Urinary tract injuries in laparoscopic gynaecological surgery; prevention, recognition and management TOG 2013

Question 1

Hoe close does the ureter pass lateral to Cx

Answer 1

2.3+/-0.8cm

Question 2

Most common visceral damage complication related to laparoscopic pelvic surgery
What is the incidence

Answer 2

Bladder injury
0.02%-8.3%

Question 3

Most common site of bladder injury? When does this occur?

Answer 3

Dissection of the bladder from cervix, most common site in the midline above inter-ureteric bar.

Question 4

Risk factors for urinary tract injury due to distorted pelvic anatomy?

Answer 4

Endometriosis
Cancer
Adhesions (previous surgery/infection/inflammatory disease/radiation)
Severe genital organ prolapse
Obesity
Pregnant uterus

Question 5

How to avoid urinary tract injury during entry

Answer 5

Do suprapubic insertion of verses needle
Direct visualisation of secondary ports
Empty bladder before peritoneal insufflation

Question 6

What proportion of bladder injuries are recognised during the primary operation

Answer 6

50%

Question 7

How to check for bladder intra-operatively?

Answer 7

Cystoscopy
Methyln blue - 200-300mls

Question 8

What bladder injury can be missed if cystoscopy not performed intra-operatively? How is this most commonly caused?

Answer 8

Bladder injury opening to the retro-pubic space (space of Retzius).
Can be caused by difficult entry

Question 9

When to suspect bladder injury post op

Answer 9

Suprapubic pain
Haematuria
Leakage urine per vagina
Oliguria
Uroperitoenum - normaal within 48 hours but 10-14 days if thermal

Question 10

How to Ix for bladder injury post-op?

Answer 10

U+E - creatinine
CT
Retrograde cystography - confirm Dx
Cystoscopy - assess the injury

If ?fistual - Methlene blue or MRI

Question 11

What to do if retrograde cystography shows leakage?

Answer 11

Leave catheter in situ and retest in 1 week

Question 12

How to repair bladder injury intra-operatively

Answer 12

1-2 layers absorbable suture - polyglactin

If injury in trigone, risk obstructing ureter/urethra - should be performed by urologist
Thermal injury - debridement

If Retzius - conservative

Ensure repair watertightm insert catheter for 2 weeks

Before catheter removal - retrograde cystography

Question 13

How common is fistula a complication of bladder injury (even with management steps discussed)

Answer 13

5%

Question 14

How to manage bladder injuries diagnosed post-op?

Answer 14

Cystosocpy
Conservative management unless wound extensive - Abx 5-7 days then 2 week catheter

Question 15

How common is ureteric injury during laparoscopic surgery?

Answer 15

<1-2%

If deep Endo - 21%

Question 16

Most common sites of ureteric injury

Answer 16

Pelvic brim
Lateral to Cx

Question 17

How much of the ureter can be mobilised without compromising viability to the blood supply?

Answer 17

15cm

Question 18

What are the 7 types of ureteric injury?

Answer 18

Angulation
Crush
Ligation
Thermal
Laceration
Transection
Resection

Transection most common

Question 19

What proportion of ureteric injuries are recognised intra-operatively?

Answer 19

1/3

Question 20

How to assess for ureteric injury intra-operatively?

Answer 20

Cysoscopy - visualise orifice - if urine jet rules out obstruction, if blood/air suggests injury
IV administration of indigo carmine, turns urine blue 5-10 mins and can help identify urine leak laparoscopically
Insert stents ?resistence
Ureteroscopy - height/extent of injury
IV uretero-pyelography

Question 21

How to recognise ureteric injury post-op

Answer 21

Same as bladder injury

Question 22

What proportion of unrecognised ureteral injuries result in ipsilateral loss of kidney?

Answer 22

25%

Question 23

How to manage minor crush or needle ureter injury?

Answer 23

Conservative if integrity/viability - can see peristalsis

Question 24

How to manage obstruction (significant crush/ligature)

Answer 24

Urethral stenting between 2-6 weeks

Question 25

How to manage thermal ureteric injury

Answer 25

Small area - stunting to prevent stenosis, if later area excision and ureteral re-anastomosis or re-implantation

Question 26

How to manage ureteric laceration

Answer 26

Suturing and stent

Question 27

Ureteric transection/resection - upper 1/3rd ureter?

Answer 27

End-to-end anastomosis (uretero-uretrostomy)

Question 28

Ureteric transection/resection - middle 1/3rd ureter?

Answer 28

uretero-ureterostomy or a trans-uretero-ureterostomy (end-to-side anastomosis of the injured ureter with the contra-lateral healthy ureter)

Question 29

Ureteric transection/resection - lower 1/3rd ureter?

Answer 29

uretero-neocystostomy (re-implantation of the ureter into the bladder)
If tension free anastomosis cannot be achieved then Psoas hitch or Boari flap