Urinary Tract Injury Research Articles

Ureter injury in obstetric hysterectomy with placenta accreta spectrum: Case report.

Introduction and importancePlacenta accreta spectrum (PAS) is a state of abnormal attachment of the placenta, including placenta accreta, placenta increta, and placenta percreta. This condition can be life-threatening due to the placenta cannot spontaneously separated, resulting in continuous bleeding. Cesarean section followed by hysterectomy is one of the treatment options for PAS. There was a great liability for urinary tract injuries during the operation of PAS patient.Case presentationWe present the case of ureter injury during subtotal hysterectomy in patient with PAS. A 30-years-old female patient was diagnosed with recurrent antepartum hemorrhage due to placenta previa accreta spectrum on G2P1 33 weeks of gestational age, singleton live breech presentation, previous c-section 1×. After uterine transverse incision, the baby was delivered. We decided to perform subtotal hysterectomy. There was severe adhesion. On the exploration after subtotal hysterectomy was performed, we found ruptured of the right ureter.Clinical discussionHysterectomy peripartum is one of the treatment of PAS, either to prevent or to control postpartum hemorrhage. In pregnant women with morbid placental adherence, there was a great liability for urinary tract injuries. Distal ureters are the most commonly injured while hysterectomy. Injuries to the ureters in this patient occurred due to severe adhesions and unclear visual organ.ConclusionAlthough it is rare, ureter injury may occur during subtotal hysterectomy in patient with placenta accreta spectrum. To prevent that condition, inserting ureter stent can be perform before the operation. Multidisciplinary approach is carried out so that patient outcomes are good.

Evolution and Transformation of Uterine Transplantation: A Systematic Review of Surgical Techniques and Outcomes.

Uterine transplantation (UTx) is acknowledged to be on the second (2A) of five steps of development in accordance with the staging system for the evaluation of surgical innovations. Accordingly, we aimed to systematically review the available evidence of the surgical techniques and outcomes of UTx in terms of graft survival. A comprehensive search was conducted across PubMed Medline, Cochrane-EBMR, Scopus, Web of Science, and CENTRAL through November 2020. Forty studies, reporting 64 recipients and 64 donors, satisfied inclusion criteria. The surgical time and the estimated blood loss were 515 minutes and 679 mL for graft procurement via laparotomy, 210 minutes and 100 mL for laparoscopic-assisted graft harvest, and 660 minutes and 173 mL for robotic-assisted procedures, respectively. Urinary tract infections (n = 8) and injury to the urinary system (n = 6) were the most common donor complications. Using the donor's internal iliac system, two arterial anastomoses were performed in all cases. Venous outflow was accomplished through the uterine veins (UVs) in 13 cases, a combination of the UVs and the ovarian/uteroovarian veins (OVs/UOVs) in 36 cases, and solely through the OVs/UOVs in 13 cases. Ischemia time was 161 and 258 minutes when using living donors (LD) and deceased donors (DD), respectively. Forty-eight uteri were successfully transplanted or fulfilled the purpose of transplantation, 41 from LDs and 7 from DDs. Twenty-five and four live childbirths from LDs and DDs have been reported, respectively. UTx is still experimental. Further series are required to recommend specific surgical techniques that best yield a successful transplant and reduce complications for donors and recipients.

Comparison of the safety and efficacy between the prone split-leg and Galdakao-modified supine Valdivia positions during endoscopic combined intrarenal surgery: A multi-institutional analysis.

To evaluate the safety and efficacy of the prone split-leg and the Galdakao-modified supine Valdivia positions during endoscopic combined intrarenal surgery. A multi-institutional, retrospective cohort study was conducted between January 2014 and December 2018.The stone-free and complication rates were compared between the prone split-leg and the Galdakao-modified supine Valdivia positions. Anatomical variations were evaluated using contrast-enhanced computed tomography imaging. In total, 118 and 100 patients underwent endoscopic combined intrarenal surgery in the prone split-leg and Galdakao-modified supine Valdivia positions, respectively. Renal punctures in the prone split-leg position were predominantly executed through the lower calyces (78.0%), whereas those in the Galdakao-modified supine Valdivia position were primarily performed through the middle calyces (64.0%; P<0.001). Surgical duration in the prone split-leg position was significantly shorter than that in the Galdakao-modified supine Valdivia position (106.5 vs 126.0min; P=0.0459). There were no significant differences in the stone-free rate between the two positions (78.8% vs 76.0%; P=0.629). Incidences of urinary tract injury (P=0.033) and febrile urinary tract infection (23.7% vs 10.0%; P=0.011) in the prone split-leg position were significantly higher than that in the Galdakao-modified supine Valdivia position. The tilt of the major renal axis was significantly greater in the prone position than the corresponding values in the oblique position (19.4° vs 8.5°; P=0.019). Anatomical variation might result in the differences of renal puncture calyx. Endoscopic combined intrarenal surgery in the Galdakao-modified supine Valdivia position may bring equal stone-free status, with a longer surgical time but fewer complications including febrile urinary tract infection and urinary tract injury than the prone split-leg position.

Risk factors for catheter-associated urinary tract infections following radical hysterectomy for cervical cancer

Objectives: Radical hysterectomy is the mainstay of treatment for early-stage cervical cancer. Urinary tract dysfunction is one of the most common complications after radical hysterectomy, and prolonged catheterization has previously been defined as a significant risk factor for catheter-associated urinary tract infections (CAUTI). The purpose of this study was to determine the rate of CAUTI after radical hysterectomy for cervical cancer and identify additional risk factors for developing CAUTI in this population. Methods: We reviewed patients who underwent a radical hysterectomy for cervical cancer from 2004-2020 after institutional IRB approval. All patients were identified from our institution's Gynecologic Oncology surgical database. Inclusion criterion was radical hysterectomy for early-stage cervical cancer. Exclusion criteria included inadequate hospital follow-up, insufficient records of catheter use in the electronic medical record, urinary tract injury, and preoperative chemoradiation. CAUTI was defined as an infection diagnosed in a catheterized patient or within 48 hours of catheter removal, with significant bacteriuria (>103 cfu/mL) and symptoms or signs attributable to the urinary tract. Data analysis was performed using comparative analysis and univariate and multivariate logistic regression using Excel, GraphPad, and SPSS. Results: A total of 276 patients were identified. After applying exclusion criteria, 160 patients were included in the data analysis. The distribution of patients across FIGO stage is as follows: IA1 4.5% (n=4), IA2 6.3% (n=10), IB1 75.6% (n=121), IB2 13.8% (n=22), IIA2 1.9% (n=3). The mean length of indwelling catheter use was 9.3 days (range 0-33 days). 28.8% of patients (n=40) had a urinary catheter placement more than 1 time prior to passing a voiding trial. 12.6% of patients (n=20) were diagnosed with CAUTI. Minimally invasive surgery (MIS) was associated with longer catheterizations compared to an open approach (mean 12.8 days vs 6.9 days, p Conclusions: Catheterization over five days significantly increased the risk for CAUTI development after radical hysterectomy for cervical cancer. Smoking history, increased age, and minimally invasive surgical route are independent predictors for CAUTI. Earlier catheter removal should be encouraged in patients with these risk factors.

A Comparative Study of the Influence of Body Mass Index on Clinical Outcomes of Total Laparoscopic Hysterectomy in Birat Medical College Teaching Hospital, Morang, Nepal

Introduction: Although laparoscopy is a safe route of hysterectomy as it provides battier view of abdominal anatomy, facilitates meticulous hemostasis and reduces surgical morbidity, laparoscopic hysterectomy in overweight and obese women may pose an increased risk of intraoperative and postoperative complications as omental fat and limited manipulation of instruments may render operation difficult.&#x0D; Objectives: The aim of the study is to evaluate the impact of Body Mass Index (BMI) on the clinical outcome of total laparoscopichysterectomy.&#x0D; Methodology: This is a comparative cross-sectional study conducted in 190 patients who underwent total laparoscopic hysterectomy (TLH) in Department of Obstetrics and Gynecology of Birat Medical College, Teaching Hospital from July, 2019 to November 2020.Ninety five patients were enrolled in high BMI group and normal BMI group each&#x0D; Result: Mean BMI was 28.90±2.27 ( Kg/M2)in high BMI group and 23.54 ± 1.14 (Kg/M2)in normal BMI group. Urinary tract injury occurred in 4 (4.21%) cases in high BMI group and 2 (2.1%) cases in normal BMI group. Intraoperative and immediate postoperative complication were similar in both groups.&#x0D; Conclusion: Intraoperative and postoperative complications were similar in both the groups. Patients with high BMI have no increased risk of complications during total laparoscopic hysterectomy.

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

Placenta accreta spectrum: Management and outcomes in a tertiary centre in India: An observational cross-sectional study.

Our observational cross-sectional study looked at the risk factors, diagnosis, management and outcomes of placenta accrete spectrum at the Christian Medical College and Hospital, Vellore, India, between January 2013 and December 2018. A total of 21 cases of placenta accrete spectrum are described among whom a preop diagnosis was available in 14 cases. A previous history of Caesarean section and placenta previa was present in 90%. Caesarean hysterectomy was carried out in 80%, but none of those managed conservatively required interval hysterectomy. Urinary tract injury was the most common surgical complication, seen in over 50%. The mean blood loss was 3.5 l and 14 patients required intensive care unit admission, but no maternal mortality ensued. Thus, we conclude that the conservative management in carefully selected cases is feasible.

Refinements in surgical techniques for visualized tunnel formation in laparoscopic-assisted anorectoplasty

Laparoscopic-assisted anorectoplasty (LAARP) is becoming a more popular procedure for anorectal malformation (ARM) repair. However, the conventional technique for creating pull-through tunnel between the perineal skin and the pelvic floor has been criticized as being semi-blind. This study aims to present a refined version of our previously reported clamp introduction technique for visualized tunnel formation in the center of the sphincter muscle complex (SMC) for rectal pull- through for ARMs. A retrospective review was performed for ARM patients who underwent LAARP from Jan 2019 to Jun 2020. Longitudinal muscle tube (LMT) tunnel was created using the clamp-dilator introduction technique: a laparoscopic dilator was used to create a pelvic tunnel within LMT in high ARM, and the clamp introduction under the direct vision technique was performed for creating the perineal tunnel of LMT for both high and intermediate ARMs. Seventy patients (1-198days) with high-type (27cases) and intermediate-type (43 cases) ARM underwent LAARP using clamp-dilation introduction technique. No patients suffered from urinary tract injury, recurrent rectourethral fistula, urethral diverticulum and urinary incontinence. One patient suffered from wound infection and rectal retraction which required a redo pull-through on postoperative day 7. Rectal prolapse requiring surgical intervention developed in one patient. Postoperative MRI examination confirmed central placement of the rectum within the LMT in all cases. Our experience demonstrates that a visualized tunnel formation in the LMT center can be achieved by the clamp-dilator introduction technique in LAARP for both high and intermediate ARMs.

Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States

Although an infrequent occurrence, the placenta can adhere abnormally to the gravid uterus leading to significantly high maternal morbidity and mortality during cesarean delivery. Contemporary national statistics related to a morbidly adherent placenta, referred to as placenta accreta spectrum, are needed. This study aimed to examine national trends, characteristics, and perioperative outcomes of women who underwent cesarean delivery for placenta accreta spectrum in the United States. This is a population-based retrospective, observational study querying the National Inpatient Sample. The study cohort included women who underwent cesarean delivery from October 2015 to December 2017 and had a diagnosis of placenta accreta spectrum. The main outcome measures were patient characteristics and surgical outcomes related to placenta accreta spectrum assessed by the generalized estimating equation on multivariable analysis. The temporal trend of placenta accreta spectrum was also assessed by linear segmented regression with log transformation. Of 2,727,477 cases who underwent cesarean delivery during the study period, 8030 (0.29%) had the diagnosis of placenta accreta spectrum. Placenta accreta was the most common diagnosis (n=6205, 0.23%), followed by percreta (n=1060, 0.04%) and increta (n=765, 0.03%). The number of placenta accreta spectrum cases increased by 2.1% every quarter year from 0.27% to 0.32% (P=.004). On multivariable analysis, (1) patient demographics (older age, tobacco use, recent diagnosis, higher comorbidity, and use of assisted reproductive technology), (2) pregnancy characteristics (placenta previa, previous cesarean delivery, breech presentation, and grand multiparity), and (3) hospital factors (urban teaching center and large bed capacity hospital) represented the independent characteristics related to placenta accreta spectrum (all, P<.05). The median gestational age at cesarean delivery was 36 weeks for placenta accreta and 34 weeks for both placenta increta and percreta vs 39 weeks for non-placenta accreta spectrum cases (P<.001). On multivariable analysis, cesarean delivery complicated by placenta accreta spectrum was associated with increased risk of any surgical morbidities (78.3% vs 10.6%), Centers for Disease Control and Prevention-defined severe maternal morbidity (60.3% vs 3.1%), hemorrhage (54.1% vs 3.9%), coagulopathy (5.3% vs 0.3%), shock (5.0% vs 0.1%), urinary tract injury (8.3% vs 0.2%), and death (0.25% vs 0.01%) compared with cesarean delivery without placenta accreta spectrum. When further analyzed by subtype, cesarean delivery for placenta increta and percreta was associated with higher likelihood of hysterectomy (0.4% for non-placenta accreta spectrum, 45.8% for accreta, 82.4% for increta, 78.3% for percreta; P<.001) and urinary tract injury (0.2% for non-placenta accreta spectrum, 5.2% for accreta, 11.8% for increta, 24.5% for percreta; P<.001). Moreover, women in the placenta increta and percreta groups had markedly increased risks of surgical mortality compared with those without placenta accreta spectrum (increta, odds ratio, 19.9; and percreta, odds ratio, 32.1). Patient characteristics and outcomes differ across the placenta accreta spectrum subtypes, and women with placenta increta and percreta have considerably high surgical morbidity and mortality risks. Notably, 1 in 313 women undergoing cesarean delivery had a diagnosis of placenta accreta spectrum by the end of 2017, and the incidence seems to be higher than reported in previous studies.

Use of a Novel Fluorescent Catheter to Locate the Ureters during Total Laparoscopic Hysterectomy

Ureteral injury can occur during total laparoscopic hysterectomy. This report documents our experience in using the near-infrared ray catheter (NIRC), a newly developed fluorescent ureteral catheter made of material that contains a fluorescent dye to improve visualization of the ureters. We have used the device in 3 patients between 40 and 50 years of age (mean, 46.3 ± 4.5 years) undergoing total laparoscopic hysterectomy and bilateral salpingectomy for uterine myomas. The time of catheter insertion ranged from 4 minutes and 9 seconds to 10 minutes and 57 seconds. A number of intraoperative procedures were performed near the ureters, namely, identification and ligation of the uterine arteries, dissection of the cardinal ligament, incision of the vaginal canal, and suturing of the vaginal stump. The abovementioned fluorescent ureteral catheter appears green on a monitor when illuminated by near-infrared light, and this facilitated real-time confirmation of the ureter positions, increasing surgical safety. The patients were followed up for 6 months postoperatively, and no urinary tract infection or injury was found. Prophylactic use of the fluorescent ureteral catheter may improve visualization of the ureters in patients considered to be at high risk of ureteral injury, such as those expected to exhibit ureteral deviation due to severe adhesions or an enlarged uterus and when the surgeon has little experience in laparoscopic surgery.

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.

Impact of Previous Gynecologic Surgical Procedures on Outcomes of Non-Gynecologic Peritoneal Malignancies Mimicking Ovarian Cancer: Less Is More?

Non-gynecologic rare peritoneal surface malignancies (PSMs) often are misdiagnosed as disseminated ovarian cancer and initially treated by gynecologic surgeons. This study aimed to assess whether these previous maneuvers (i.e., full surgical staging and/or cytoreductive attempts) affect outcomes after the definitive surgery performed in a tertiary center. The study reviewed 298 women affected by non-gynecologic PSM who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) after previous gynecologic surgery. Prior surgery was categorized as limited surgery (pLS: abdominal exploration with biopsy plus adnexectomy and/or appendectomy) or extended surgery (pES: full surgical staging or cytoreductive attempts including hysterectomy with bilateral salpingo-oophorectomy). Of the 298 patients, 143 had pLS and 153 had pES. Morbidity was similar between the groups (P = 0.143), but the pES group had more severe urinary tract injuries (19 vs. 3; P < 0.001), longer operating time (585.9 vs. 506.7; P = 0.027), and more patients needing more than two anastomoses (41 vs. 26; P = 0.033). Ageolder than 55years (odds ratio [OR] 2.42; P = 0.009) and number of anastomoses (OR 3.17; P = 0.002) correlated with severe morbidity; pES correlated with urinary tract grades 3 and 4 injuries (OR 7.9; P = 0.001). The 5-year cumulative incidence of locoregional relapse was significantly higher in the pES group (0.41 vs. 0.27; P = 0.012; median follow-up period, 69months). The multivariate analysis identified a Peritoneal Carcinomatosis Index (PCI) higher than 20 and pES as independent risk factors. For women undergoing CRS±HIPEC for non-gynecologic PSM, the risk for locoregional relapse and severe postsurgical urinary tract complications is increased by pES. Therefore, prior full surgical staging or cytoreductive attempts without definitive gynecologic histology should be avoided. Prophylactic ureteral stenting and stricter oncologic follow-up assessment must be considered in this scenario.

Urethral Masturbation, Urethral Foreign Body—Review of Cases

Intravesical foreign body is a rarity. Studies have reported several items in urinary bladder like gauze pieces, worms, electrical wires, chicken bones, thermometers, pieces of Foley catheter, batteries and snakes. Herein, a case of an electrical wire inserted in male urethra and coiled in the bladder is presented. A seventeen-year-old male presented with history of insertion of electric wire per-urethra. The wire got stuck when he tried to pull it. He had made several unsuccessful attempts to remove it. On examination, the wire was seen protruding from external urethral meatus. An X-ray demonstrated the wire coiled and knotted inside the bladder. Considering high chances of endoscopic treatment failure, suprapubic cystotomy was performed and the wire was removed. The most common reason for self-insertion of a foreign body into male urethra is of erotic or sexual nature. In majority of cases, patient feels guilty and humiliated; therefore, he delays medical help. Many authors advocate psychiatric evaluation of these patients, considering it an indication of self-punishing and impulsive behaviour. However, it is controversial as many of these patients are psychologically normal. The definite management is complete removal of the foreign body by endoscopic or open approach. However, choosing the optimal technique depends upon the patient’s condition, urinary tract injuries and the size, shape and material of foreign body. A self-inflicted foreign body in urethra and bladder is rarity. Endoscopic manipulation is the preferred treatment, and if unsuccessful, open procedures may be necessary.

RE: Intraoperative Evaluation of Urinary Tract Injuries at the Time of Pelvic Surgery: A Systematic Review.

RE: Intraoperative Evaluation of Urinary Tract Injuries at the Time of Pelvic Surgery: A Systematic Review.

Incidence of urinary tract injury while performing total laparoscopic hysterectomy and role of cystoscopy

Introduction: Total laparoscopic hysterectomy is a common surgical procedure performed by a gynaecological endoscopic surgeon. Urinary tract injuries, though rare, is a serious complication requiring early detection and management. The aim of this study is to determine the incidence and risk factors for injury to the lower urinary tract during total laparoscopic hysterectomy and the role of cystoscopy in diagnosing the injury. Materials and Methods: All patients who underwent total laparoscopic hysterectomy for benign disease from January 1, 2017, to November 1, 2019, at the Institute of Kidney Diseases and Research Centre were included. Intraoperative cystoscopy with oral Pyridium given before surgery was routinely performed. Relevant data were abstracted to determine the incidence of lower urinary tract injury, predictors of injury and post-operative complications and the role of cystoscopy. Results: Total laparoscopic hysterectomy was performed in 150 consecutive subjects. Out of the encountered 6 cases (4%) of renal injuries in our study, two (1.3%) cystotomies were noted and repaired. An absent ureteral spill of Pyridium was detected in one subject, ureteral injury that was detected and confirmed with retrograde pyelography and managed with percutaneous nephrostomy and ureteric implantation. Three patients had a ureteric injury which was missed initially with a cystoscope. Later on, the patient presented with a urinary leak. The injury was identified and managed surgically. Only 25% (1/4) of injuries were recognised with the use of cystoscopy with Pyridium. All patients recovered with no long-term complications on follow-up. Conclusions: Renal injuries are relatively uncommon during total laparoscopic hysterectomy. Nevertheless, when an injury does occur, quick recognition of the problem and a working knowledge of its location and treatment are essential in providing patients with optimal medical care. Surgeons should consider performing cystoscopy at the time of total laparoscopic hysterectomy.

Improving the Evaluation and Management of Cystotomy in Gynecologic Surgery with a Cadaver Surgical Curriculum

Objectives: Urinary tract injuries are a known complication of gynecologic surgery, occurring in 0.18% - 0.80% of procedures and most commonly involving the bladder. Appropriate identification, evaluation, treatment, and follow-up by gynecologic surgeons are important to reduce the associated long-term morbidities. The purpose of this study was to implement a comprehensive cadaver curriculum in cystotomy repair for OBGYN residents. Methods: This was a prospective observational cohort study including 10 OBGYN residents (PGY1-3) at a single institution in 2020 (56% of the 18 eligible residents). The curriculum consisted of a one-hour didactic lecture and one-hour hands-on surgical skills training with fresh frozen cadavers. Residents were evaluated in three domains: 1) knowledge, 2) surgical skills, and 3) confidence. Knowledge, confidence, and resident satisfaction were evaluated with pre- and post-surveys. The bladder model, derived from the ACOG Simulation Working Group, was used to evaluate surgical skills at baseline and at completion of the curriculum. Results: Across all three PGY levels, statistically significant improvements were observed in knowledge, surgical skills, and confidence after didactic and cadaver education (p = 0.001, p Conclusions: Educating and training OBGYN residents to manage and repair cystotomies can be challenging given the low incidence of injury in the operating room. The cadaver surgical skills curriculum was an effective training module and remains an important component of skills training in conjunction with simulation and traditional didactic sessions.

IATROGENIC URINARY TRACT INJURY IN OBSTETRIC AND GYNECOLOGICAL PROCEDURES: FIVE-YEAR- EXPERIENCE FROM TWO UNIVERSITY HOSPITALS

Background: Owing to improvements in gynecological and obstetric techniques that help to prevent urinary tract injury and immediate recognition and repair of any injury occur, long-term complications are less frequent nowadays. Aim of the Work: To evaluate the role and importance of the presence of a urogynecology team in management of Obstetrics and gynecology cases with high risk of urological injuries for preoperative assessment, intra operative management and post operatively for follow up of cases repaired and cases need late management like cases presented with urinary tract fistulae. Patients and Methods: This retrospective study included all patients with genitourinary injuries following obstetric and gynecologic procedures that were treated at the Department of Urology and department of obstetrics and gynecology, Al-Hussein and Sayed Galal University Hospitals during the past 5 years. All cases with urological injuries were managed by urogynecological team of urology department of Al-Azhar Cairo University. Results: In our study we detected 97 cases. We found 35 patients (36.1 %) were complicated in gynecological procedures while 62 patients (63.9%) were complicated in obstetric procedures, As regard our study three types of injuries were detected ureteric injuries (8.2%), bladder injuries (27.8%) and fistula formation (63.9%). Conclusion: Complicated gynecological and obstetric procedures with high risk of urological injuries should be managed in collaboration between obstetric ,gynecological and urogynecological teams for: preoperative assessment or intervention like; endoscopic stent fixation in cases with risk of injury, early detection of any urological injuries in all gynecological and obstetric procedures, early intervention and management of all types of urological injuries and follow up all managed patients and assessment and preparation of all cases need late repair.

The urological complications of vaginal birth after cesarean (VBAC) - a literature review.

The appearance of urological complications is a major problem in obstetrics and gynecologic surgery; the bladder is the most common damaged organ. Due to a continuous increase in the rate of cesareans, the incidence of urologic complications will be potentially higher. We reviewed the most important risk factors for urinary tract injury and analyzed the strategies necessary to avoid these situations during vaginal birth after cesarean (VBAC). The risks and benefits of VBAC should be balanced before deciding the mode of delivery.