Avoidance and Management of Genitourinary Complications
Javier F. Magrina
If you operate long enough, you will have complications. Because the ureters and the bladder are very close neighbors to the uterus and adnexa, they are at risk for injury ANYTIME you operate in the pelvis.
Take home message: Genitourinary injuries remain at about the same incidence for the past 20 years. Bladder injuries are more common than ureteral injuries.
Bladder and ureteral injuries remain a common problem. Although their mortality is very low, they are a frequent cause of litigation when diagnosed postoperatively and specially when associated with complications deriving from their repair. The overall incidence of urinary injuries associated with laparoscopic gynecologic surgery has remained stable during the past 20 years ranging from 0.02% to 1.7%,1,2 with bladder injuries being more common than ureteral injuries. When considering only laparoscopic hysterectomy, the overall urinary tract injury is 0.7%, with injury rates of 0.02% to 0.4% for ureters and 0.05% to 0.7% for bladder.3 In a more recent review considering open, vaginal, and laparoscopic hysterectomy in 296,130 patients, ureteral injuries were diagnosed in 1% and bladder injuries in 0.7%.4 The open hysterectomy had a higher risk for urinary injury than vaginal and laparoscopic.
Take home message: Most ureteral injuries remain unrecognized during surgery.
Unrecognized ureteral injuries are more common than bladder injuries, and symptoms may be delayed for up to 6 weeks or longer. Ureteral entrapments can be permanently silent. In a more recent review of 45,139 open, vaginal, and laparoscopic hysterectomies, during the period of 2014 to 2016, the incidence of delayed injuries during the first 30 days was 0.2%, including ureteral obstruction in 0.1% of patients, ureteral fistula in 0.07%, and bladder fistula in 0.06%.4
INTRAOPERATIVE VERSUS POSTOPERATIVE DIAGNOSIS (RECOGNIZED VS. UNRECOGNIZED)
Take home message: Bladder injuries are more commonly diagnosed intraoperatively, whereas ureteral injuries are more commonly diagnosed postoperatively. Performing a cystoscopy will diagnose unrecognized intraoperative injuries but not all types of injuries and not in all patients.
There is no doubt intraoperative recognition is favorable for the patient and the surgeon. In a series of 223,872 patients undergoing hysterectomy, ureteral injuries occurred in 0.7% of them, and it was unrecognized in 62.4% of them.5 In a systematic review of benign laparoscopic surgery, 60% of ureteral injuries were recognized postoperatively.6
Unrecognized ureteral injuries increase the risk of readmission, sepsis, urinary fistula, renal insufficiency, and death as compared to recognized injuries.5
Intraoperative diagnosis of a ureteral injury required surgical repair in only 9% of patients (most were corrected by cutting a suture or placing a stent), whereas postoperative diagnosis required a surgical repair in 61% of patients.3
Intravenous indigo carmine is helpful to diagnose an intraoperative ureteral leak. Bladder distension with methylene blue will diagnose a leak or a near full-thickness injury.
Cystoscopy is a friendly tool which identifies most, but not all, injuries. You will not regret performing a negative cystoscopy, but you will if an injury is diagnosed after the patient is discharged and you did not perform a cystoscopy. Routine cystoscopy decreased postoperative ureteral injuries from 0.16% to 0.07%. Delayed bladder injuries were diagnosed in 0.08% and 0.1% without and with cystoscopy, respectively.2
Ureteral obstruction (suture or sealing) or transection is revealed by lack of a ureteral jet. Full-thickness or near full-thickness thermal bladder injuries are identified by blanching of the vesical urothelium.
Incomplete thermal injuries of the ureter or sutures involving near fullness of the bladder wall in the cuff closure will not be diagnosed by cystoscopy.
AVOIDANCE OF BLADDER INJURY
Preparation for Dissecting the Vesicovaginal Space
For a safe dissection, you need to place the anterior vaginal fornix and the bladder wall under stretch and sometimes distend the bladder with 300 mL of water.
A vaginal probe, a cervical cup, or a uterine manipulator is necessary for a safe bladder dissection and identification of the cervicovaginal junction.
A distended bladder is useful to identify its margins if unclear. We use a three-way Foley catheter in all patients to distend the bladder with water whenever necessary during the operation or to visualize its integrity at the end. There should never be a bladder injury with normal anatomy.
Take home message: In the absence of adhesions, start the dissection of the vesicovaginal space in the midline. There are no vessels in the vesicovaginal space, so if you encounter bleeding, you are in the wrong plane of dissection.
In the absence of obliteration of the vesicovaginal space (i.e., no adhesions), always start the dissection in the midline to avoid bleeding from the lateral vesicouterine ligaments (bladder pillars).
There are no vessels in the vesicovaginal space; therefore, if you encounter bleeding, you are either in the cervix, the vagina, or the detrusor muscle, and you are not in the vesicovaginal space.
Stop, distend the bladder with 300 mL of water, clearly visualize its contour, and find the correct space.
How far to dissect the vesicovaginal space?
Continue the dissection in the midline past 2 cm from the cervicovaginal junction and then widen the space laterally.
Why 2 cm?
Simply because the vaginal wall is stretched from the manipulator and once it is removed with the uterus, the vaginal wall will retract and the distance from the vaginal cuff to the bladder will be reduced to 1 cm or less. This distance is adequate to take 5-mm bites away from the cut adventitial edge of the vagina without risk of including the bladder wall.
Bladder Adhesions and/or Obliteration of the Vesicovaginal Space
Take home message: Distend the bladder with 300 mL of water and start the dissection of the vesicovaginal space lateral to the adhesions such as from a cesarean scar.
The most common cause of midline adhesions is a previous cesarean section (Fig. 28.1A). In that case, the dissection always starts lateral to the cesarean scar.
The vesicovaginal space is not usually obliterated from a cesarean because the myotomy is in the lower uterine segment and not in the lower part of the cervix or vagina. Therefore, once you are past the cesarean scar, the rest of the dissection is in virginal territory.
Distend the bladder with 300 mL of water at the start of the dissection, which will delineate the area of bladder-uterus attachment. ALWAYS start the dissection of the vesicovaginal space lateral to the scar, right or left. Continue the dissection until you identify the vesicovaginal space free of adhesions (Fig. 28.1B,C). This outlines the cesarean scar, superiorly and inferiorly, which then can be safely divided (maintaining a full bladder), starting on the right or left and proceeding to the contralateral side (Fig. 28.1D,E). If you have any doubts about the plane of dissection, dissect deeper on the uterus instead than on the bladder.
You will end up with the cesarean scar left in the bladder wall which does not need to be removed (unless it has myometrium or the patient had bladder symptoms).
If the adhesions are from infiltrating endometriosis, proceed as if a cesarean, but you will need to resect a portion of the bladder wall to obtain clearance of the lesion.