Urologic Injuries Research Articles

Laparoscopic Hysterectomy Following Robotic Radical Trachelectomy

<h3>Study Objective</h3> To demonstrate safe laparoscopic technique in performing hysterectomy following a previous radical trachelectomy. <h3>Design</h3> Stepwise demonstration using narrated video footage. <h3>Setting</h3> An academic safety net county hospital. <h3>Patients or Participants</h3> A 38-yo G5P0050 with a history of Stage 1B1 squamous cell carcinoma of the cervix was treated with robotic radical trachelectomy in 2011. She represented ten years later with abnormal uterine bleeding from a large prolapsing fibroid requiring multiple blood transfusions. Patient desires to proceed with definitive surgical management and underwent laparoscopic hysterectomy, bilateral salpingectomy, and cystoscopy. <h3>Interventions</h3> In certain cases of cervical cancer, patients can be offered fertility sparing options such as trachelectomy. Following radical dissection of the parametria, pelvic anatomy becomes distorted due to the development of fibrotic tissue. Additionally, following a trachelectomy a colpotomizer cup cannot be used to help lateralize and protect the ureters from inadvertent injury. Therefore, a completion hysterectomy has an elevated risk of urologic injury. We demonstrate a surgical technique to perform a completion hysterectomy laparoscopically. 1. Ureteral stent placement aids in identification of the ureters in the previously dissected surgical field. 2. Identification of pelvic anatomy and restoring normal anatomy is vital in performing a completion hysterectomy laparoscopically. <h3>Measurements and Main Results</h3> The patient underwent a laparoscopic hysterectomy, bilateral salpingectomy, bilateral ureterolysis, and cystoscopy without intraoperative complications. Her postoperative course was uncomplicated and had no further complaints at her six-week postoperative visit. <h3>Conclusion</h3> This case demonstrates a surgical technique to perform a laparoscopic hysterectomy following a robotic radical trachelectomy.

Systematic review of urological injury during caesarean section and hysterectomy

Introduction and hypothesisWe aim to review iatrogenic bladder and ureteric injuries sustained during caesarean section and hysterectomy.MethodsA search of Cochrane, Embase, Medline and grey literature was performed using methods pre-published on PROSPERO. Eligible studies described iatrogenic bladder or ureter injury rates during caesarean section or hysterectomy. The 15 largest studies were included for each procedure sub-type and meta-analyses performed. The primary outcome was injury incidence. Secondary outcomes were risk factors and preventative measures.ResultsNinety-six eligible studies were identified, representing 1,741,894 women. Amongst women undergoing caesarean section, weighted pooled rates of bladder or ureteric injury per 100,000 procedures were 267 or 9 events respectively. Injury rates during hysterectomy varied by approach and pathological condition. Weighted pooled mean rates for bladder injury were 212–997 events per 100,000 procedures for all approaches (open, vaginal, laparoscopic, laparoscopically assisted vaginal and robot assisted) and all pathological conditions (benign, malignant, any), except for open peripartum hysterectomy (6,279 events) and laparoscopic hysterectomy for malignancy (1,553 events). Similarly, weighted pooled mean rates for ureteric injury were 9–577 events per 100,000 procedures for all hysterectomy approaches and pathologies, except for open peripartum hysterectomy (666 events) and laparoscopic hysterectomy for malignancy (814 events). Surgeon inexperience was the prime risk factor for injury, and improved anatomical knowledge the leading preventative strategy.ConclusionsCaesarean section and most types of hysterectomy carry low rates of urological injury. Obstetricians and gynaecologists should counsel the patient for her individual risk of injury, prospectively establish risk factors and implement preventative strategies.

Urological Injuries in Obstetrical and Gynaecological Surgery at Tertiary Care Hospital

Objectives: To determine the frequency of urological injuries in obstetrical and gynaecological surgery. Study Design and Setting: The Cross Sectional Study was conducted at Department of Obstetrics &amp; Gynaecology, Jinnah Postgraduate Medical Center, Karachi for duration of 6 months from 31st December 2020 to 30th June 2021. Methodology: A total of 142 patients selected between the ages of 25 to 55 years of age were included. In this study all patients were included who fulfilled the inclusion criteria undergoing obstetric(cesarean section) &amp; gynecological surgeries (laparatomies &amp; hysterectomies). They were enrolled after taking written and informed consent. Risk factors for urological injuries were assessed in terms of indication (risk for surgery), site of urologic injury, duration of surgery and time interval after surgery. Patients having urological injury from other than obstetric and gynecologic surgeries and those who did not give consent were excluded. Results: Age range in this study was from 25 to 55 years with mean age of 40.20 ± 6.92 years. Majority of the patients 77 (54.23%) were between 41 to 55 years of age. Mean duration of surgery was 62.16 ± 14.52 minutes. Mean time interval after surgery was 37.51± 13.89 hours. In this study, frequency of ureteral injury, urinary bladder injury and mixed injury in obstetrical and gynaecological surgery was found in 01 (0.70%), 19 (13.38%) and 01 (0.70%) patients respectively. Conclusion: This study concluded that knowledge of pelvic anatomy, careful dissection and patience in difficult cases are the key factors to anticipate and prevent injury.

S1871 A Case of Ketamine-Induced Cholangiopathy: A Novel Diagnosis Associated With Chronic Recreational Ketamine Use

Introduction: Ketamine, an analgesic commonly used for procedural sedation, has become a popular agent for recreational use among young adults. The diagnosis of ketamine-induced cholangiopathy is uncommon. We report a case of a young adult with clinical and radiological features consistent with cholangiopathy induced by chronic ketamine use. Case Description/Methods: A 19-year-old female with past medical history of peptic ulcer disease presented to emergency department (ED) with one year history of severe epigastric abdominal pain. On further questioning, patient reported chronic recreational ketamine use. Physical exam revealed mild epigastric and RUQ tenderness. Liver function test demonstrated elevated alkaline phosphatase of 174 U/L, AST of 237 U/L and ALT of 224 U/L. All other hematology and chemistry results were within normal limits. RUQ ultrasound showed minimally dilated common bile duct (CBD). An MRCP was obtained, showing mild-to-moderate dilatation of intra-/extra-hepatic bile ducts and dilated cystic duct (CD) without obvious intraductal calculi (Figure A). Endoscopic ultrasonography (EUS) was performed showing dilatation of CBD, minimal dilatation of common hepatic duct, and minimal dilatation of CD, once again without obvious calculi (Figure B). These imaging findings are compatible with ketamine-induced cholangiopathy. After being admitted for 6 days, the patient demonstrated significant improvement in her abdominal pain, with gradually improving liver test values. She was discharged with the recommendation to abstain from ketamine use and outpatient gastroenterology follow-up. Discussion: Chronic exposure to ketamine has been known to cause urologic injury, referred to as ketamine-induced ulcerative cystitis. In comparison to the urologic complications of chronic ketamine use, its effects on the biliary system have been less commonly reported. Existing reports have mostly come from regions of Asia where recreational ketamine use is more prevalent. The nonspecific gastrointestinal symptoms that are typically reported by patients with ketamine-induced cholangiopathy may make the diagnosis more challenging to recognize. Due to increasing recreational ketamine use among young adults in recent years, cases of ketamine-induced cholangiopathy are likely to rise. Therefore, a better understanding of the clinical and radiological features of this condition are needed to allow for prompt recognition of ketamine-induced cholangiopathy.Figure 1.: A. MRCP image showing mild-to-moderate dilatation of the intrahepatic and extrahepatic bile ducts and dilatation of the cystic duct. There are no visible stones or evidence of other etiology for the dilatation. B. EUS image displaying CBD dilatation measuring up to 10.6 mm in the head region, with smooth tapering to the ampulla where it measured 2.7 mm.

Frequency of Urological Injuries in Obstetrical and Gynaecological Surgery at Tertiary Care Hospital

Introduction: Due to the anatomical proximity of the urogenital organs, reproductive and obstetrical procedures have been intrinsically linked to urological damage. The connection of the genital and urine tracts anatomically and during embryologic development makes the urinary system particularly vulnerable to damage during surgical procedures in the female. Urinary bladder and ureter injuries are a common post-gynecological or obstetrical surgery complication. Objectives: To determine the frequency of urological injuries in obstetrical and gynaecological surgery. Materials &amp; Methods: A total of 142 women who are undergoing obstetric and gynecologic surgeries, 25 to 55 years of age were included. Patients having urological injury from other than obstetric and gynecologic surgeries were excluded. In this study all patients were included who are fulfilling inclusion criteria undergoing obstetric (cessarean section) &amp; gynaecologic (laprotomies &amp; hysterectomies) were enrolled after taking written informed consent. Risk factors for urological injuries were assessed in terms of indication (risk for surgery), site of ureteric injury, location of bladder injury was noticed. Results: Age range in this study was from 25 to 55 years with mean age of 40.20 ± 6.92 years. Majority of the patients 77 (54.23%) were between 41 to 55 years of age. Mean duration of surgery was 62.16 ± 14.52 minutes. Mean time interval after surgery was 37.51 ± 13.89 hours. In this study, frequency of ureteral injury, urinary bladder injury and mixed injury in obstetrical and gynaecological surgery was found in 20 (14.08%), 14 (9.86%) and 07 (4.93%) patients. Conclusion: This study concluded that understanding pelvic anatomy, detailed dissection, and patience in challenging cases are the essential elements to predict and reduce damage. Keywords: obstetrical and gynaecological surgery, ureteric injury, bladder injury.

The impact of obesity class on perioperative outcomes in minimally invasive surgery for endometrial cancer (594)

<b>Objectives:</b> Minimally invasive surgeries (MIS) have been shown to reduce complication rates and length of hospital stays in patients with obesity. However, there is limited data analyzing outcomes for specific obesity classes (Class I [30-34.9 kg/m2], Class II [35-39.9 kg/ m2], and Class III [≥40.0 kg/m2]). This study aimed to evaluate differences in perioperative outcomes, stratified by obesity class, in obese patients undergoing minimally invasive surgery for endometrial cancer. <b>Methods:</b> This is an IRB-exempt retrospective cohort study investigating women who underwent MIS for treatment and staging of endometrial cancer. Inclusion criteria were age 18 years or older, MIS performed for endometrial cancer, and BMI of 30 kg/m² or greater. We excluded those who underwent neoadjuvant chemotherapy or radiation therapy. Data were collected from the de-identified National Surgical Quality Improvement Program (NSQIP) between 2012-2018. The primary outcome was intraoperative complications, such as bowel injury, urologic injury, and conversion to laparotomy. Secondary outcomes were unplanned re-admission, unplanned reoperation, and postoperative infection. Chi-square and Kruskal- Wallis rank-sum tests were used as appropriate for categorical and continuous variables, respectively. P-values of < 0.05 were considered significant. Statistical analysis was performed using SAS 9.4v (SAS Institute Inc., Cary, NC, USA). <b>Results:</b> We identified 12,956 patients who met the inclusion criteria within NSQIP. Of these, 29.3% (<i>n</i> = 3,801) patients were Class I (avg. BMI 32.5 kg/m²), 26.7% (<i>n</i>= 3,467) were Class II (avg. BMI 37.4 kg/m²), and 43.9% (<i>n</i> = 5,688) were Class III (avg. BMI 47.5 kg/m²) (see Table 1). The average ages were 64.1, 62.7, and 59.2 years old for Class I, II, and III, respectively. Intraoperatively, there were no statistically significant differences among the three classes for bowel injury, urologic injury, or conversion to laparotomy (p= 0.575). Re-admission rates were higher for Class III patients (4.1%) than Class I and II (3.1%, p=0.005). There was a higher rate of superficial surgical site infection in Class III obese patients versus Class I and II (0.6% vs 1.1% vs 1.3%, respectively; p=0.005). There were no significant differences among Class I, Class II, and Class III obesity for deep wound (0.1%, 0.1%, and 0.3%, respectively, p=0.052) and organ space (0.9%, 1.2%, 1.4%, respectively, p=0.101) surgical site infections. <b>Conclusions:</b> In conclusion, among obese women undergoing MIS for endometrial cancer, there were no statistical differences between the risks of intraoperative complications, such as bowel injury, urologic injury, and conversion to laparotomy, when assessing the different obesity classes. However, postoperatively, patients with Class III obesity had higher re-admission rates and superficial surgical site infections when compared to Class I and Class II obese patients.

Etiology, characteristics and management of ureteric injury: experience from a nationwide study.

BackgroundTo investigate the common etiologies, characteristics, and management of ureteric injury.MethodsA nationwide study was performed in 38 medical centers from Mar 2017 to Mar 2019. The data of patients with ureteric injury were retrospectively collected.ResultsOverall, 294 patients were included in this study. Ten cases (3.4%) were due to abdominal injuries, and 284 cases (96.6%) were due to iatrogenic injuries, including 48.6% from urological procedures, 41.9% from gynecological procedures, 6.3% from general surgery, and 3.2% from other treatments. Most urological injuries (79.7%) were caused by endourological procedures. Injury occurred in the distal ureter in 178 cases (60.5%), the mid-ureter in 31 cases (10.5%), and the proximal ureter in 85 cases (28.9%). Only 51 patients (17.3%) were diagnosed immediately during primary surgery. Immediate ureter reconstruction was performed in 30 patients (58.8%), while delayed urinary diversion was performed in 148 patients (60.9%) in the delayed diagnosis group. The side and the location of the injury were different between the urological and nonurological injury groups (P<0.001). Ureteric injuries were diagnosed timelier in the urological group than in the nonurological group (P=0.037).ConclusionsIatrogenic injury was the most common cause of ureteric injury. The majority of iatrogenic injuries were caused by urological procedures and were primarily due to aggressive endourological techniques. Depending on the condition of the patient, the time of diagnosis, and the location and length of the ureteric injury, different management strategies should be applied.

Opioid and Multimodal Analgesia Use Following Urological Trauma

ObjectiveTo examine opioid use following Urological trauma. Increased opioid use is associated with inferior outcomes and risk of dependence, particularly in vulnerable populations. In contrast, multimodal analgesia following trauma allows decreased pain and readmission. Currently there is a paucity of data describing opioid usage following urological trauma. The purpose of this study was to assess utilization of opioids and multimodal pain regimens following urologic trauma. MethodsWe retrospectively examined 116 patients hospitalized following urologic trauma from 2016-2021. Inpatient and discharge utilization of opioids, multimodal analgesia and length of stay were stratified by affected organ. Analyses were performed in STATA with p<0.05 reaching significance. Results116 patients were assessed; 84 (72.4%) required surgery. In the first 10 days, bladder injuries incurred higher mean and median OMEQ than other urological injuries. In nearly all groups, OMEQ prescribed at discharge is less than average inpatient OMEQ. Eighty-six (74.1%) patients received at least 2 different opioid medications while inpatient. Those with a history of opioid use received a significantly higher OMEQ dose per day (p<0.001). There were no significant differences between opioid prescribing patterns or average OMEQ dosages prescribed at discharge between those patients managed either surgically or non-operatively. Only 24 (20.7%) patients met the criteria for utilization of multimodal analgesia. ConclusionMultimodal analgesia is severely underutilized following urological trauma. Combined with the development of opioid tolerance over long hospital stays, this creates an avenue for opioid misuse following discharge and provides an opportunity for improvement.

MP20-01 OPIOID AND MULTIMODAL ANALGESIA USE FOLLOWING UROLOGICAL TRAUMA

You have accessJournal of UrologyCME1 May 2022MP20-01 OPIOID AND MULTIMODAL ANALGESIA USE FOLLOWING UROLOGICAL TRAUMA Mary Rostom, Andrew Gabrielson, Ryan Fransman, Shirley Wang, Albert Holler, Isabella Pan, Nikita Gupta, Joseph Sakran, and Andrew Cohen Mary RostomMary Rostom More articles by this author , Andrew GabrielsonAndrew Gabrielson More articles by this author , Ryan FransmanRyan Fransman More articles by this author , Shirley WangShirley Wang More articles by this author , Albert HollerAlbert Holler More articles by this author , Isabella PanIsabella Pan More articles by this author , Nikita GuptaNikita Gupta More articles by this author , Joseph SakranJoseph Sakran More articles by this author , and Andrew CohenAndrew Cohen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002553.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Following trauma, increased opioid use is associated with inferior outcomes and increased risk of opioid dependence, particularly in vulnerable populations. In contrast, multimodal analgesia following trauma results in decreased pain and readmission. Currently there is a paucity of data describing opioid usage following urological trauma. We assess utilization of opioids and multimodal pain regimens following urologic trauma. METHODS: We retrospectively examined 121 patients hospitalized following urologic trauma from 2016-2021. Inpatient and discharge utilization of opioids, multimodal analgesia and length of stay were stratified by affected organ. Analyses were performed in STATA with p<0.05 reaching significance. RESULTS: 121 patients were assessed; affected organ and mechanism of injury are shown in Table 1. Displayed in Figure 1, though differences in average opioid morphine equivalence (OMEQ) per day are not significant (p=0.368), bladder injuries incurred higher mean OMEQ than other urological injuries with 14 (88%) requiring surgery and 8 (50%) associated with pelvic fracture. ISS’s were significantly different between trauma groups (p=0.011) with multiorgan trauma having the highest average. In nearly all groups, OMEQ prescribed at discharge is less than average inpatient OMEQ. Shown in Table 2, 87 (73%) patients were given acetaminophen in the hospital, but only 12 (10%) used non-opioid NSAIDs despite significantly lower average OMEQ prescriptions per day with acetaminophen use (p=0.009). CONCLUSIONS: Multimodal analgesia is severely underutilized following urological trauma. Combined with the development of opioid tolerance over long hospital stays, this creates an avenue for opioid misuse following discharge and opportunities for improvement. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e317 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mary Rostom More articles by this author Andrew Gabrielson More articles by this author Ryan Fransman More articles by this author Shirley Wang More articles by this author Albert Holler More articles by this author Isabella Pan More articles by this author Nikita Gupta More articles by this author Joseph Sakran More articles by this author Andrew Cohen More articles by this author Expand All Advertisement PDF DownloadLoading ...

Learning Curve of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy – an Analysis of Critical Perioperative and Surgical Outcomes among 155 Peritoneal Surface Malignancy Patients Treated at a Tertiary Care Cancer Centre

AimsVarious factors can influence the learning curve of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Initiating CRS and HIPEC programmes in low- and middle-income countries is challenging due to resource constraints and limited availability of expertise. We present our experience of CRS and HIPEC from a learning curve perspective among a cohort 155 peritoneal surface malignancy patients. Materials and methodsPatients undergoing CRS and HIPEC between May 2015 and February 2019 were included in the study. Patients were divided into two consecutive cohorts: the first 73 cases comprised the learning phase, group 1; the subsequent cohort of 82 patients were considered as the implementation phase, group 2. A comparative analysis of clinical and surgical outcome parameters was carried out between the two groups. ResultsThe clinical spectrum was comparable among group 1/group 2. Most were ovarian (56.8%), colorectal (13.5%) and appendiceal (11.0%) malignancies. Group 2 had a higher number of moderate to high peritoneal cancer index patients (34.1% versus 19.1%), total peritonectomies (48.8% versus 45.2%), multi-visceral resections (colonic 41.5% versus 27.4%, small bowel 25.6% versus 19.1%, diaphragmatic 8.5% versus 6.5% and hepatic resections 8.5% versus 2.7%) and completeness of cytoreduction 0/1 rates (97.6% versus 93.1%). A lower incidence of intraoperative urological injuries (2.6% versus 12.3%) was noticed in group 2 (P = 0.007). Non-significant improvements seen in group 2 included surgery duration (6.0 ± 1.3 h versus 6.4 ± 1.7 h), intensive care unit stay (1.3 ± 1.1 days versus 1.8 ± 1.5 days), overall hospital stay (8.1 ± 0.9 days versus 8.8 ± 1.4 days) and reduction in Clavien-Dindo grade 3–4 complications (25.4% versus 36.9%). ConclusionsThe results of the current study indicate that by implementing standard protocols and mentoring by an experienced team, a learning curve of CRS and HIPEC can be achieved in fewer than 75 cases. The baseline expertise of the treating team can also influence the learning curve.

Risk Factors for Urologic Injury in Women Undergoing Hysterectomy for Benign Indication.

To investigate risk factors associated with urologic injury in women undergoing hysterectomy for benign indication. A retrospective cohort study for the period of 2011-2018 was conducted using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Women without urologic injury were compared with women with injury. A pre-specified multivariable logistic regression model, controlling for key patient demographic factors and intraoperative variables, was used to assess for surgical factors associated with urologic injury. Among 262117 women who underwent hysterectomy for benign indication, 1539 (0.6%) sustained urologic injury. On average, patients with urologic injury were younger, had lower body mass index (BMI), and more frequently underwent a transabdominal surgical approach. Patients who underwent total hysterectomy had increased odds of urologic injury than those who underwent subtotal hysterectomy (adjusted OR [aOR] 1.49; 95% confidence interval [CI] 1.21-1.84). Patients with class III obesity had lower odds of injury than patients with normal BMI (aOR 0.64; 95% CI 0.51-0.80). For risk of urologic injury, an interaction was observed between surgical approach and surgical indication. Abdominal compared with laparoscopic approach was associated with urologic injury for women with endometriosis (aOR 2.98; 95% CI 1.99-4.47), pelvic pain (aOR 3.51; 95% CI 1.74-7.08), menstrual disorders (aOR 4.33; 95% CI 1.68-11.1), and fibroids (aOR 2.28; 95% CI 1.72-3.03). Vaginal compared with laparoscopic approach was associated with increased odds of injury for women with menstrual disorders (aOR 7.62; 95% CI 1.37-42.5). While the risk of urologic injury during hysterectomy for benign indication is low, the risk is dependent on patient disease factors and surgical approach.

Quantifying Urinary and Sexual Dysfunction After Pelvic Fracture.

To quantify the severity of urinary and sexual dysfunction and to evaluate the relationship between urinary and sexual dysfunction, injury, and treatment factors in patients with pelvic fracture. Prospective cohort study. Level 1 trauma center. One hundred thirteen patients with surgically treated pelvic fracture (65.5% OTA/AO 61B fractures; 7 open fractures; 74 men). Surgical pelvic stabilization. The 36-Item Short Form Health Survey and International Consultation Incontinence Questionnaire responses were collected at baseline, 6 months, and 1, 2, and 5 years. Patients were scored on symptoms of voiding and incontinence, and filling (for women), to derive urinary function. Sexual function was scored as a single domain. Both genders reported urinary and sexual bothersome symptoms. Regression analysis was used to isolate the importance of predictive factors on urinary and sexual function, urinary and sexual bother, and their impact on quality of life. Patients with pelvic fracture have significant urinary and sexual dysfunction, which is sustained or worsens over time. Male urinary function was predicted by Injury Severity Score (P = 0.03) and 61C fracture (odds ratio: 3.23, P = 0.04). Female urinary function was predicted by urinary tract injury at admission (odds ratio: 7.57, P = 0.03). Neurologic injury and anterior fixation were identified as significant predictors for male sexual function and sexual bother, whereas urological injuries were important in predicting female urinary and sexual bother (P < 0.01). Sexual function (P = 0.02) and sexual bother (P < 0.001) were important predictors of overall mental well-being in men. Urinary and sexual dysfunction are prevalent and sustained in men and women and do not follow the prolonged slow recovery trajectory seen in physical function. Male urinary and sexual dysfunction was closely tied to neurologic injury, whereas female urinary and sexual dysfunction was predicted by the presence of a urinary tract injury. Urinary and sexual dysfunction were important to overall mental well-being in men. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous screw fixation of pubic symphysis disruption: A preliminary report

BackgroundPercutaneous techniques are commonly used to treat pelvic ring disruptions but are not mainstream for fixation of pubic symphysis disruption worldwide. Potential advantages include less blood loss and lower risk of surgical site infection, especially in the morbidly obese or multiply injured patient. This study was performed to describe the clinical and radiographic outcomes of patients after percutaneous reduction and screw fixation of pubic symphysis disruption and to evaluate the preliminary safety and efficacy of this technique and its appropriateness for further study as an alternative method of fixation. MethodsA retrospective review was performed to identify all patients who underwent percutaneous fixation of pubic symphysis disruption by two surgeons at an academic Level I trauma center over a 3-year period. Patients underwent percutaneous reduction and fixation of the pubic symphysis using 1 or 2 fully or partially threaded 5.5, 6.5, or 7.3 mm cannulated screws in a transverse or oblique configuration. Associated posterior ring injuries were fixed with trans-sacral and/or iliosacral screws. The primary outcome of interest was loss of reduction, defined as symphysis distance greater than 15 mm measured on final AP pelvis radiograph. Secondary outcomes collected by chart review were operative time, blood loss, vascular or urologic injury, sexual dysfunction, infection, implant loosening or breakage, and revision surgery. ResultsTwelve patients met criteria and primary and secondary outcomes were collected. Mean clinical and radiographic follow-up were 15 months each. One patient lost reduction. Mean operative time and blood loss were 124 min and 29 cc, respectively. No vascular or urologic injuries occurred. Two patients reported sexual dysfunction. No patients became infected or required revision surgery. Four patients underwent implant removal. Seventeen additional patients were excluded due to short follow-up and limited outcomes were collected. Two of these patients lost reduction. Three underwent implant removal. ConclusionThese data support percutaneous reduction and screw fixation of pubic symphysis disruption as a potentially safe and effective method of treatment that warrants further investigation.

Risk Factors for Urological Complications Associated with Caesarean Section-A Case-Control Study.

Background and Objectives: Acute urologic complications, including bladder and/or ureteric injury, are rare but known events occurring at the time of caesarean section (CS). Delayed or inadequate management is associated with increased morbidity and poor long-term outcomes. We conducted this study to identify the risk factors for urologic injuries at CS in order to inform obstetricians and patients of the risks and allow management planning to mitigate these risks. Materials and Methods: We reviewed all cases of urological injuries that occurred at CS surgeries in a tertiary university centre over a period of four years, from January 2016 to December 2019. To assess the risk factors of urologic injuries, a case-control study of women undergoing caesarean delivery was designed, matched 1:3 to randomly selected women who had an uncomplicated CS. Electronic medical records and operative reports were reviewed for socio-demographic and clinical information. Descriptive and univariate analyses were used to characterize the study population and identify the risk factors for urologic complications. Results: There were 36 patients with urologic complications out of 14,340 CS patients, with an incidence of 0.25%. The patients in the case group were older, had a lower gestational age at time of delivery and their newborns had a lower birth weight. Prior CS was more prevalent among the study group (88.2 vs. 66.7%), as was the incidence of placenta accreta and central praevia. In comparison with the control group, the intraoperative blood loss was higher in the case group, although there was no difference among the two groups regarding the type of surgery (emergency vs. elective), uterine rupture, or other obstetrical indications for CS. Prior CS and caesarean hysterectomy were risk factors for urologic injuries at CS. Conclusions: The major risk factor for urological injuries at the time of CS surgery is prior CS. Among patients with previous CS, those who undergo caesarean hysterectomy for placenta previa central and placenta accreta are at higher risk of surgical haemostasis and complex urologic injuries involving the bladder and the ureters.

Perioperative Serum Creatinine Change and Delayed Urologic Complications Following Total Laparoscopic Hysterectomy for Benign Indications.

Objectives:The objective of the study was to investigate the association between perioperative serum creatinine change and delayed urologic complications following total laparoscopic hysterectomy (TLH) for benign indications.Materials and Methods:A total of 510 cases (503 cases without delayed urologic injuries and 7 cases with delayed urologic injuries) in which TLH was performed for benign indications were retrospectively reviewed. The patient characteristics and surgical outcomes were compared between patients with and without delayed urologic injuries. Laboratory markers (serum creatinine level at the preoperative and postoperative periods, white blood cell [WBC] ratio, and C-reactive protein [CRP] ratio) were analyzed to evaluate the diagnostic value of these laboratory markers.Results:There were no statistically significant differences in age, parity, body mass index, the presence of diabetes mellitus, preoperative GnRH agonist use, previous history of abdominal surgery or the performance of adnexal surgery, ASRM score, the presence of cul-de-sac obliteration, operative time, blood loss or weight of the resected specimens between the two groups. The proportions of patients who showed an elevated creatinine level on postoperative day 1 was significantly higher in the delayed urologic injury group (9.9% vs. 57%, P < 0.001). The combination of the three laboratory markers yielded an area under the ROC curve value of 0.75 (95% confidence interval, 0.491–1) in the detection of delayed urologic injuries.Conclusion:A change in the serum creatine level over baseline after surgery may indicate the possibility of urologic injuries. The combination of creatinine change and other factors, such as WBC or CRP would be helpful for detecting urologic complications after TLH.

A novel endoscope-assisted technique for lateral lumbar interbody fusion: feasibility study, technical note, and operative video.

The lateral approach to the spine is generally well tolerated, but reports of debilitating injury to the lumbar plexus, iliac vessels, ureter, and abdominal viscera are increasingly recognized, likely related to the lack of direct visualization of these nearby structures. To minimize this complication profile, the authors describe here a novel, minimally invasive, endoscope-assisted technique for the LLIF and evaluate its clinical feasibility. Seven consecutive endoscope-assisted lateral lumbar interbody fusion (LLIF) procedures by the senior authors were reviewed for the incidence of approach-related complications. One patient had a postoperative approach-related complication. This patient developed transient ipsilateral thigh hip flexion weakness that resolved spontaneously by the 3-month follow-up. No patient experienced visceral, urological, or vascular injury, and no patient sustained a permanent neurological injury related to the procedure. The authors' preliminary experience suggests that this endoscope-assisted LLIF technique may be clinically feasible to mitigate vascular, urological, and visceral injury, especially in patients with previous abdominal surgery, anomalous anatomy, and revision operations. It provides direct visualization of at-risk structures without significant additional operative time. A larger series is needed to determine whether it reduces the incidence of lumbar plexopathy or visceral injury compared with traditional lateral approaches.

Urologic morbidity associated with placenta accreta spectrum surgeries: single-center experience with a multidisciplinary team

Hysterectomy for placenta accreta spectrum may be associated with urologic morbidity, including intentional or unintentional cystostomy, ureteral injury, and bladder fistula. Although previous retrospective studies have shown an association between placenta accreta spectrum and urologic morbidities, there is still a paucity of literature addressing these urologic complications. We sought to report a systematic description of such morbidity and associated factors. This was a retrospective study of all histology-proven placenta accreta spectrum deliveries in an academic center between 2011 and 2020. Urologic morbidity was defined as the presence of at least one of the following: cystotomy, ureteral injury, or bladder fistula. Variables were reported as median (interquartile range) or number (percentage). Analyses were made using appropriate parametric and nonparametric tests. Multinomial regression analysis was performed to assess the association of adverse urologic events with the depth of placental invasion. In this study, 58 of 292 patients (19.9%) experienced urologic morbidity. Patients with urologic morbidity had a higher rate of placenta percreta (compared with placenta accreta and placenta increta) than those without such injuries. Preoperative ureteral stents were placed in 54 patients (93.1%) with and 146 patients (62.4%) without urologic injury (P=.003). After adjusting for confounding variables, multinomial regression analysis revealed that the odds of having adverse urologic events was 6.5 times higher in patients with placenta percreta than in patients with placenta accreta. Greater depth of invasion in placenta accreta spectrum was associated with more frequent and severe adverse urologic events. Whether stent placement confers any protective benefit requires further investigation.

Genitourinary complications in orthopaedic surgery

Genitourinary complications following orthopaedic intervention are uncommon but well-described occurrences and exist on a spectrum of severity. These complications vary depending on the anatomic location and surgical approach, with surgery of the spine, hip, and pelvis of particular concern. Injuries to the urinary tract may present acutely with urinary retention or hematuria. However, they often have a delayed presentation with severe complications such as urinary fistula and recurrent infection. Delayed presentations may place the onus of timely and proper diagnosis on the orthopaedic provider, who may serve as the patient’s primary source of long-term follow-up. Detailed knowledge of anatomy and at-risk structures is key to both preventing and identifying injury. Although iatrogenic injury is not always avoidable, early identification can help to facilitate timely evaluation and management to prevent long-term complications such as bladder dysfunction, obstructive renal injury, sexual dysfunction, and chronic pain. Keywords: urologic injury, bladder injury, genitourinary injury, hip arthroplasty, pelvic ring injuries, spine surgery

Etiology and Ureteral Reconstruction Strategy for Iatrogenic Ureteral Injuries: A Retrospective Single-Center Experience

Objective: To analyze the etiology, characteristics, and ureteral reconstruction strategies of iatrogenic ureteric injuries in a high-volume center. Methods: Between September 2010 and August 2019, we retrospectively collected patients who underwent ureteral reconstruction due to iatrogenic ureteric injuries. Patient profiles, laboratory data, imaging studies, perioperative data, and complications were recorded. Results: Sixty-eight patients were enrolled in this study. The upper, middle, and lower thirds of the ureter were affected in 30, 2, and 36 cases, respectively. Of the 68 ureteric injuries, 69.1% occurred during urological procedures, followed by gynecological procedures, general surgery, radiotherapy, and orthopedic surgery. The majority of urological injuries (41, 87.2%) occurred due to stone removal. There was a significant difference in the age, sex, and location of ureteric injuries between the urological and nonurological groups. The median follow-up time was 17.9 months. The overall symptom remission rate was 91.2% and ranged from 87.5 to 100% for different reconstructive surgeries. Conclusions: Urological procedures were the most common cause of iatrogenic ureteric injury; thus, extra care should be taken. Timely detection and appropriate treatment of the ureteric injuries are necessary. Treatment strategies should be depended on the location and length of injury.

Incidence and Predictive Risk Factors of Postoperative Urinary Retention After Primary Total Knee Arthroplasty

BackgroundPostoperative urinary retention (POUR) after total knee arthroplasty (TKA) may cause urologic injury and delay patient discharge. This study measures the incidence of POUR and identifies predictive risk factors. MethodsTwo-hundred seventy-one consecutive patients undergoing primary unilateral TKA were prospectively enrolled. Bladder scans were performed in the postanesthesia care unit (PACU) and every four hours thereafter. POUR was defined as >400cc with inability to void and was treated with catheterization. Patient demographics, urologic history, operative data, perioperative medications, and bladder scanner volumes were investigated with the univariate and multivariate logistic regression analysis. ResultsFifty-five patients (20%) developed POUR. Compared with non-POUR patients, PACU bladder scan volumes were greater in patients who developed POUR (344cc vs 120cc, P < .001). POUR patients had lower BMI (27.8 vs 29.4, P = .03), longer operative duration (83.9 vs 76.0 minutes, P = .002), and lower ASA scores (2.2 vs 2.4, P = .02). Total intravenous fluid was equivalent between groups (1134cc vs 1185cc, P = .41). POUR patients received less narcotics measured by morphine milligram equivalents (16.1 vs 23.9, P < .001). Fifteen variables including spinal type (bupivacaine and ropivacaine) and paralytic use were not predictive of POUR. Potentially predictive variables included anesthetic types administered (spinal, general, regional, and combination) and perioperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs), glycopyrrolate, and muscle relaxants. The multivariate analysis showed that NSAIDs (P = .05) and glycopyrrolate (P = .04) were significant predictors. ConclusionA significant percentage of patients develop POUR after TKA. Select patient demographics and PACU bladder scanning may identify those at risk. Appropriate pain control and judicious use of perioperative NSAIDs and glycopyrrolate may help minimize the risk of POUR.