Lower Urinary Tract Injury Research Articles

Lower urinary tract injury in transvaginal reconstructive pelvic surgery

Objective: To explore the characteristics, prevention and treatment strategies of lower urinary tract injury in transvaginal reconstructive pelvic surgery (vRPS). Methods: A retrospective analysis was conducted on 24 patients who suffered lower urinary tract injuries occuring in vRPS from January 2005 to June 2021, among which 4 cases were referred to our hospital from other hospitals. Results: (1) In our hospital, 1 952 patients underwent vRPS for anterior and (or) middle pelvic organ prolapse during that study period, with a 1.0% (20/1 952) incidence of lower urinary tract injuries occurring in 20 cases. (2) Ureteral injuries were observed in 14 cases who underwent transvaginal high uterosacral ligament suspension (1.4%, 14/966). The symptoms were relieved after the removal of sutures. (3) Bladder injuries occurred in 6 cases in our hospital, with 4 cases (0.7%, 4/576) in anterior transvaginal mesh surgery (aTVM), one (0.4%, 1/260) in colpocleisis, and one (0.7%, 1/150) in apical suspension for fornix prolapse. An additional 4 cases of bladder injury were referred to our hospital after aTVM. Among the 8 cases of bladder injury during aTVM, 2 cases were intraoperative incidents. Cystoscopy confirmed that the superficial branch or puncture rod of anterior vaginal mesh had penetrated into the bladder. Re-puncturing and placement of the mesh were successfully performed. No abnormalities were observed during a follow-up period of 4-5 years. Postoperative bladder injuries were identified in 6 cases, characterized by mesh erosion into the bladder and formation of calculi. These injuries were confirmed between 6 months to 2 years after vRPS. The exposed mesh and calculi in the bladder were removed through laparotomy or cystoscopy, followed up for 2-12 years. One case experienced slight re-erosion of mesh to the bladder. Conclusions: Lower urinary tract injuries are difficult to avoid in vRPS, particularly in transvaginal high uterosacral ligament suspension and aTVM. However, the incidence is low. Lower urinary tract injuries during vRPS could be easily detected and managed intraoperatively because of the use of cystoscopy. As long-term postoperative complications, erosion of transvaginal mesh to lower urinary tract postoperatively could be treated correctly, seldom with severe sequelae.

Urinary tract injuries during surgery for placenta accreta spectrum disorders

ObjectiveThe main purpose of this study was to report the incidence of lower urinary tract injuries (UTI) during cesarean section (CS) hysterectomy in cases of Placenta Accreta Spectrum (PAS) disorders.Study designRetrospective analysis including all women with a prenatal diagnosis of PAS between January 2010 and December 2020. A dedicated multidisciplinary team was involved to define a tailored management for each patient. All relevant demographic parameters, risk factors, degree of placental adhesion, type of surgery, complications and operative outcomes were reported. ResultsOne hundred and fifty-six singleton gestations with a prenatal diagnosis PAS were included in the analysis. 32.7% of cases were classified as PAS 1 (grade 1-3a FIGO classification), 20.5% as PAS 2 (grade 3b FIGO classification) and 46.8% as PAS 3 (grade 3c FIGO classification). A CS hysterectomy was performed in all cases. Surgical complication occurred in seventeen cases (0% in PAS 1, 12.5% in PAS 2 cases and in 17.8% in PAS 3). The incidence of UTI in our series was 7.6% in all women with PAS, including 8 cases of bladder and 12 of ureteral lesion, and 13.7 % in those with PAS 3 only. ConclusionDespite advances in prenatal diagnosis and management, surgical complications, mainly those involving the urinary system, still occur in a significant proportion of women undergoing surgery for PAS. The findings from this study highlight the need for a multidisciplinary management of women with PAS in centers with high expertise in prenatal diagnosis and surgical management of these conditions.

C-Clamp Technique: A Retrospective Review of a Novel Technique to Prevent Bladder Injury in Retropubic Midurethral Slings

ABSTRACT The original technique for mesh midurethral sling, which utilized a retropubic approach for sling placement, also recognized a risk of simultaneous iatrogenic bladder injury. While synthetic mesh midurethral slings have the criterion standard for SUI treatment, there is still no available technique that entirely eliminates the risk of bladder injury at the time of implantation. The retropubic approach holds a 0.7% to 34% rate of bladder injury. Some providers still opt for the transobturator approach because of a perceived decreased risk of intraoperative bladder perforation. This article describes the “C-clamp technique,” a method directly addressing the perceived key causes of bladder injury via the retropubic approach. This study aimed to determine bladder injury rates upon surgical implantation of retropubic synthetic mesh midurethral sling by 1 provider using the C-clamp technique. The article provides step-by-step instructions for this technique, as well as a link to a video (https://links.lww.com/FPMRS/A362). Briefly, the technique involves use of a deflecting catheter guide in steep Trendelenburg, “clamping” the pubis with the operator's nondominant hand to decrease the retropubic distance, and using the nondominant thumb on the inner curve of the trocar to guide the trocar passage toward the nondominant finger tips and suprapubic exit through the skin. This retrospective review identified 201 bottom-up retropubic synthetic mesh midurethral slings placed using the C-clamp technique between April 2012 and June 2022. General data collected included average age (51 years), average weight (46–139 kg), average body mass index (BMI, 15–57 kg/m2), and a range of prior surgical procedures and concomitant procedures. Approximately 15% of patients had a history of prior retropubic urethropexy or some form of midurethral sling. There were no lower urinary tract injuries in the entire cohort. Strengths of this study include its description of the C-clamp technique, the extremes and range of data points included within the study, and the 10-year range of the study. Limitations include its retrospective nature, the single surgeon provider, the vast majority of slings used produced by 1 manufacturer, and limited comprehensive data collection. Using data from 201 consecutive bottom-up synthetic mesh midurethral sling outcomes during a 10-year span, the authors argue that this technique addresses key anatomic issues contributing to bladder and urethral injury during placement of such slings, with a promising ability to eliminate bladder and urethral injury. Favorable data in a larger number of patients and by multiple providers could provide further support to this technique and support retropubic sling as a preferred method of midurethral sling.

Fracture Types Influence the Likelihood of Lower Urinary Tract Injuries in Patients with Pelvic Fractures.

The combination of pelvic fractures with lower urinary tract injuries (LUTIs) is a severe traumatic injury. This study was performed to determine the relationship between LUTIs and pelvic fracture types. Patients who sustained pelvic fractures combined with LUTIs between 1 January 2018 and 1 January 2022 in our institution were retrospectively analyzed. The patients' demographics, mechanism of injury, presence of open pelvic fractures, types of pelvic fractures, patterns of LUTIs, and early complications were analyzed. The association between pelvic fracture types and the identified LUTIs was statistically analyzed. This study involved 54 patients diagnosed with pelvic fractures combined with LUTIs. The overall incidence of pelvic fractures combined with LUTIs was 7.7% (n = 54/698). All patients had unstable pelvic fractures. The male:female ratio was approximately 2.4:1.0. The incidence of LUTIs was higher in men than women with pelvic fractures (9.1% vs. 4.4%). Bladder injuries occurred at roughly equal rates in men and women (4.5% vs. 4.4%, p = 0.966), but urethral injuries were more frequent in men (6.1% vs. 0.5%, p = 0.001). The most common pelvic injury pattern was a type C fracture according to the Tile classification and a vertical-shear-type fracture according to the Young-Burgess classification. The Young-Burgess fracture classification was related to the severity of bladder injury in men (p = 0.037). There was no significant difference in bladder injury according to the two classifications among women (p = 0.524 vs. p = 1.000) or among the entire cohort (p = 0.454 vs. p = 0.342). Men and women are equally likely to sustain a bladder injury, but a urethral injury with pelvic fracture is more frequent in men. LUTIs tend to be accompanied by unstable pelvic fractures. It is imperative to be vigilant for potential bladder injury when men sustain vertical-shear-type pelvic fractures.

MP53-19 URINARY MICRORNAS ARE POTENTIAL BIOMARKERS OF SEVERITY OF URINARY TRACT DYSFUNCTION IN PATIENTS WITH POSTERIOR URETHRAL VALVES

You have accessJournal of UrologyCME1 Apr 2023MP53-19 URINARY MICRORNAS ARE POTENTIAL BIOMARKERS OF SEVERITY OF URINARY TRACT DYSFUNCTION IN PATIENTS WITH POSTERIOR URETHRAL VALVES Elizabeth Mann, Melissa Mogle, Aditi Paranjpe, Marion Schulte, and Pramod Reddy Elizabeth MannElizabeth Mann More articles by this author , Melissa MogleMelissa Mogle More articles by this author , Aditi ParanjpeAditi Paranjpe More articles by this author , Marion SchulteMarion Schulte More articles by this author , and Pramod ReddyPramod Reddy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003301.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Current management strategy for patients presenting with posterior urethral valves (PUV) includes monitoring of renal function to determine when urinary tract (UT) intervention such as intermittent catheterization or urinary diversion is indicated. The challenge with this approach is that ongoing renal injury may no longer be reversible and exposes the child to progression of chronic kidney disease (CKD). We hypothesize that microRNAs (miRNA) derived from urinary small extracellular vesicles (sEV) reflect the physiological status of the UT and may serve as real-time indicators of lower urinary tract injury. These biomarkers could permit the development of a proactive strategy of serial monitoring of the lower UT in patients with PUV and permit timely intervention prior to the progression of renal injury. METHODS: We have undertaken an IRB approved prospective study. Informed consent was obtained at time of enrollment. Urine samples are collected for each patient at least once a year and urinalysis performed. We excluded samples with active infections. Patients (1-18 yrs) with PUV were stratified into clinical categories based on the severity of the involvement of their UT. Patients with isolated genital pathology and a normal UT served as negative controls. sEVs were isolated from the urine by ultracentrifugation and total RNA extracted. Next-generation small RNA sequencing and differential expression analysis was performed. RT-qPCR was used to verify the expression of candidate miRNAs. RESULTS: A total of 76 PUV Patients and 35 controls have been enrolled in the study, with 244 urine samples collected. Principle component analysis of the most variable miRNAs demonstrated a clear clustering of the patients in the moderate/severe category compared to the patients with mild disease and non-PUV controls. We have identified 61 miRNAs that were upregulated and 45 miRNAs that were downregulated in the moderate/severe patients (≥1.5-fold, p≤0.05). We selected 4 miRNAs to analyze further by RT-qPCR and confirmed the decreased expression of miRNA-30a-5p in moderate/severe cases (>5-fold, p≤0.01). CONCLUSIONS: This study demonstrates that urinary miRNAs can serve as biomarkers of the severity of UT dysfunction in patients with PUV. Ongoing studies seek to further validate these findings. The development of a noninvasive urinary assay for a set of predictive miRNA biomarkers will enhance our ability to care for patients with PUV and enable real-time assessment of the health of their lower urinary tract. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e719 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elizabeth Mann More articles by this author Melissa Mogle More articles by this author Aditi Paranjpe More articles by this author Marion Schulte More articles by this author Pramod Reddy More articles by this author Expand All Advertisement PDF downloadLoading ...

Predictive Factors of Lower Urinary Tract Injuries and Spontaneous Voiding Failure After Pelvic Fractures.

This study aimed to describe the voiding patterns of patients after surgical treatment of pelvic fractures and determine the predictive factors of lower urinary tract injuries (LUTIs) and spontaneous voiding failure among patients with surgically treated pelvic fractures at a tertiary trauma center in Japan. We retrospectively assessed patients with surgically treated pelvic fractures in our tertiary trauma center during May 2009-April 2021. We excluded patients who died during hospitalization and who had indwelling catheter prior to the injury. Patients' LUTIs and spontaneous voiding failure at discharge were recorded. Multivariate analysis was performed to assess the predictive factors of LUTIs and spontaneous voiding failure at discharge. In total, 334 eligible patients were identified. Among them, 301 patients (90%) voided spontaneously with or without diapers at discharge. Thirty-three patients required some form of catheterization for bladder drainage. LUTIs were found to be associated with chronological age [odds ratio (OR)=0.96; 95% confidence interval (CI)=0.92-0.99; p=0.024] and pelvic ring fracture (OR=12.0; 95%CI=1.39-255.2; p=0.024). Spontaneous voiding failure was associated with intensive care unit admission (OR=7.17; 95%CI=1.49-34.4; p=0.004). Overall, 10% of patients with surgically treated pelvic fractures were not able to void spontaneously at discharge. Spontaneous voiding failure after pelvic fractures was related to injury severity.

A case of blunt abdominal trauma resulting in significant bladder injury (AAST grade IV)

Introduction: Bladder injuries are uncommon and its diagnosis is often missed. However, in patients presenting with blunt abdominal trauma, bladder, and other lower urinary tract injuries must be ruled out using adequate investigations. Case Report: A 33-year-old male presented to the Emergency Department 24 hours after a fall, complaining of lower abdominal pain and inability to void. Examination revealed a mildly distended abdomen with no signs of peritonism. A random bladder scan showed a volume of 583 mL. Basic investigations showed the patient to be in acute kidney injury (AKI) stage III with a creatinine of 350 mmol/L. Clinical findings were suggestive of a bladder injury. However, due to the rarity of such cases, clinicians reviewing the patient did not think of a bladder injury as one of the differential diagnoses. Instead of also requesting for a computed tomography (CT) cystography, only a trauma CT abdomen and pelvis with contrast was requested which demonstrated an intraperitoneal bladder injury. The patient was taken to theater for an emergency laparotomy and repair of a 4 cm bladder laceration. According to the American Association for the Surgery of Trauma (AAST) classification, the patient had a Grade IV bladder injury. A cystogram performed 4 weeks after the surgery showed no urine leak and the urethral catheter was removed. Fortunately, no harm was brought to the patient. Conclusion: Intraperitoneal bladder injuries, if missed, can be associated with serious morbidities and even increase the risk of mortality.

Lower urinary tract injuries in patients with pelvic fractures at a level 1 trauma center – an 11-year experience

Background Urological injuries can occur in patients with pelvic fractures. Treatment recommendations lack solid evidence and is often pragmatical. There is a continuous need to describe short- and long-term morbidity following lower urinary tract trauma. Objective To describe incidence, diagnosis, treatment, and morbidity following lower urinary tract injuries in pelvic fractures. Patients and methods Retrospective study including patients with pelvic, including acetabular, fractures admitted to a Level I Trauma Centre covering 2.8 million citizens between 2009 and 2020. Outcome measurements comprised primary management, treatment trajectory, short- and long-term complications and outcomes. Results A total of 39 (5%) patients with pelvic fractures had concomitant urethral and/or bladder injuries, and one patient with an acetabular fracture had a bladder injury. The management of urethral injuries varied vastly, and complete urethral ruptures were associated with severe short- and long-term complications. Only one patient with bladder injury experienced severe long-term complications. Conclusions Management of lower urinary tract injuries in patients with major pelvic fractures remains a major challenge. Special attention should be focused on urethral injuries where we uncovered an unsystematic treatment and follow-up even in a highly experienced centre, although this is also attributed to complicated multidisciplinary patient trajectories. There is a continuous need to reduce long-term complications following urethral trauma which should be addressed in multicenter studies.

Expression of transforming growth factor-β1 and autophagy markers in the bladder of rats with neurogenic lower urinary tract injury.

This study was conducted to explore the expression of transforming growth factor-beta 1 (TGF-β1) and its correlation with autophagy markers in the bladder of rats with neurogenic lower urinary tract dysfunction (NLUTD) post spinal cord injury (SCI). A total of 36 male Wistar rats were randomly divided into the SCI group and control group. Rats in the SCI group were subjected to T10-T11 spinal cord transection. At day 1, 4, and 7, 6 rats were euthanized daily and the Basso, Beattie and Bresnahan score (BBB score), post-void residual (PVR), urinary bladder function score (UBFS) and bladder weight were assessed. The expression TGF-β1 and autophagy markers were evaluated by immunofluorescence staining, Western bolt, and qRT-PCR. A total of 36 male Wistar rats were randomly divided into the SCI group and control group, with three time points in each group. Not applicable. SCI modeling impaired the motor function of the hind limbs and the bladder function of rats. NLUTD muscle exhibited a punctated immunostaining pattern for LC3, suggesting the accumulation of autophagosomes. Our results further indicated that compared with the control group, the expression levels of TGF-β1 and LC3 were increased, while the level of P62 was decreased after SCI modeling. TGF-β1 was significantly increased in SCI rats with NLUTD and was correlated with autophagy markers LC3 and p62.

Transobturator-tape outside in (TVT-O) as saviour for female stress urinary incontince without available cystoscope for gynecologist: A case series

SUI affects quality of life. Ulmsten and Petros reported mid urethral sling operations using Tension-free Vaginal Tape (TVT) and Delorme used Transobturator Tape (TOT). Cystoscopy is often used in retropubic sling procedures to identify lower urinary tract injury. Cystoscopy protects patients and accurately identifies iatrogenic injuries. The goal is to evaluate the efficacy of a standard Trans-Obturator (TOT-O) mid urethral sling for female Stress Urinary Incontinence (SUI) without intraoperative cystoscopy. A total of 120 female SUI patients from 2014 to 2019 were studied. Stress-related incontinence and diaper use were preoperative variables. Under spinal anesthesia, the procedure improved stress incontinence, sexual dysfunction, complications, and overall satisfaction. All patients improved after the procedure, and 116 (96.6%) completely resolved. Post-operative complications included urinary retention in 3 patients (2.5%), increased daytime urinary frequency in 3 (2.5%), urge incontinence in 4 (3.33%), groin/thigh pain in 2 (1.66%), and local mesh excision for mesh erosion in 1 (0.83%). Open EPI software calculated insignificant p values for clinical profile and satisfaction with symptom resolution. Brief Index of SF for Women was used to assess sexual function. At 6-month followup, all patients were satisfied with sexual function. TOT-O technique for female stress urinary incontinence is easy to learn and reproducible for beginners.

Implementation of a policy of universal cystoscopy at the time of hysterectomy for benign indications: A retrospective comparative study.

Lower urinary tract injury (LUTI) is a serious complication of major gynaecologic surgery. Although intra-operative cystoscopy can facilitate timely diagnosis and treatment of LUTI, the optimal approach to cystoscopy at the time of benign hysterectomy remains debatable. To assess whether implementation of a policy of universal cystoscopy at the time of benign hysterectomy was associated with a difference in intra-operative detection and rates of LUTI. Retrospective cohort study at a large regional teaching hospital where a policy of universal cystoscopy at the time of benign hysterectomy was implemented on 30 September 2019. Hysterectomies performed from 1 November 2016 to 31 March 2021 were included and categorised into the 'pre-policy' and 'post-policy' groups. Primary outcomes included the intra-operative detection and overall rates of LUTI. Secondary outcome was the policy adherence rate. Multivariate analysis was used to examine the effect of this policy on the outcomes. There were 584 hysterectomies identified, including 325 in the pre-policy group and 259 in the post-policy group. Cystoscopy was performed in 55.1% in the pre-policy group and 97.7% in the post-policy group (P < 0.01). Adjusted for age, indication and route of hysterectomy, there were no significant differences in the intra-operative cystoscopic detection of LUTI (42.9% vs 25.0%, P=0.55) or the rate of LUTI (2.2% vs 1.5%, P=0.25) after implementation of the policy. The practice of universal cystoscopy at the time of benign hysterectomy has not been associated with a significant change in the intra-operative detection and rates of LUTI at our institution.

MP21-06 IMPACT OF SEXUAL DYSFUNCTION ON QUALITY OF LIFE IN WOMEN AFTER PELVIC FRACTURE

You have accessJournal of UrologyCME1 May 2022MP21-06 IMPACT OF SEXUAL DYSFUNCTION ON QUALITY OF LIFE IN WOMEN AFTER PELVIC FRACTURE Helen Gambrah, and Niels Vass Johnsen Helen GambrahHelen Gambrah More articles by this author , and Niels Vass JohnsenNiels Vass Johnsen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002554.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pelvic neurovascular damage accounts for the well-known association between pelvic fracture and sexual dysfunction. The impact of sexual dysfunction on quality of life has been well-documented but has historically focused on patients with lower urinary tract injuries. These injuries have been shown to be associated with higher rates of SD and therefore are more likely to influence patient-reported quality of life. We hypothesized that the presence of SD following pelvic fracture negatively impacts health-related quality of life (HrQOL) even for patients with no lower urinary tract injuries. METHODS: Women treated for pelvic fracture at a level 1 trauma center between 2012 and 2017 were invited to complete an online survey. Patients with spinal cord injuries, associated lower urinary tract injuries, and isolated acetabular fractures were excluded. Sexual function was assessed using the Female Sexual Function Index (FSFI). HrQOL was evaluated using the visual analog scale (VAS) component of the EuroQol 5 Dimensions Questionnaire (EQ-5D). Inverse probability weighting was utilized to adjust for subject nonresponse. Multivariate regression was performed to evaluate the impact of sexual function on HrQOL. RESULTS: 98 of the 780 potential subjects completed the survey (12.6%). Responders had a mean age at time of injury of 42.2 years (SD 22.4) and median time since injury of 45 months (IQR 30.0, 57.4). After weighting, median FSFI score was 19.1 (IQR 5.5, 27.7), and median EQ-5D VAS score was 71 (IQR 60, 85). Bivariate linear analysis showed that FSFI scores and time since injury were significantly associated with patient-reported HrQOL. A decrease in FSFI scores correlated to a decline in EQ-5D VAS score (β = 0.62, 95% CI 0.30–0.95, p <0.001). Additionally, after adjustment for potential confounders, FSFI, time from injury, and age were all independently associated with HrQOL, with FSFI having the largest effect size (Table 1). CONCLUSIONS: Younger age, increased time since injury, and higher FSFI scores were all independently associated with improved HrQOL scores among women with a history of traumatic pelvic fracture, with FSFI scores as the strongest independent predictor for decreased HrQOL in this patient population. These data highlight the importance of addressing sexual health issues in female pelvic trauma survivors in the post-injury setting. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e329 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Helen Gambrah More articles by this author Niels Vass Johnsen More articles by this author Expand All Advertisement PDF DownloadLoading ...

Technique for cost effective cystoscopy following laparoscopic hysterectomy

The objectives of this video are (1) review the incidence of lower urinary tract injury (2) summarize the evidence of cost effectiveness of cystoscopy following hysterectomy and (3) demonstrate a technique for cystoscopy following laparoscopic hysterectomy utilizing only instruments using during hysterectomy without use of a cystoscopy tray. We demonstrate a technique for post hysterectomy cystoscopy utilizing the 5mm 30-degree laparoscope, suction irrigator, and foley without the use of a cystoscopy tray. The demonstrated technique allows for efficient use of time and resources thereby allowing a cost-effective approach to universal cystoscopy.

Risk factors of lower urinary tract injury with laparoscopic sacrocolpopexy

BACKGROUNDLower urinary tract injuries can occur during pelvic reconstructive surgery, including sacrocolpopexy. The reported injury rates range from 0.4% to 10.6% with laparoscopic sacrocolpopexy, 1.1% to 3.3% with abdominal sacrocolpopexy, and 2.3% to 10% with robotic sacrocolpopexy. Specific literature identifying the risk factors for lower urinary tract injury during pelvic reconstructive surgery is lacking; therefore; we aim to identify the patient characteristics predisposing a patient to lower urinary tract injury during laparoscopic sacrocolpopexy.OBJECTIVEThe primary objective of this study was to identify the patient-specific risk factors for lower urinary tract injury with laparoscopic sacrocolpopexy.STUDY DESIGNThis was an age-matched, case-control study including patients who underwent laparoscopic sacrocolpopexy from July 2014 to December 2017 in a high-volume female pelvic medicine and reconstructive surgery practice. The patients were excluded if they underwent laparoscopic uterosacral ligament suspension, had abnormal urinary tract anatomy, or for incorrect, incomplete, or duplicated data. Risk factors such as race, body mass index, pelvic organ prolapse quantification stage, previous abdominal and/or vaginal surgeries, and concurrent procedures (lysis of adhesions, adnexal surgery, midurethral sling placement, and anterior or posterior colporrhaphy) were analyzed. Groups were compared using the Student t-test for independent samples and chi-square tests. Conditional logistic regression was used to estimate the crude and adjusted odds ratios.RESULTSA total of 930 patients were identified during electronic medical record chart review using the current procedural terminology code 57425 (laparoscopic colpopexy). A total of 167 patients met the exclusion criteria, resulting in a total of 763 patients for primary analysis. The prevalence of lower urinary tract injury was 2.4% (17 bladder injuries and 1 ureteral injury out of 763 laparoscopic sacrocolpopexy procedures). These 18 cases were age-matched to 72 controls. The mean age and body mass index of all patients was 64.8 years (±9.32) and 26.5 kg/m2 (±3.99), respectively. Most of the patients were Caucasian, had previously undergone abdominal and/or vaginal surgery, had pelvic organ prolapse stage 3 or greater, and underwent concurrent surgeries, including adnexal surgery and midurethral sling placement at the time of laparoscopic sacrocolpopexy. A history of previous hysterectomy (odds ratio, 19.94; 95% confidence interval, 2.48–160.38; P=.005) and lysis of adhesions at the time of laparoscopic sacrocolpopexy (odds ratio, 4.94; 95% confidence interval, 1.05–23.19; P=.043) were associated with an increased odds of lower urinary tract injury in unadjusted models. In a multivariable logistic regression model controlling for the previously listed variables, a history of previous hysterectomy remained significantly associated with lower urinary tract injury (adjusted odds ratio, 162.41; 95% confidence interval, 3.21–8227; P=.011). Race, body mass index, pelvic organ prolapse quantification system stage, previous abdominal and/or vaginal surgery, and concurrent procedures were not associated with an increased risk of lower urinary tract injury.CONCLUSIONAlthough lower urinary tract injury with laparoscopic sacrocolpopexy only occurred in 2.4% of patients, previous hysterectomy increased this risk substantially. As sacrocolpopexy is the common treatment for prolapse after hysterectomy or recurrent prolapse, this increased risk of lower urinary tract injuries can guide surgical counseling on the basis of patient-specific risk factors and aid in setting appropriate postoperative patient expectations.

Le Fort Colpocleisis

<h3>Study Objective</h3> To highlight a safe and effective technique of the Lefort Colpocleisis for treating pelvic organ prolapse in an elderly patient. <h3>Design</h3> Educational Video. <h3>Setting</h3> OR. <h3>Patients or Participants</h3> The index patient is an 82-yo G2P1011 patient with symptomatic stage III pelvic organ prolapse; the anterior compartment was the leading edge. Due to the prolapse the patient was unable to exercise and walk as much as she desired. She failed an initial trial of ring pessary. After appropriate counseling, the patient opted for surgical intervention via a Lefort Colpocleisis with the understanding that this would preclude vaginal intercourse in the future. Preoperative evaluation with cystoscopy, urodynamic studies and a pelvic ultrasound were all within normal limits. We started the procedure by marking rectangular areas on the anterior and posterior vagina. The marked areas are then removed by careful sharp and blunt dissection. The edges of the rectangle and the denuded vaginal mucosa were then closed; leaving laterally created tunnels for drainage of cervical mucus. As successive sutures were placed; it was ensured that the knots were within the epithelial lined tunnels. This carefully maneuvered technique allowed the uterus and vaginal apex to be gradually turned inward. A bladder neck plication suture was then placed due to the high risk of stress incontinence accompanying these cases. A perineorrhaphy was completed to narrow the vaginal introitus. A cystoscopy was then performed confirming ureteral patency and excluding lower urinary tract injury. At her postoperative visit the patient had resolution of her symptoms and was pleased with the outcome of her surgery. <h3>Interventions</h3> LeFort Colpocleisis. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> This technique is a good approach for the management of pelvic organ prolapse in elderly patients or those who are not candidates for major reconstructive surgery.

PSU2 IMPACT of Recognized and Unrecognized Iatrogenic Lower Ureteral Injury at Time of Hysterectomy: A Nationwide Populational Database Study

Iatrogenic lower urinary tract injury (LUT) is an uncommon but potentially morbid complication of pelvic surgery. An unrecognized LUT can lead to significant consequences, including abscess, ureteral stricture, and potential loss of ipsilateral kidney or even death. This study was to characterize the 90-day complications associated with LUT and assess the impact of recognized vs unrecognized LUT.

45 Risk factors for lower urinary tract injury with laparoscopic sacrocolpopexy

The objective of this study was to identify patient-specific risk factors for lower urinary tract (LUT) injury with laparoscopic sacrocolpopexy (LSCP). This is an age-matched case-control study including patients who underwent LSCP from 2014-2017 in a high volume Urogynecology practice. Patients were excluded if they had abnormal urinary tract anatomy. Risk factors such as race, body mass index (BMI), preoperative pelvic organ prolapse quantification (POP-Q) stage, prior abdominal and/or vaginal surgery, and concurrent procedures were analyzed. Groups were compared using Student’s t-test for independent samples and chi-square tests. Conditional logistic regression was used to estimate odds ratios, and all regression models were conditioned on the matching variable. The model for adjusted odds ratios included all potential risk factors. The prevalence of LUT injury was 2.4% (17 bladder injuries and 1 ureteral injury out of 763 LSCP procedures). These 18 cases were age-matched to 72 controls. History of prior hysterectomy (unadjusted OR 162.41; CI 3.21, 8227; P= 0.011; adjusted OR 19.94, CI 2.48, 160.38; P= 0.005) and lysis of adhesions (unadjusted OR 5.15; CI 0.50, 52.76; P= 0.168; adjusted OR 4.94, CI 1.05, 23.19; P= 0.043) were associated with an increased risk of LUT injury. Concurrent posterior colporrhaphy appeared to have a protective association with LUT injury (unadjusted OR 0.78, CI 0.02, 27.67; P= 0.892; adjusted OR 0.32; CI 0.11, 0.88; P= 0.028). Race, BMI, POP-Q stage, prior abdominal and/or vaginal surgery, as well as concurrent bilateral salpingo-oophorectomy, mid-urethral sling placement, and anterior colporrhaphy were not associated with an increased risk of LUT injury. The prevalence of LUT injury with LSCP is rare, occurring in 2.4% of patients. History of prior hysterectomy significantly increased LUT injury risk. Concurrent lysis of adhesions increased the risk of LUT injury, while posterior colporrhaphy showed a protective effect. Although these two procedures may impact LUT injury risk, the associations are less clear due to the rarity of cases and baseline differences between groups. Based on our findings, the clinician can individualize surgical counseling based on patient-specific risk factors. This may also aid in setting appropriate postoperative patient expectations, including discussion as necessary regarding potential for prolonged catheterization or additional procedures and/or postoperative imaging in the case of LUT injury.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

52 Lower urinary tract injury and the role of cystoscopy at the time of hysterectomy for gynecologic cancer

52 Lower urinary tract injury and the role of cystoscopy at the time of hysterectomy for gynecologic cancer

Timing of Diagnosis of Complex Lower Urinary Tract Injury in the 30-Day Postoperative Period Following Benign Hysterectomy

(Abstracted from Am J Obstet Gynecol 2020; doi: 10.1016/j.ajog.2020.10.050) Complex lower urinary tract injury (cLUTI) resulting from hysterectomy is a rare but potentially devastating complication. A number of risk factors for cLUTI at the time of hysterectomy have been identified.

Lessons learned from lower urinary tract complications of anorectoplasty for imperforate anus with rectourethral/rectovesical fistula: Laparoscopy-assisted versus posterior sagittal approaches

PurposeTo report the sequelae of and preventive strategies for selected lower urinary tract (LUT) complications, i.e., posterior urethral diverticulum (PUD), intraoperative LUT injuries, postoperative dysuria, and fistula recurrence in male imperforate anus (IA) with rectourethral/rectovesical (RU/RV) fistula after laparoscopy-assisted anorectoplasty (LAARP) or posterior sagittal anorectoplasty (PSARP). Methods153 boys with IA and RU/RV fistula treated 1986–2019 by LAARP (n = 56) or PSARP (n = 97) at two unrelated institutes were studied retrospectively. ResultsAfter mean follow-up of 17.0 years (range: 36.5 days-32.0 years), the overall incidences of LUT complications were: LAARP (6/56; 10.7%); PSARP (7/97; 7.2%); p = 0.55, comprising PUD: LAARP (n = 5), PSARP (n = 0); p = 0.006; injuries: LAARP (n = 0), PSARP (n = 5); p = 0.16; dysuria: LAARP (n = 1), PSARP (n = 1); p>0.999; and recurrence: LAARP (n = 0), PSARP (n = 1); p>0.999. Mean onset of PUD was 5.1 years (range: 1.0–15.1 years). Treatment: PUD: surgery (n = 2/5), conservative (n = 3/5); injuries: intraoperative repair (n = 5/5); dysuria: conservative (n = 2/2), and recurrence: redo PSARP (n = 1/1). ConclusionsStrategies devised to improve dissection accuracy resolved the specific technical issues causing LUT complications (remnant RU fistula dissection in LAARP and blind posterior access in PSARP). Currently, the incidence of new cases of PUD and LUT injuries is zero.Level of Evidence: Level III