ 6 ] All of the bladder injuries occurred during TLH; common site being posterior wall of the bladder. All of them were identified intraoperatively and repaired in the same setting. The ureteric injury was identified post TLH; common site being middle 1/3 rd of the ureter, and managed by ureteric catheterization. Ureterovaginal and vasicovaginal fistulae occurred post-TLH/radical hysterectomy or post cesarean section and identified postoperatively. One of the UVFs was managed by ureteric catheterization, while others were managed with ureteric re-implantation. All cases of the vesicovaginal fistulae (VVF) were managed by fistula repair [ Table 2 ]. Preoperative and intra-operative factors in urinary tract injuries TLH: Total laparoscopic hysterectomy, BSO: Bilateral salpingo-oophorectomy The common indications for TLH were fibroid uterus, adenomyosis, and endometriosis [ Table 3 ]. The risk factors were history of previous lower segment cesarean section (LSCS) or laparotomy, endometriosis, PID, adhesions, and broad ligament fibroid uterus. The ureteric injuries were diagnosed 10 days to 1 month postoperatively and managed 1–2 months postoperatively. Most of the cases of UVF and VVF were diagnosed around 1.5 months postoperatively and managed around 3–6 months postoperatively [ Table 4 ]. distribution of the patients according to the diagnosis, procedure performed and injury Timing of diagnosis and management (after surgery)

Anatomical proximity of the ureters and urinary bladder with uterus, i.e., surgical field of the gynecologists makes them prone to injuries. Hence, the sound anatomical knowledge of pelvic anatomy, risk factors associated with urinary tract injury, and meticulous operative procedure are important to prevent injuries. Complete dissection of ureter from pelvic brim to bladder insertion may help in preventing uterine injuries during laparoscopic surgeries in case of endometriosis or pelvic adhesions. It is also important that intraoperative urinary tract injuries are recognized and treated in the same sitting to minimize the morbidity postoperatively. With technical advances, urinary tract injuries can be managed by laparoscopy with excellent outcome. AS, NN, FVP and PP collected the relevant data (Resources, Data Curation, Conceptualization, Methodology, Investigation). AS, NN, PF drafted the manuscript (Writing – Original Draft Preparation) with direction from PP (Supervision, Project Administration,). AS, FVP, NN and PP critically evaluated the manuscript (Software, Validation, Formal Analysis, Writing – Review & Editing, Visualization). All authors approved the final version of the manuscript. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. There are no conflicts of interest.

Urinary tract injury occurs during pelvic surgery, most commonly being gynecological procedures.[ 13 ] It is due to the close anatomical relationship between the urinary tract organs and the female internal genitalia. Based on timing, urinary tract injuries are of two kinds; bladder or ureteric injury that can be identified and repaired immediately during the operation, and chronic complications such as VVF and UVF which can surface many days after surgery.[ 7 ] Seventy-five percentage of the urinary tract injuries occurs during gynecology surgery for a benign indication and 26%–95% of them go unrecognized at the time, leading to diagnosis postoperatively.[ 14 ] A total of 25 patients were operated for urinary tract injuries at our hospital during the study period with median age and parity of 43 years and 3, respectively. All cases were managed laparoscopically. Out of 25 patients, 10 had bladder injuries, 6 had UVF, 5 had VVF, and 4 had ureteric injuries. The incidence of type of injury is variable in different studies. A study from Egypt including 103 patients reported, urinary bladder injury in 38 (36.9%), ureteral injury in 11 (10.7%), and genitourinary fistula in 54 (52.4%). The fistulae were included vesico-uterine in 13, VVF in 36, and UVF in 5 cases.[ 15 ] Another study from India reported urinary bladder, occurring in 54% patients followed by ureter in 35.13%.[ 16 ] The factors associated with an increased risk of injury are previous pelvic or abdominal surgery, adhesions, endometriosis, and urinary tract abnormalities.[ 17 18 ] The present study observed similar major risks factors as adhesions, previous LSCS, and endometriosis. A study by Nayak et al . also observed the increase odds of injuries in case of endometriosis, hysterectomies for pelvic pain and menstrual disorders, and distorted anatomy due to fibroids.[ 19 ] The present study included 10 cases of the bladder injuries, all occurred during TLH, identified intraoperatively and repaired in two layers in the same setting. Usually, bladder injuries diagnosed intraoperatively by direct visualization of tissue injury, urine in the operative field, air in the Foley catheter collection bag, or direct visualization of the Foley catheter. In another study, 80% of the injuries were diagnosed intraoperatively.[ 2 20 ] Postoperatively, bladder injury may present with suprapubic pain, hematuria, oliguria, and abdominal distension and tenderness.[ 21 ] The incidence of bladder injuries varies among procedures and surgical approaches; 0.24% in gynecologic laparoscopy, 0.44% during cesarean section, and 1.54% during hysterectomy for benign disorders. Previous studies also reported bladder injuries are most often repaired by a two-layer suture, if diagnosed intraoperatively. (11, 12, acog) In the present study, postoperatively, Foley’s catheter was kept for 14 days. All patients showed complete recovery. Other studies also reported length of catheterization following iatrogenic urinary tract injury for 5–14 days.[ 22 ] The present study included four cases with ureteric injuries and 6 cases with UVF. All cases of ureteric injuries were post-TLH. In UVF group, two patients operated for radical hysterectomy with lymph node dissection, 1 for endometriosis with adenomyosis, one patient developed fistula 6 weeks following second stage LSCS in the injury occurred following left uterine artery ligation, one patient who presented with complaints of leaking 1 month post-LSCS and was operated after 10 weeks. One fistula and all four cases of ureteric injury and were managed by ureteric catheterization done under cystoscopic guidance with ureteric double J stent (6.5Fr) kept for 6 weeks and showed complete recovery. Five patient with ureterovaginal fistula were managed with laparoscopic ureteric re-implantation. Mean follow-up for the patients was up to 12 months. Ultrasonography done in all patients showed no evidence of hydronephrosis. In all of them, risk factors for injury being deep infiltrating endometriosis with extrinsic involvement of ureters. A study by Ogan et al . including six patients of ureteral injuries (after pelvic laparoscopic procedures and ureteroscopy) showed no statistical difference in the success and complication rates between the laparoscopic and open groups, respectively. However, operative blood loss was greater and hospital stay was longer in the open group.[ 23 ] However, another study by by Simmons MN et al .[ 24 ] showed in patients with very distal strictures, a direct ureteroneocystotomy was performed, whereas, a Boari flap in patients with longer segment and more proximal strictures. They also stated that the visualization gained during laparoscopy benefited ureteral and bladder mobilization, enabling an adequate bladder flap and tension free anastomosis. In the present study, in vesicovaginal fistula group, three patients were post-TLH, 1 presented 20 years after LSCS, and one patient 6 weeks post-LSCS. For all patients with VVF, laparoscopic VVF repair was done. All patients with VVF repair showed complete recovery. A study by Miklos JR et al. including 44 patients diagnosed and underwent laparoscopic VVF repair, the most common cause of VVF was hysterectomy (95%) followed by mesh surgery and subsequent erosion in 5% of the cases. The study stated that laparoscopic extravesical VVF repair using a three-layer closure technique (without interpositioning omentum) is a safe, effective, minimally invasive technique with excellent cure rates in an experienced surgeon’s hands. No matter which approach decided upon, the authors believe that the most important aspects of VVF repair remain adequate dissection, a watertight seal, and good postoperative bladder decompression to allow for tissue healing.[ 25 ] Another study by Giannakopoulos S et al . also concluded that minimally invasive laparoscopic approach with only three trocars and limited posterior cystotomy provides excellent results with minimum morbidity.[ 26 ]

A retrospective cohort study including 25 patients with urinary tract injuries in duration from January 1, 2015 to May 31, 2023 was conducted at a tertiary care hospital from Central India after the approval from Mahatma Gandhi Mission’s Ethics Committee for Research on Human Subjects was obtained (approval number: MGM-ECRHS/2024; approval date: 30 April, 2024) and was performed in accordance with the Declaration of Helsinki. Informed consent was obtained from the participants. All the cases were managed by laparoscopic route by a single surgeon with more than 15 years of experience. The cases of urinary tract injuries operated laparoscopically during the study duration were included in the study. Cases with the incomplete information about the clinical details and surgery and the outcome were excluded from the study. The complete data including maternal demographic data (age, parity, etc.), clinical details (diagnosis, history of surgery, etc.), site of injury (bladder and part of the ureter) and management done, and postoperative follow-up were recorded in a case pro forma. Data analysis was done by descriptive statistics methods such as frequency distribution tables, drawing graphs, calculating numerical indices, and Chi-square statistical tests. P <0.05 was considered significant. Identification of the ureter is crucial, when operating deep in the female pelvis. Superiorly, the ureters descend into the pelvis posterior to the infundibulo-pelvic ligaments. The ureters maintain this relationship until approximately the level of the iliac vessels, where they begin to travel more medially. As the ureters continue to travel inferiorly, they lie in close proximity to the transverse cervical ligament. The ureters dive under this structure. Knowledge of this relationship is considered crucial when performing a hysterectomy. A popular pneumonic used by medical students is, “water under the bridge.” After passing under the transverse cervical ligament, the ureters continue to travel medially towards the bladder and get inserted into the inferior aspect of the bladder. The insertion points are also visible from inside the bladder itself, during cystoscopy.[ 10 11 12 ] All procedures were performed transperitoneally. Following induction of anesthesia and the administration of intravenous prophylactic antibiotics, the patient is positioned in the lithotomy position. A supraumbilical incision is made, a 10-mm pyramidal tip trocar is then inserted by direct method and used as the camera port where 30° telescope with an three-dimensional endoscopic camera system is introduced into the abdominal cavity followed by adequate pneumoperitoneum with CO 2 gas. Two 5 mm trocar on surgeons’ side and one 5 mm trocar on assistant side were placed. Once trocars are within the abdomen, the colon is mobilized medially along the line of Toldt. V shaped uterine manipulator was used. The intraoperative identification of the injury was done followed by repair in the same setting during the surgery. The bladder repair was done in two layers (first layer mucosal and second layer muscular) with 3-0 polygalactin or 2-0 barbed sutures. Cystoscopy was performed and ureteric catheter/ureteric double J stents (6.5Fr) were inserted in both the ureters. The ureter was identified cephalad to the bifurcation of the iliac vessels, away from the point of obstruction. Ureterolysis was then carried out in a caudal direction meticulously taking care not to devascularize the ureter. If the length of the stricture extends more proximally, the ureter can be mobilized cephalad to the lower pole of the kidney. If the ureter found to be entrapped in scar tissue, the ureter was transacted, taking care to excise only nonviable tissue. The healthy ureter was then sharply spatulated posteriorly. The bladder was filled with 200 mL of normal saline, and the overlying peritoneum was divided between the obliterated umbilical ligaments. This allowed entrance into the space of Retzius, and the bladder can then subsequently be further mobilized by dividing anterolateral attachments. Urinary bladder was mobilized from space of Retzius and bladder was fixed above the iliac vessels by psoas hitch. Adequate sub mucosal tunnel was created on superior border of bladder. Neocystotomy was done at tunnel base, DJ stenting done with no. 1 polygalactin two sutures. Ureteric reimplantation was done with polyglactin 4-0, taking 4-5 sutures. Mucosa of ureter was approximated with mucosa of bladder and the knot was tied outside the lumen of ureter. Bladder muscle flaps was approximated to cover the lower end of ureter with 3-0 polygalactin sutures. This acted as anti-reflex mechanism at the lower end of ureter. Then, saline wash was given followed by suction. The surgical steps can be seen in Figure 1 . Surgical steps of ureteric re-implantation Cystoscopy was performed and DJ tail stents were inserted in both ureters to aim in constant identification of ureteral orifices during the procedure. A tamponade was inserted into the vagina to prevent loss of pneumoperitoneum. The patient was then placed in a slight Trendelenburg position with a 20° 30° tilt. In case of adhesions from previous surgery, adhesiolysis was performed using a combination of sharp and blunt dissection to expose the vaginal stump and the posterior aspect of the bladder. The bladder was filled with approximately 150 mL saline. The bladder was dissected from vagina and site of fistula identified. Then, the bladder was mobilized adequately, fibrous margins refreshened, and ureteric opening identified. Using sharp and blunt dissection the fistula was dissected circumferentially to raise the bladder and vaginal flaps. The scarred tissue which remains on the vaginal edges was excised in all cases. The vaginal defect was closed with a no. 1-0 polygalactin suture in a transverse fashion. The bladder was closed in two layers with first layer mucosal and second layer muscular with 3-0 polygalactin or 2-0 barbed sutures. A drain was placed at the completion of surgery. The surgical steps are shown in Figure 2 . Surgical steps of vesicovaginal fistula repair In all the cases, broad spectrum antibiotics prophylaxis was given for 5–7 days and 16-Fr foley’s catheter was kept for 14 days postoperatively and removed with intermittent clamping and bladder training in last 3 days. In case of ureteric re-implantation cases, the ureteral stents were kept 6 weeks postoperatively and ultrasonography was done after its removal to look for any evidence of hydronephrosis.