Gynecologic Injury to the Ureters, Bladder, and Urethra: Prevention, Recognition, and Management

34 Gynecologic Injury to the Ureters, Bladder, and Urethra


Prevention, Recognition, and Management



W. Glenn Hurt



INCIDENCE 436

PREVENTION OF INJURIES 436
Preoperative Assessment 436

Intraoperative Care 437

Abdominal Approach 437

Vaginal Approach 437

Laparoscopic Approach 438

RECOGNITION AND MANAGEMENT OF INJURIES 438
Recognition of Ureteral Injury 438

Management of Ureteral Injury 439

Recognition of Bladder Injury 442

Management of Bladder Injury 442

Recognition of Urethral Injury 442

Management of Urethral Injury 443

POSTOPERATIVE EVALUATION OF SUSPECTED GENITOURINARY FISTULAS 443

In the female body, the intimate anatomic relationship between the reproductive and lower urinary tracts predisposes the lower urinary tract to involvement by gynecologic disorders and places it at risk for injury during gynecologic surgery. Between 50% and 90% of all lower urinary tract injuries occur during gynecologic surgery. Some of these injuries cannot be avoided, but the majority are avoidable.


Reviews of the surgical literature reveal two disturbing facts: most lower urinary tract injuries occur during gynecologic surgery performed for benign and otherwise uncomplicated conditions, and most lower urinary tract injuries are not recognized during the operative procedure in which they occur. For these reasons, the emphasis in this chapter is on the prevention and recognition of lower urinary tract injuries.



INCIDENCE


Injuries to the bladder or ureter occur in approximately 1% to 2% of all major gynecologic procedures. The true incidence is probably somewhat higher when one considers the number of unreported cases, the spontaneous resolution of partial ureteral obstructions, and the loss of some renal systems. Seventy-five percent of the injuries occur during a hysterectomy. Because about 500,000 hysterectomies are performed annually in the United States, an estimated 5000 women will experience a bladder or ureter injury each year as a result of this procedure.


Studies of genitourinary fistulas reveal that the ratio of bladder injury to ureteral injury is approximately 5:1. Also, most injuries that result in the formation of genitourinary fistulas are not recognized during surgery.



PREVENTION OF INJURIES



Preoperative Assessment


The patient’s history, physical examination, and preoperative laboratory evaluation may suggest abnormal function of the urinary tract. The elective nature of most gynecologic surgery allows time for an evaluation that may include imaging, endoscopy, and consultation. When emergency surgery is performed on women with undiagnosed and untreated urinary tract abnormalities, it is accompanied by an increased incidence of preoperative and postoperative complications.


Because many gynecologic conditions are associated with an increased frequency of lower urinary tract infections, the urine should be tested for infection before surgery. If there is evidence of urinary tract infection, either asymptomatic or symptomatic, it should be treated until the urine is sterile. Many gynecologic procedures require catheterization, and because gynecologic surgery may initiate or aggravate a urinary tract infection, the patient should go to the operating room with sterile urine.


Sonographic imaging of the urinary tract is useful in determining kidney size and detecting ureteral obstruction. Sonography can also be used to image the bladder and estimate urinary residual volumes. Intravenous urography documents anatomic abnormalities, further defines renal function, and localizes ureteric obstruction; it is important in the evaluation of genitourinary fistulas. Routine preoperative imaging studies have not been shown to reduce the incidence of operative injuries to the lower urinary tract.


Cystourethroscopy is indicated in the preoperative evaluation of hematuria, abnormal urine cytology, persistent or recurrent urinary tract infections, lower urinary tract fistulas, urethral or bladder diverticula, bladder and urethral pain, selected cases of urinary incontinence, and staging of gynecologic malignancies. Retrograde pyelograms are helpful in locating ureteral obstructions and fistulas.


Preoperative retrograde ureteral stent or catheter placement has not been shown to reduce the incidence of surgical injury to the ureter. The procedure itself may cause bleeding, edema, and perforation of the ureter. The stent is often difficult to feel within an area of fibrosis, and it may predispose the ureter to damage as a result of the immobility that it imparts to the ureter. During surgery, when it is difficult to determine the course of the ureter or the integrity of its wall, placement of a ureteral catheter may be indicated. This may be done via cystoscopy or cystotomy. Ureteral catheter insertions can also be helpful during endoscopic surgery. If the endoscopic surgeon observes the ureter during the insertion of a catheter, the movement of the ureter will help define its retroperitoneal course.



Intraoperative Care


In the operating room there is no substitute for good lighting, proper patient preparation and positioning, adequate exposure, and strict adherence to sterile techniques. Lighting can be improved by the use of headlamps, light-containing suction irrigators, or fiberoptic lighted retractors. During complicated cases, abdominal-perineal-vaginal preparation, drapes that permit access to the abdominal and vaginal areas, positioning of the patient in universal stirrups, and a transurethral three-way continuous irrigation balloon catheter (16 or 18 French) for emptying and filling the bladder are recommended. These measures give the surgeon the flexibility to operate abdominally or vaginally, to perform endoscopy, and to detect and repair lower urinary tract injuries.


During all surgical procedures, sharp dissection is preferable to blunt dissection, and taking small pedicles is preferred to taking large pedicles. When hemostasis is a problem, pressure should be applied until the bleeding vessel can be identified and selectively clamped. Many ureters are damaged by the application of clamps in a frantic effort to control pelvic hemorrhage.



Abdominal Approach


Abdominal incisions should allow adequate exposure of the entire pelvis. Entry into the peritoneal cavity should be as high as possible to avoid direct cystotomy. The surgeon should be aware that the bladder may be pulled up beneath the anterior abdominal wall by its peritoneal reflection as a result of incomplete emptying, tumor, or previous surgery, especially cesarean section.


Entry into the peritoneal cavity should be followed by exploration of its contents, restoration of normal anatomic relationships, and exposure of the operative site. Attention should be given to the location and size of each kidney. With the patient in the Trendelenburg’s position, the bowel may be packed into the upper abdomen and retained by a retractor.


At this point, an effort should be made to identify both ureters and to trace their pelvic courses. The ureters are most easily identified as they descend into the pelvis over the bifurcation of the common iliac arteries. They then follow the posterior boundaries of the ovarian fossae to pass beneath the uterine arteries and to course anteriorly and laterally about the cervix and upper vagina. Each ureter enters a separate tunnel within the base of the bladder. An alternative approach to the ureter is through an incision of the lateral broad ligament. Dissection of the pararectal space reveals the ureter on its medial margin as it approaches the uterine artery. Although palpation of the ureter between the forefinger and thumb imparts a “clicking” sensation and sound, these characteristics can also be obtained by palpating other retroperitoneal structures. To positively identify the ureter, it is best to observe its distinctive periodic peristalsis.


The ureter usually can be dissected away from or out of a gynecologic disease process. The aim is to do so with the least possible ureteral trauma. Placing the tips of a right-angle or Adson tonsil forceps between the adventitial sheath of the ureter and the adjacent tissue to guide the dissection is helpful. If at all possible, the ureter should not be separated from its overlying peritoneum. This attachment protects the ureter’s blood supply, elevates it out of the depths of the pelvis (where it might be surrounded by blood and serum), and assists its peristalsis. If a portion of the ureter is invaded by endometriosis or cancer, it may have to be resected and a ureteroneocystostomy or ureteroureterostomy performed.


Likewise, determining the location and extent of the outer wall of the bladder is important. Dissecting the bladder from adjacent pathologic conditions is usually possible. Rarely, in some cases of endometriosis or cancer, resecting a portion of the bladder wall is necessary.


Increasingly, urogynecologists and reconstructive pelvic surgeons are encountering dense adherence of the bladder to the posterior symphysis when performing repeat retropubic procedures. Under these circumstances, performing an extraperitoneal cystotomy in the dome of the bladder is best and then dissecting the bladder and upper urethra from the posterior symphysis under direct vision. Experience has shown that this procedure reduces the extent of damage to both organs.


The pelvic surgeon should always be ureter-conscious. Throughout an abdominal procedure, knowing where the ureters are and keeping them out of harm’s way is important. Care should be taken not to kink the ureters during obliteration of the cul-de-sac, plication of the uterosacral ligaments, or suspension of the vaginal apex.



Vaginal Approach


In preparing the patient for vaginal surgery, we drain the bladder with a transurethral catheter, and then we sometimes instill undiluted indigo carmine (5 mL) into the bladder. After this is done, the catheter is clamped or removed to keep the dye within the bladder. During surgery, if the bladder is partially or completely incised, the blue color of the indigo carmine is recognized, alerting the surgeon to the bladder injury.


During vaginal operations, the surgeon should avoid a cystotomy by identifying the trigone and base of the bladder. Their location may be determined by palpating the balloon of a transurethral catheter, inserting a probe or Kelly clamp and palpating its tip, or reaching through a posterior colpotomy incision around and in front of the lower uterine segment with a finger and seeing the tip of the finger between the bladder and the lower uterine segment. Once the base of the bladder has been dissected free of the lower uterine segment and the vesicoperitoneal fold has been incised, a vaginal retractor should be placed between the bladder and the uterus. This retractor is protective in that it elevates the bladder and lateralizes the ureters. However, care should be taken not to perforate the bladder with the tip of the refractor.


During vaginal surgery, visualization of the ureter is difficult and somewhat hazardous. When the pelvic cavity has been opened, it is possible, with experience, to palpate the ureters against an appropriately placed vaginal sidewall retractor. This is a very important maneuver when operating on patients with prolapse and when performing extensive culdoplasties. If there is any question about the integrity of the ureters or bladder, cystoscopy should be performed.


Dissection of the anterior vaginal wall exposes the urethra and the bladder trigone to injury. Most urethral injuries result from diverticulum repair, anterior colporrhaphy, or instrumentation of the urethra. Some urethral injuries are caused by urethropexies and sling procedures. Urethral injuries, both direct and indirect, may damage the organ’s sphincter mechanism and cause stress urinary incontinence.

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Epidemiology and Psychosocial Impact of Pelvic Floor Disorders Urethral Injection of Bulking Agents for Intrinsic Sphincter Deficiency Laparoscopic Surgery for Stress Urinary Incontinence and Pelvic Organ Prolapse Historical Milestones in Female Pelvic Surgery, Gynecology, and Female Urology Constipation Painful Bladder Syndromes

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Mar 11, 2016 | Posted by in Reconstructive surgery | Comments Off on Gynecologic Injury to the Ureters, Bladder, and Urethra: Prevention, Recognition, and Management

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