Urinary tract injury in gynecologic surgery: Prevention
- 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
The reproductive and urinary tracts in women are closely related anatomically and embryologically . Knowledge of this anatomy plays an important role in the prevention of urinary tract injury during gynecologic surgery. The primary approach to prevention is careful surgical dissection and knowledge of the position of urinary tract structures within the surgical field.
The prevention of urinary tract injury in gynecologic surgery, primarily hysterectomy, will be reviewed here. The evaluation and management of urinary tract injury in gynecologic surgery, 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: Evaluation and management" and "Radical hysterectomy" and "Cesarean delivery: Technique" and "Operative vaginal delivery".)
The overall rate of urinary tract injury associated with pelvic surgery in women is approximately 1 percent . Bladder injury is more common than ureteral injury . However, the exact incidence of these injuries is difficult to ascertain. Reported rates vary depending primarily on the approach to diagnosis of injury and the type of surgery; other factors include patient characteristics and study design.
Injury diagnosed with cystoscopy — Markedly higher rates of urinary tract injuries have been reported in studies in which cystoscopy was routinely performed immediately after the procedure rather than other approaches to diagnosis (typically intraoperative visual inspection). This was illustrated in a systematic review of 47 retrospective studies and two subsequent prospective studies of urinary tract injury during benign gynecologic surgery [1,3,4]. For hysterectomy, studies that used routine cystoscopy found, compared to studies that used other techniques, higher rates of ureteral injury (15 to 18 versus 0.2 to 7 per 1000 procedures) and bladder injury (17 to 29 versus 0.3 to 6 per 1000 procedures).
These findings demonstrate that injuries are underreported when routine cystoscopy is not performed immediately after the procedure. The true incidence is probably higher since cystoscopy does not detect all injuries, particularly partial ureteral obstruction or transection [1,5]. On the other hand, some injuries detected with cystoscopy may be asymptomatic and/or heal spontaneously [1,6,7]. Clinical use of cystoscopy in the diagnosis of operative urinary tract injury is discussed separately. (See "Urinary tract injury in gynecologic surgery: Evaluation and management", section on 'Cystoscopy'.)
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- Injury diagnosed with cystoscopy
- Type of procedure
- RISK FACTORS
- Patient characteristics
- Procedural factors
- Mechanisms of injury
- Sequelae of injury
- APPROACH TO PREVENTION
- PREOPERATIVE EVALUATION
- Informed consent
- Medical history
- Imaging studies
- OPERATIVE SET-UP
- Patient positioning
- Bladder catheter
- Prophylactic ureteral catheters
- OPERATIVE TECHNIQUE
- Avoiding ureteral injury
- - Ligation of the ovarian vessels
- - Ligation of the uterine arteries
- - Vaginal cuff closure
- Avoiding bladder injury
- Identifying a pelvic kidney
- SUMMARY AND RECOMMENDATIONS