TOG - Urinary tract injuries in laparoscopic gynaecological surgery Flashcards
What is the most common visceral injury during laparoscopic surgery and what is the rate of occurrence?
Bladder injury
0.02 - 8.3%
When do most injuries to the bladder occur during laparoscopic surgery?
During dissection from the cervix
Less commonly Veress needle / trocar injury
What are the 4 causes of inadvertent laparoscopical electrosurgcial injuries?
- Inadvertent tissue contact
- Insulation failure
- Direct coupling
- Capacitive coupling
May have delayed tissue breakdown in the days following surgery
How long post-op will a bladder injury with uroperitoneum present?
Within 48 hours
When do thermal injuries to the bladder typically present and how?
10-14 days with uroperitoneum or vesico-genital fistula
What will the biochemistry show with a uroperitoneum?
Raised creatinine - reabsorption across peritoneum
Which suture can be used to repair the majority of bladder injuries?
2-0 or 3-0 absorbable such as polyglactin
Thermal will need debridement first
Caution around trigone - ureters
How can a bladder injury into the space of Retzius be managed?
Conservatively - indwelling catheter for 2/52
What is the incidence of fistual formation even with correct bladder injury repair?
5%
What is the incidence of ureteric injury during laparoscopic gynaecological surgery?
<1 - 2%
Can be as high as 20% in e.g. deep infiltrating endometriosis
What are the most common sites for ureteric injury during gynae laparoscopic surgery?
- At pelvic brim where ureter close to infundibulopelvic ligament containing ovarian vessels
- Lateral to cervix when dividing uterine artery/cardinal/uterosacral ligaments
Less common: ovarian fossa in e.g. endo, ovarian remnant resection
Which vessel does the ureter cross at the pelvic brim?
Bifurcation of the common iliacs
What are the 7 types of ureteric injury?
- Angulation
- Crush
- Ligation
- Thermal
- Laceration
- Transection - most common at laparoscopy
- Resection
What is a urinoma and how is it managed?
Retroperitoneal leakage of urine which leads to encapsulation by reactive fibrous tissue, such that a cyst containing urine is formed. This may develop into an abscess and present with sepsis and electrolyte imbalance
Mx: P/C drainage, nephrostomy, stents, bladder drainage +/- abx
How many unrecognised ureteric injuries will lead to eventual loss of the ipsilateral kidney?
Up to 25%
How are minor crush or needle injuries to the ureter managed?
Conservatively provided that the ureter’s integrity and
viability have not been compromised, i.e. there is peristalsis and no urine leak
How are obstructive injuries to the ureters best managed?
Stenting - 2 to 6 weeks
How should major injuries to the upper 1/3 of the ureter be managed?
Uretero-uretrostomy (end to end)
How should major injuries to the middle 1/3 of the ureter be managed?
Uretero-uretrostomy or a trans-uretero-ureterostomy (end to side - not first line)
How should major injuries to the lower 1/3 of the ureter be managed?
Uretero-neocystostomy (re-implantation of the ureter into
the bladder)
Psoas hitch or a Boari flap (12-15cm additional length) if ureter too short for tension-free repair
what is the characteristic presentation of uroperitoneum?
diffuse abdo pain, distenstion, ileus. Tenderness is absent
when repairing bladder injuries, what 2 measures will improve healing and reduce risk of subsequent vesico-vag fistula?
- watertight closure
2. indwelling catheter
if bladder injury is diagnosed post-operatively, what is the management?
conservative- provided that the wound isnt extensive.
indwelling catheter for 2 weeks
antibiotics for 5-7/7
if IV indigocarmine is given when diagnosing ureteric injury intraoperatively, how long do you wait until it colours the urine blue?
5-10 minutes
what criteria must the anastomosis fit when repairing ureteric injury?
- watertight
- tension free
- spatulated or fishmouth
