Urinary tract injury in gynecologic surgery: Evaluation and management
- Donna Gilmour, MD, FRCSC
Donna Gilmour, MD, FRCSC
- Associate Professor
- Department of Obstetrics and Gynecology
- Dalhousie University
- Section Editors
- Linda Brubaker, MD, FACS, FACOG
Linda Brubaker, MD, FACS, FACOG
- Section Editor — Urogynecology and Pelvic Organ Prolapse
- Dean and Professor of Obstetrics and Gynecology
- Stritch School of Medicine Loyola University, Chicago
- Howard T Sharp, MD
Howard T Sharp, MD
- Section Editor — Gynecologic Surgery
- Professor and Vice Chair for Clinical Activities
- Department of Obstetrics and Gynecology
- University of Utah Health Sciences Center
Urinary tract injuries are reported in approximately 1 percent of women who undergo pelvic surgery . Intraoperative discovery of injury permits prompt repair. Delayed diagnosis of urinary tract injuries is of greater concern, since they may result in genitourinary fistula formation or severe renal complications.
The evaluation and management of urinary tract injury in gynecologic surgery are reviewed here. Prevention of urinary tract injury, urinary tract injuries during advanced procedures performed for urinary incontinence, pelvic organ prolapse, or gynecologic malignancy, as well as during obstetric procedures, are discussed separately. (See "Urinary tract injury in gynecologic surgery: Prevention" and "Radical hysterectomy" and "Cesarean delivery: Technique" and "Operative vaginal delivery".)
Screening for injury with cystoscopy — The routine intraoperative use of cystoscopy for women undergoing major gynecologic surgery has been proposed as a secondary preventive measure for urinary tract injury [2,3]. Cystoscopy detects a greater proportion of injuries than visual inspection of the urinary tract. Visual inspection detects a greater proportion of bladder injuries than ureteral injuries. This was illustrated in two prospective series of hysterectomy (abdominal, vaginal, or laparoscopic) in which cystoscopy was used routinely (n = 839 and 471) [2,4]. Visual inspection of the urinary tract injury failed to detect 87 to 93 percent (7 of 8 and 14 of 15) of ureteral injuries and 62 to 65 percent of bladder injuries (15 of 24 and 11 of 17) that were subsequently diagnosed with cystoscopy [2,3]. Only one injury in each series was not detected by either visual inspection or cystoscopy and each of these women presented postoperatively with a genitourinary fistula.
Cystoscopy detects injuries that require repair, as well as others that would likely not result in clinical consequences (eg, a transmural bladder suture that would absorb if not removed). Despite the potential for overdetection, however, it appears that most injuries detected by routine cystoscopy are clinically significant. In the prospective studies described in the preceding paragraph, the majority of ureteral injuries (nearly all of which were detected solely by cystoscopy) were likely to require repair rather than heal spontaneously (transection, crush injury, ligation: 9 of 15 and 7 of 8 versus kinking: 6 of 15 and 1 of 8). Only one of the studies specified which bladder injuries were detected solely by cystoscopy . The majority of these injuries were also likely to require versus not require treatment (cystotomy: 9 of 11 versus abrasion or transmural suture: 2 of 11). All five of the bladder injuries detected by cystoscopy were cystotomies, rather than more subtle injuries.
When routine intraoperative cystoscopy is used, it appears that there is a reduced rate of urinary tract injuries discovered postoperatively. A systematic review of 47 retrospective studies of gynecologic surgery evaluated the effect on diagnosis of urinary tract injury with routine use of intraoperative cystoscopy . The rate of urinary tract injury diagnosed postoperatively was lower in studies with versus without routine cystoscopy: bladder injury (0.8 versus 2.2 per 1000 procedures) and ureteral injury (1.0 versus 2.2 per 1000). This rate combines data for several types of procedures (eg, hysterectomy, prolapse repair), which may obscure procedure-specific differences. This analysis was also limited by the use of retrospective data, which may have omitted complications (eg, patients who presented to other institutions).
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- INTRAOPERATIVE EVALUATION
- Screening for injury with cystoscopy
- Findings suggestive of injury
- Inspection of the urinary tract
- Intravesical or intravenous dye
- POSTOPERATIVE RECOGNITION OF INJURY
- Clinical manifestations
- Postoperative evaluation
- - Physical examination
- - Laboratory evaluation
- - Cystoscopy
- - Imaging studies
- Intraoperative versus postoperative management
- Antibiotic prophylaxis
- Ureteral injury
- Bladder injury
- - Bladder dome
- - Bladder trigone
- - Neurogenic bladder dysfunction
- Urethral injury
- SUMMARY AND RECOMMENDATIONS