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
- Health Sciences Clinical Professor
- University of California, San Diego
- 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: Identification 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 ranges from 0.3 to nearly 1 percent [1,2]. Bladder injury is more common than ureteral injury . However, the exact incidence of these injuries is difficult to ascertain because reported rates vary depending on the approach to diagnosis, the type of surgery, patient characteristics, and study design.
Factors that affect reported incidence
Use of cystoscopy — Cystoscopy (full terminology cystourethroscopy) is associated with a higher detection rate of urinary tract injuries compared with visual inspection alone, particularly for ureteral injuries. In a systematic review and meta-analysis of 79 studies that included multiple types of benign gynecologic surgeries, more than double the number of ureteral injuries were detected with routine use of cystoscopy than without (1.6 versus 0.7 per 1000 surgeries) . An increased detection rate with cystoscopy was also seen for bladder injuries, although the impact was not as large (1.0 versus 0.8 injuries per 1000 surgeries detected with cystoscopy use or non-use).
Clinical use of cystoscopy in the diagnosis of operative urinary tract injury is discussed separately. (See "Urinary tract injury in gynecologic surgery: Identification and management", section on 'Cystoscopy' and "Diagnostic cystourethroscopy for gynecologic conditions", section on 'Procedure'.)
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- Factors that affect reported incidence
- - Use of 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
- SURGICAL TECHNIQUE
- Avoiding ureteral injury
- - Ligation of the ovarian vessels
- - Ligation of the uterine arteries
- - Vaginal cuff closure
- Avoiding bladder injury
- Intraoperative maneuvers
- Identifying a pelvic kidney
- SUMMARY AND RECOMMENDATIONS