Urological trauma during Obstetric & Gynecological procedures

1. ACUTE UROLOGICAL
INJURIES DURING OBSTETRIC
& GYNECOLOGICAL
PROCEDURES
Gaurav Nahar,
Deptt.of Urology,
MMHRC

2. INTRODUCTION
• Urological injuries to urinary bladder & ureter- uncommon but
imp.surgical complications during various obstetric &
gynecological procedures.
• Anatomic proximity of ureters & bladder to genital tract.
• Bladder injuries- most frequent urologic injury.
• Bladder injuries usually recognized and repaired immediately,
and potential complications are typically minor.
• But ureteral injuries(70%) typically are not recognized
immediately & can lead to long term complications.

3. URETERAL INJURIES
• Iatrogenic trauma is the commonest cause of
ureteral injury.
• Two-thirds of injuries- during gynecologic
surgeries.
• Most occur through abdominal than vaginal
route.

4. ANATOMIC COURSE OF
PELVIC URETER
• Ureter- 25-30 cm length.
• Abdominal part lies
anteriorly on psoas muscle.
• At the level of common iliac
artery bifurcation, it crosses
internal iliac vessels to enter
the pelvis.
• Ovarian vessels travel in
infundibulo-pelvic ligament
of the ovary and cross
ureters anteriorly and
laterally to the iliac vessels.

5. • Runs posterior to ovary and
then deep into broad ligament
and through the cardinal
ligament.
• Uterine artery crosses the
ureters anteriorly (“water under
the uterine-artery bridge”).
• Distance between ureter &
cervix-1.5cm.
• Ureter then courses out to
ischial spines and continues
medially onto the anterior
vaginal fornix.
• It then penetrates the base of
the bladder just above the
trigone.

6. • Blood supply:
1. Upper third- renal and ovarian arteries,
2. Middle third-aortic branches and common
iliac arteries,
3. Lower third- uterine, vaginal, middle
haemorrhoidal, vesical and hypogastric
vessels.

7. INCIDENCE

9. • Most ureteral injuries occur during technically
straightforward hysterectomies for benign
disease.
• Ureteral injuries from gynecologic surgery:
50% during radical hysterectomy, 40% from
abdominal hysterectomy and <5% result from
vaginal hysterectomy.

10. ETIOLOGY
RISK FACTORS:
• Enlarged uterus
• Previous pelvic surgery or radiation
• Advanced malignancy
• Endometriosis, PID
• Pelvic adhesions
• Distorted pelvic anatomy
• Coexistent bladder injury
• Massive intraoperative haemorrhage

11. SITES OF INJURY
• Injury: most frequently lower third of ureter(51%),
f/b upper third(30%) and middle third(19%).
Most common sites of injury are:
Lateral to uterine vessels
Area of ureterovesical junction close to cardinal
ligaments
Base of the infundibulopelvic ligament as ureters
cross pelvic brim at ovarian fossa
at the level of uterosacral ligament.
• Most common site of injury during laparoscopy-
adjacent to Uterosacral ligaments(USL).

12. Ureteral injuries during Laparoscopic gynec
surgeries: during
• Laser ablative endometriosis surgery
• Laparoscopic-assisted vaginal hysterectomy
(LAVH)
• Laparoscopic tubal ligation,
• Laparoscopic adnexectomy (removal of one of
the uterine tubes and an ovary) and
• Laparoscopic uterosacral ligament ablation.

13. • Most LAVH ureteral injuries occur near
cardinal and uterosacral ligaments.
• Caused by either thermal-electrocautery or
sharp dissection, CO2 laser, endoscopic linear
stapler and loop ligature.

14. MECHANISMS OF INJURY

15. CLASSIFICATION
• Americal Association for the Surgery of
Trauma(AAST) Ureteral injury grading scale:

16. PREVENTION

17. ROLE OF PREOPERATIVE PROPHYLACTIC
URETERAL STENTING:
Assists in visualisation and palpation in
complicated cases.
Also advantageous in making it easier to detect
ureteral injury.
But it does not decrease the rate of injury.
Lighted fibreoptic ureteral catheters(5Fr)- new
introduction.

18. • Haematuria is an unreliable & poor indicator of ureteral
injury, present in only 50-75%.
• Cystoscopy without indigo carmine/methylene blue
administration, used to document the absence of hematuria and
the presence of bilateral ureteral jets, is a poor predictor of
injury.

19. MANAGEMENT
• No specific medical therapy for ureteric injury.
• Immediate repair of ureteral injury advisable.
• Optimal time for repair of a ureteral injury is during the
operation; the tissues are in their best condition, options
and likelihood for success are greatest.
• Immediate repair provides better results and fewer
complications than in a delayed fashion.
• Management depends on nature, severity, length &
location of injury.

20. Reconstructive Procedures
• Ureteral resection & Uretero-ureterostomy
• Trans-uretero-ureterostomy
• Uretero-neo-cystostomy/Reimplantation
• Ureterocalycostomy
• Psoas hitch
• Boari flap
• Ileal interposition graft/Ileal ureter
• Renal autotransplantation

21. Uretero-ureterostomy
Technique of uretero
ureterostomy after traumatic
disruption.
A, Injury site definition by
ureteral mobilization.
B, Debridement of margins and
spatulation.
C, Stent placement.
D, Approximation
with 5-0 absorbable suture.
E, Final result.

22. Trans-uretero-ureterostomy

23. Uretero-neo-cystostomy

24. Uretero-calycostomy

25. Psoas-hitch

26. Boari flap

27. Ileal Interposition/Ileal ureter

28. Auto-transplantation

29. Principles of surgical repair of ureteral injury:
• Debridement of necrotic tissue.
• Ureteric dissection preserving adventitial sheath and its
blood supply.
• Spatulation of ureteral ends.
• Tension-free, watertight mucosa-to-mucosa anastomosis
with absorbable sutures.
• Internal stenting.
• External drain.
• Isolation of injury with peritoneum or omentum.

30. M/m Based on Type of injury

31. • Immediate diagnosis of a ligation injury
intraoperatively can be managed by de-ligation
& stent placement.
• Partial injuries can be repaired immediately
with a stent.
• Stenting is helpful because it provides
canalisation and may decrease the risk of
stricture.

32. M/m Based on Site of injury

34. PROXIMAL & MID-URETERAL INJURY:
• Injuries shorter than 2-3 cm- Primary uretero-
ureterostomy.
• When not feasible- Uretero-calycostomy.
• Extensive ureteral loss- Transuretero-
ureterostomy(proximal stump of ureter is transposed
across the midline and anastomosed to the
contralateral ureter).
DISTAL URETERAL INJURY:
• Ureteroneocystostomy/Ureteric reimplantion- best.
• Refluxing vs.non-refluxing--controversial.
• Psoas hitch- relieves tension off the anastomosis,
bridges gap.
• Boari flap- for extensive mid-lower ureteral injury.

35. COMPLETE URETERAL INJURY:
• Replacement using Ileal interposition
graft(Ileal ureter)- Yang-Monti principle.
• Extensive ureteral loss or after multiple
attempts of ureteral repair-
Autotransplantation.

36. COMPLICATIONS

37. Ureteral Injuries: Pearls of Wisdom
• Iatrogenic ureteral trauma gives rise to the commonest cause
of ureteral injury.
• Haematuria is an unreliable and poor indicator of ureteral
injury.
• The diagnosis of ureteral trauma is often delayed.
• Preoperative prophylactic stents do not prevent ureteral injury,
but may assist in its detection.
• Visually identify the ureters and meticulously dissect in their
vicinity to prevent ureteral trauma.
• Use preoperative prophylactic stents only in selected cases
based on risk factors.

38. BLADDER INJURIES
• Urinary bladder- urological
organ most often suffering
iatrogenic injury.
• Occurred mostly during
separation of bladder from
lower segment of uterus in
patients with previous
cesarean sections.
• Primary repair during
operation has excellent
results.

39. INCIDENCE

40. CLASSIFICATION
• Location of bladder injury is important to
guide further management:
Intraperitoneal;
Extraperitoneal;
Combined intra-extraperitoneal.

41. INTRAOPERATIVE DETECTION
• Signs of external iatrogenic bladder trauma: extravasation of
urine, visible laceration, clear fluid in surgical field,
appearance of bladder catheter, and blood and/or gas in urine
bag during laparoscopy.
• Direct inspection is the most reliable method of assessing
bladder integrity.
• Large cystotomy is easily detected while smaller tears can
be detected by Intravesical instillation of methylene blue. If
bladder perforation is close to the trigone, the ureteric orifices
should be inspected.

42. CYSTOSCOPY:
• Preferred method for detection of intra-
operative bladder injuries, as it may directly
visualise the laceration.
• Cystoscopy can localise the lesion in relation
to the position of trigone and ureteral orifices.
• Lack of bladder distension during cystoscopy
suggests a large perforation.

43. MANAGEMENT
• Uncomplicated extraperitoneal injury:
Clinical observation, continuous bladder
drainage and antibiotic prophylaxis.
• Complicated extraperitoneal injuries with
symptomatic extravesical collection:
Exploration, drainage & repair.
• Intraperitoneal injuries: surgical exploration
with repair(double-layer closure with
absorbable suture + Foley's catheter drainage).

44. FOLLOW-UP:
• Simple injuries- Continuous F.C. drainage for
7-10 days f/b CR without cystogram.
• Complex injuries(repaired)- Continuous F.C.
drainage for 14 days f/b control cystogram &
CR.

45. CONCLUSION
• Iatrogenic urologic injuries can be prevented
by adequate pre-operative assessment, good
surgical technique, and visualisation of the
bladder & ureters.
• Anticipation and high index of suspicion, early
urological referral, and appropriate
investigation of suspected urologic injury is of
paramount importance.

46. Thank you...