Management Of Urinary Tract Injuries Research Articles

Urological injuries following gynecologic surgery: clinical manifestations, diagnosis and management

Iatrogenic urinary tract injury constitutes a rare but serious complication of gynecologic surgery, occurring in 0.3% to 1.5% of all procedures. Delayed diagnosis and repair are associated with increased postoperative morbidity, mortality and a long-term negative impact on the quality of life. Intraoperative detection of urinary tract injuries allows for prompt repair, facilitates management and speeds up recovery. Bladder injuries are 3 times more common than ureteral injuries, and usually are recognized and repaired immediately with minimal complications. Undetected ureteral injuries lead to severe postoperative complications such as the formation of genitourinary fistulas, sepsis, renal loss and death. In this review we aim to describe the postoperative clinical manifestations, the diagnostic methods and therapeutic strategies for the management of urinary tract injuries, whether in the acute or delayed setting, in an effort to reduce the potential impact of subsequent complications to both patient and surgeon. Timely and effective repair of urinary tract injuries is critical to improve patient outcome, mitigate litigation risk, and allow an uneventful postoperative recovery in a careful manner.

Simulated management of urinary tract injury during robotic pelvic surgery utilizing the porcine model.

Urologic injury is an infrequent but serious complication of pelvic surgery. Training in the assessment and management of this injury might be enhanced through animated simulation. Our objective was to assess the intraoperative management of urologic injury with robotic pelvic surgery using a simulated injury animal model. We used a female domestic pig to create three types of urologic injury, which we then managed with robotically assisted surgery. An edited video of the model was assessed by 14 senior learners and 10 attending faculty. The assessments included key competencies and domains of fidelity. A scale of poor, fair, or good was utilized. The defects and repairs simulated those seen in humans, both anatomically and surgically, although deficiencies were noted. Related to fidelity of the anatomy of the ureter and bladder, lower ratings were given for some of the key competencies (determining the relationship to the trigone, ureteral mobilization, repair of all 3 injuries). The porcine model for simulation of urologic injury during robotically assisted pelvic surgery may be useful for training purposes.

Management of Urinary Tract Injuries Following Total Hysterectomy

Objective: This study elaborated on the clinical experience of patients who underwent urologic management due to urologic complications after receiving a total hysterectomy at a regional hospital. Materials and methods: A total of 696 female patients received the four types of total hysterectomy including total abdominal hysterectomy, transvaginal hysterectomy, lapaparoscopic hysterectomy or robotic hysterectomy for variant gynecologic pathologies. Only 22 cases (3.2%) had urologic procedures performed during or after the operations from 2012/1/1 to 2016/6/30. Results: Of the 22 cases, thirteen (1.9%) received a series of conservative managements only, including cystoscopy, ureteroscopy, endoscopic ureterotomy, ureteral catheterization or double J stenting during the follow-up period. Nine more complicated cases (1.3%) eventually had definitive management, including repair of the urinary bladder rupture, repair of the vesicovaginal fistula, ureteroureterostomy or ureteroneocystostomy. However, five of these nine cases had both conservative and definitive management. The mean delay interval between the initial management and gynecologic procedure was 19.3 days. For definitive management and the gynecologic procedure, the period was 52.8 days. Conclusions: Compared to previous studies, the incidence of urologic injuries following a total hysterectomy in our hospital was similar. From the paper review, it seems early recognition does not improve the outcome but we found a 100% good outcome in patients with definitive management. Copyright © 2017, Taiwan Urological Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Management of urinary tract injuries following total hysterectomy—A single hospital experience

ObjectiveThis study elaborated on the clinical experience of patients who underwent urologic management due to urologic complications after receiving a total hysterectomy at a regional hospital. Materials and methodsA total of 696 female patients received the four types of total hysterectomy including total abdominal hysterectomy, transvaginal hysterectomy, lapaparoscopic hysterectomy or robotic hysterectomy for variant gynecologic pathologies. Only 22 cases (3.2%) had urologic procedures performed during or after the operations from 2012/1/1 to 2016/6/30. ResultsOf the 22 cases, thirteen (1.9%) received a series of conservative managements only, including cystoscopy, ureteroscopy, endoscopic ureterotomy, ureteral catheterization or double J stenting during the follow-up period. Nine more complicated cases (1.3%) eventually had definitive management, including repair of the urinary bladder rupture, repair of the vesicovaginal fistula, ureteroureterostomy or ureteroneocystostomy. However, five of these nine cases had both conservative and definitive management. The mean delay interval between the initial management and gynecologic procedure was 19.3 days. For definitive management and the gynecologic procedure, the period was 52.8 days. ConclusionsCompared to previous studies, the incidence of urologic injuries following a total hysterectomy in our hospital was similar. From the paper review, it seems early recognition does not improve the outcome but we found a 100% good outcome in patients with definitive management.

How to Avoid Open Repair - Management of Urinary Tract Injuries During Laparoscopic Surgeries

We describe laparoscopic minimally invasive methods of intraoperative and post-operative management of urinary tract injuries.

Prevention and management of urologic injury during gynecologic laparoscopy.

This article provides an update on the best practices for the prevention, recognition, and management of urinary tract injuries that may occur during gynecologic laparoscopic surgery. Higher surgical volume is directly associated with improved surgical outcomes, denoted by consistently lower rates of complications for commonplace procedures such as hysterectomy. As a result, expert opinion on prevention of iatrogenic urologic injury suggests a real need for improved education and training of gynecologic surgeons. Discontinued manufacturing of indigo carmine has led to the utilization of alternative methods to assess ureteral patency during cystoscopy, such as phenazopyridine or sodium fluorescein. Intraoperative cystoscopy has been shown to detect approximately 50% of urinary tract injuries during hysterectomy, but has limited accuracy and does not necessarily decrease delayed postoperative complications. When identified, most urologic injuries can be managed in a minimally invasive fashion. A thorough understanding of pelvic anatomy and early recognition of urinary tract injuries can significantly reduce surgical morbidity for women undergoing laparoscopic surgery.

Laparoscopic Hysterectomy and Urinary Tract Injury: Experience in a Health Maintenance Organization.

To evaluate the incidence, detection, characteristics, and management of urinary tract injury in a cohort undergoing laparoscopic hysterectomy, and to identify potential risk factors for urinary tract injury with laparoscopic hysterectomy. Retrospective analysis (Canadian Task Force classification II-2). Kaiser Permanente San Diego Medical Center, 2001 to 2012. Women who underwent attempted laparoscopic hysterectomy for benign indications. Total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparoscopic supracervical hysterectomy. Demographic and clinical characteristics, surgical techniques, and perioperative complications were abstracted from the medical record. Multivariable logistic regression analysis assessed independent risk factors for ureteral or bladder injury. A total of 3523 patients (mean age, 45.9 ± 8.0 years; median parity, 2; range, 0-10), with a median body mass index (BMI) of 29 kg/m(2) (range, 16-72 kg/m(2)), underwent laparoscopic hysterectomy; 20% had intraoperative cystoscopy. The incidence of urinary tract injury was 1.3% (46 of 3523); of the 46 patients with injuries, 19 (0.54%) had ureteral injuries, 25 (0.71%) had bladder injuries, and 2 (0.06%) had both types. Of the 21 ureteral injuries, 6 (29%) were diagnosed intraoperatively and 15 (71%) were diagnosed postoperatively, including 4 with normal intraoperative cystoscopy. Of the 27 bladder injuries, 23 (85%) were identified intraoperatively. In multivariable logistic analysis, a BMI of 26 to 30 kg/m(2) (compared with >30 kg/m(2)) was associated with an increased risk of ureteral injury, and a BMI ≤25 kg/m(2) (compared with >30 kg/m(2)) and the presence of endometriosis were associated with an increased risk of bladder injury. Urinary tract injury occurred in 1.3% of laparoscopic hysterectomies, with ureteral injuries almost as common as bladder injuries. Normal intraoperative cystoscopy findings did not exclude the presence of ureteral injury.

Incidental ureteral injury and repair during robotic-assisted total laparoscopic hysterectomy.

To show a surgical educational video in which an incidental ureteral injury was recognized intraoperatively and was repaired during robotic-assisted total hysterectomy for a very large uterus. Step-by-step demonstration of ureterolysis and repair of ureteral injury via a ureteroureterostomy technique using an educational video and schematic pictures. Ureteral injuries are estimated to occur with a frequency of approximately 0.02% to 0.4% during laparoscopic hysterectomy. When compared with bladder injuries, ureteral injuries are much less likely to be recognized intraoperatively, and in some cases can be missed despite the use of intraoperative cystoscopy. The sequelae from ureteral injury are not insignificant, which can easily be prevented by intraoperative recognition and immediate repair. Minimally invasive surgery using the robotic system has led to a paradigm shift in the management of urinary tract injuries, which has been traditionally approached with open surgery. Robotic total hysterectomy and repair of incidental ureteral injury via ureteroureterostomy using standard end-to-end anastomosis technique and intracorporeal retrograde double J stent placement. Robotic repair of ureteral injury during gynecologic surgery was associated with good outcomes, appeared safe and feasible, and saved the patient and the physician significant morbidity and medicolegal implications, respectively.

Management of Urinary Tract Injuries in Minimally Invasive Gynecologic Surgery

Dr. Moawad is Assistant Professor, and Dr. von Walter Gonzalez is a Fellow, Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, The George Washington University, 2150 Pennsylvania Ave, NW, Suite 6A-426, Washington, DC 20037; E-mail: [email protected]. All faculty and staff in a position to control the content of this CME activity, and their spouses/partners (if any) have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity. Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This activity expires on February 14, 2014.

Management of Urinary Tract Injuries in Minimally Invasive Gynecologic Surgery

Management of Urinary Tract Injuries in Minimally Invasive Gynecologic Surgery

Successful treatment of upper ureteral injury using renal autotransplantation

Ureteral injuries are uncommon. Upper ureteral defect more than 7-8 cm in length is a challenge for urologists, requiring experience and several steps in its management. We report a case of iatrogenic upper urinary tract injury and successful treatment of 8-cm ureteral defect using autotransplantation of the kidney. A male patient underwent surgery due to retroperitoneal tumor. Iatrogenic ureteral injury was recognized 18 days after operation. Three-step management of urinary tract injury was performed. The first step included minimally invasive recovery of the urine flow and treatment of infection. The second step was unsuccessful renal descensus and new formation ureteropyeloanastomosis because of difficulties of kidney mobilization caused by previous surgery. The third step included a successful autotransplantation of the kidney and complete reconstruction of the urinary tract. Autotransplantation can be successfully used for the management of long upper ureteral injury in referral urological centers.

What Would You Do?: Laparoscopic Management of Urinary Tract Injuries during TLH

What Would You Do?: Laparoscopic Management of Urinary Tract Injuries during TLH

Urinary incontinence following gynaecological surgery

The proximity of the urinary tract to the reproductive organs puts it at risk of injury and incontinence as a consequence of gynaecological surgery. Incontinence to urine after gynaecological surgery is distressing to both the patient and the surgeon; in particular, formation of a urinary fistula after surgery is seen as a disaster by both. It also has long-term medicolegal implications. In this review. the main emphasis is on the prevention, evaluation, diagnosis and management of urinary tract injury. Other causes of postoperative incontinence are addressed briefly.

Post-operative incontinence and fistulae

The proximity of the urinary tract to the reproductive organs puts it at risk of injury and incontinence as a consequence of gynaecological surgery. Incontinence of urine after gynaecological surgery is not only distressing and disappointing to the patient but also causes considerable stress to the surgeon. It also leads to medico-legal implications. Post-operative incontinence can occur in those who had it prior to surgery, whilst others develop it after surgery. Surgery may fail in those who came for surgery for incontinence if there is inadequate evaluation and counselling before surgery, if an inappropriate operation is performed or when there is poor surgical technique. In those who were continent, incontinence may develop as an undesired outcome of surgery. This may be due to de novo detrusor instability, retention with overflow in the immediate post-operative period, or to inadequate evaluation before vaginal surgery unmasking occult incontinence. Rarely, it may be due to unrecognised injury to the lower urinary tract. This article will deal with the prevention, evaluation, diagnosis and management of urinary tract injury and other causes of post-operative incontinence.

Post-operative incontinence and fistulae

The proximity of the urinary tract to the reproductive organs puts it at risk of injury and incontinence as a consequence of gynaecological surgery.Incontinence of urine after gynaecological surgery is not only distressing and disappointing to the patient but also causes considerable stress to the surgeon. In particular, formation of a urinary fistula after surgery is seen as a disaster both by the patient and the surgeon. It also has long-term medico-legal implications.Post-operative incontinence can be broadly divided into two groups.•Patients who had incontinence before surgery•These women have surgery to address this problem in the first place. If surgery fails, the reasons could be:•inadequate evaluation and counselling before surgery,•inappropriate operation or operative technique,•development of detrusor instability,•unrecognized injury to the lower urinary tract.•Patients who did not have incontinence but developed this complaint after vaginal or abdominal surgery.•Here, incontinence develops as an undesired outcome of surgery. This may be due to:•retention with over flow in the immediate post-operative period,•inadequate evaluation before vaginal surgery unmasking occult incontinence,•unrecognized injury to the lower urinary tract.In this article, the main emphasis will be on prevention, evaluation, diagnosis and management of urinary tract injury. Other causes of post-operative incontinence will be addressed briefly.A list of references has been provided for the interested reader.

The management of urinary tract injuries after gunshot wounds of the anterior and posterior abdomen

Gunshot wounds of the urinary tract are seen with increasing frequency due to the widespread use of firearms. There is much controversy regarding the optimal preoperative diagnostic evaluation and intraoperative management of such injuries. Debate also arises as to the need for mandatory exploration or the safety of non-operative management for carefully selected patients. Seventy-nine prospective patients with injuries of the urinary tract after a truncal GSW were analyzed. The incidence of renal repair, nephrectomy, bladder repair and ureteral repair was 14, 21, 27 and 9 per cent, respectively. Five (6 per cent) patients were managed non-operatively and 16 (20 per cent) more underwent abdominal but not renal exploration. From 21 (26.5 per cent) cases with complications, only three (4 per cent) patients developed complications which were associated with the urinary tract injuries. Although the majority of patients with GSWs of the urinary tract will require abdominal exploration, invasion of Gerota's fascia may be spared in cases of stable renal haematomas. A high index of suspicion followed by adequate exploration is required to avoid missed ureteral injuries. Bladder perforations almost always require surgical repair.

URETERAL INJURIES ASSOCIATED WITH GYNECOLOGIC SURGERY: PREVENTION AND MANAGEMENT

Gynecologic surgery is responsible for most of the ureteral injuries that occur. The "easy" operation--the "simple" abdominal hysterectomy--and not the technically difficult pelvic one, is responsible for most ureteral injuries. Total abdominal hysterectomy accounts for almost 50% of the genitourinary fistulas and perhaps 80-99% of all surgical ureteral injuries. This problem will persist until a most important surgical axiom is applied routinely during the accomplishment of all pelvic operations: With all dissections, the contiguous structures subject to injury must be exposed. This step not only will avoid injuries to the ureter but also will facilitate an equally important aspect, that is, urinary tract injuries must be recognized at the time of operation. With recognition and adequate repair, problems such as fistula formation and serious morbidity (and litigation) can be avoided almost entirely. Because the gnecologic surgeon frequently will find that urologic consultation is not available at the time of urinary tract injury, he or she must be aware of and familiar with the various ureteral reconstructive procedures that may be required. The gynecologic surgeon must devote time and study to the management of urinary tract injuries before their occurrence. All pelvic surgeons eventually will encounter ureteral problems. The methods of bladder mobilization and ureteroneocystostomy should be within the ability of all who operate within the pelvis. When extensive damage has occurred and a urologist is not available, the gynecologist who is unfamiliar with the more demanding techniques (that is, ureteroureterostomy, bladder flaps, ileal conduits) should avoid additonal damage to the urinary tract and accomplish a simple catheter ureterostomy, deffering the definitive repair for a urologist.

Management of Urinary Tract Injuries in Fractures of the Bony Pelvis

Management of Urinary Tract Injuries in Fractures of the Bony Pelvis