Urological injuries during obstetric and gynaecological surgical procedures.
Urological injuries during obstetric and gynaecological operations carried out between Jan. '88 to Dec. '88, at a hospital involved in resident teaching programmes were analysed retrospectively. Each case was reviewed for predisposing factors, location and type of injury, time and method of recognition and management. Fifteen injuries were documented in 892 gynaecological procedures and 296 obstetric procedures. Twelve injuries occurred during gynaecological operations whereas 3 occurred during obstetric operations. Thirteen were bladder injuries and two were ureteric injuries. Infiltrating carcinoma of cervix, pelvic adhesions, adhesions because of previous operations and distorted anatomy, were the important risk factors.
The close cmbryo-logic development and anatomic proximity of the urinary and genital organs, predisposes the urinary tract to injury during surgical procedures in the female pelvis. It is difficult to estimate the true incidence of such injuries; the quoted incidence of ureteral injury in gynaecological operations is 0.43% (0.2-0.5%) and of bladder injury is 0.5-1%.
Incidence of ureter and bladder injury in obstetric operations is 0.25% and 0.3% respectively. Urological injuries occurred during both obstetric and gynaecological operations carried out between Jan. 88-Dec. 88, were analysed retrospectively and are presented here.
Case papers of patients, who had undergone obstetric or gynaecological procedures between Jan. and Dec. 88 were analysed for incidence of urological injury. For such cases past medical and surgical history, disease process, indication for the initial surgery and the type of procedure done were recorded. Each injury was evaluated with respect to its cause (i.e. cutting, crushing, ligating etc) and its location. The time of recognition of the injury, the method of repair and the outcome were also recorded.
During the year 1988 in our institution 607 vaginal hysterectomies, 77 exploratory laparotomies, 56 operations for stress urinary incontinence and 14 Wertheim's operations were performed. In addition, there were 292 lower segmental caesarean sections (LSCS) and 4 obstetric hysterectomies. There were 15 urological injuries (Table 1). The incidence of bladder and ureteric injuries in gynaecological surgery was 1.23% and 0.11% respectively, whereas in obstetric surgery incidence of bladder and ureter injury was 0.67% and 0.33% respectively.
Of the 13 bladder injuries, 12 were recognised on the table. They were sutured immediately by the gynaecologist, and healed well with continuous post-operative bladder drainage.
The bladder injury which occurred during the Burch's repair was recognised post-operatively because of post-operative urine leak through the abdominal wound. The leaking stopped with continuous wide bore (18 F Foley's) bladder catheterization and the patient did not require any operative treatment.
The gynaecological ureteric injury occurred during Wertheim's operation, when the ureter was accidentally transected near the uterine vessels. The injury was recognised on the table. Ureteroneocystostomy was done by a urologist. However, patient had postoperative leak, hence a nephrostomy had to be performed. Another ureteric injury occurred during obstetric hysterectomy and internal iliac ligation, wherein ureter was partially transected. It was recognised on the table and was repaired by a urologist. In these patients certain predisposing factors were noticed viz. infiltrating carcinoma of cervix, pelvic adhesions, distorted anatomy like in cases of procedentia of the uterus, repair of the bladder, previous operations (e.g. exploratory laparotomy, LSCS) causing altered anatomy and adhesions.
Close anatomic association of genital and urinary organs, predisposes the urinary tract to injury, during pelvic surgery.
The factors, which make one suspect ureteric injury on the table, are leaking of the urine in the field of operation or dilatation of the proximal portion of the ureter. To detect this one should try and visualise the ureter all along its course in case of an abdominal surgery. A diuretic can be administered parenterally and the ureter can be observed for peristalsis, proximal dilatation or a leak.
Injury to the bladder on the table may be suspected if there is a leakage of urine. In these cases, the suspected area must be observed carefully and in case of doubt the bladder should be filled with a dye like methylene blue to identify the site of injury.
Bilateral ureteral ligation is evident by post-operative anuria. Patients with unilateral ureteral injury may present with persistent fever, pain in the flanks, unexplained Haematuria, lump in the abdomen or leakage of urine per vaginum. Bladder injuries gone unnoticed during surgery, manifest with postoperative urinary incontinence or rarely with menouria. The diagnosis of these injuries can be reached by proper per speculum examination: three swab test, cystoscopy, intravenous urography. Renal function tests should also be performed in these patients.
Certain precautions to be taken to prevent urinary tract injuries and post-operative fistulae formation are:
* A Thorough knowledge of anatomy and common sites where urinary injuries are likely to occur is essential.
* The patients at high risk should be identified. These are the cases with possibility of altered anatomy, fibrosis or direct extension of disease process as in cases of chronic pelvic inflammatory disease, endometriosis, large fibroids especially in the broad ligament, previous pelvic surgery, malignancy, previous irradiation and congenital abnormalities of urogenital system.
* A complete pre-operative evaluation of high risk patients (renal function tests, IVP, cystoscopy, ureteric catheterization) should be done.
* Only a simple precaution of emptying the bladder prior to surgery can prevent many a bladder injuries.
* Whenever prolonged surgery is anticipated, an indwelling catheter is mandatory.
* Urinary output should be properly monitored during the operation.
* Gynaecologist should be ureter-conscious. There should be good, adequate pelvic exposure and direct visualisation of ureters in the high risk cases. A proper surgical technique should be followed.
In spite of these precautions, the bladder or ureter may get injured during surgery. Failure to recognise the injury is certainly negligence on the part of the surgeon. One should be on his/her guard not to overlook such incidence. This can prevent many postoperative fistulae.