Chapter 14 Complications of Gynaecological Surgery
Urinary tract injuries
Gynaecological surgery, in common with other surgical specialties, can be associated with complications. Most complications are minor, self limiting and have no long-term consequence for the patient, but they must still be avoided where possible, and actively managed where necessary, to make sure they do not become major complications.
Gynaecological surgery involves close dissection to viscera including the bladder, rectum, ureters as well as the great vessels of the pelvis. Complications can occur during difficult surgical dissections, especially when the anatomy is distorted (e.g. malignancy, endometriosis or infection).
Other complications, such as pulmonary embolus, myocardial infarction, pneumonia, or fluid or electrolyte imbalance are common to all surgery. For the purposes of this chapter, the most common complications related only to gynaecological surgery will be discussed.
Urinary tract injuries
Bladder Injuries
If a bladder injury is suspected intraoperatively, it can be localised by intravenous injection of indigo carmine, retrograde instillation of methylene blue through the urethral catheter or by opening the dome of the bladder and inspecting the mucosa. Subtle injuries can also be diagnosed using cystoscopy. Early involvement of an urologist is advised.
Primary closure of a cystotomy can be performed using a simple one or two-layered running closure with absorbable suture.
In general, it takes approximately 3–4 days for the bladder to re-epithelialise and about 3 weeks to regain its normal strength. A catheter can be left in situ for about 7 days with a cystogram performed just prior to its removal, to confirm healing.
In circumstances where a primary closure is difficult (e.g. vaginal surgery, unstable patient, history of pelvic irradiation) and there is a small injury (3 cm or less) in the bladder dome, a suprapubic catheter can be placed. A Foley catheter is placed through the cystotomy, with the bulb remaining in the bladder and the catheter exiting through a stab wound in the lower abdomen.
Women who have received prior lower pelvic radiation or have severe bladder injury require a stronger repair. A carefully dissected omentum, from the hepatic flexure to the splenic flexure, can be used over the two-layer closure to provide neovascularity.
After any repair to the bladder, it must be ensured that the ureteral orifices near the trigone are not compromised. This can be done by passing a stent, retrograde from the bladder toward the kidney or by dissection and visual identification of the distal ureter.
Injury to the ureter
The ureter will occasionally be damaged no matter how much skill and care are exercised. It is essential to directly visualise the ureters at surgery to check for peristalsis, gross dilation (obstruction) or urine leakage, in order to prevent ureteral damage.
The operating surgeon must have a thorough knowledge of the location of the ureter and where it is most susceptible to trauma. The three most common sites of ureteral injury, in the order of frequency of occurence are:
The ureter’s course is to some extent variable, and when under pressure, it will gradually change its position in the pelvis. A large tumour filling the pelvis will displace it laterally. A tumour in the broad ligament may displace the ureter outwards and upwards. Duplex (double) ureters are occasionally met with.
A ureter displaced by a fibroid which has occupied the broad ligament.
Radical surgery may destroy so much of the pelvic blood supply that the pelvic ureter becomes ischaemic, leading to fibrotic narrowing or fistula. Damage to the blood vessels may also be produced by pelvic irradiation.
Management of ureteric injury
Ureteric injury should be managed in consultation with a urologist, or a gynaecologist with subspecialty training in urogynaecology.
The ligation of the ureter should be treated by an end-to-end anastomosis, reimplantation of the ureter into the bladder or by uretero-ureteric anastomosis into the opposite ureter.
Clinical Features
The signs and symptoms relate to the leakage of urine into the ureteric fistulae, and to ureteric obstruction, when the ureter has been ligated. If a ureteric fistula is present, urine leakage may be observed in an abdominal drain, or from the surgical incisions. The patient may develop lower abdominal pain and pyrexia. If the ureter has been ligated, the patient may develop loin pain and pyrexia.
Investigations
If ureteric obstruction is suspected, an ultrasound may be a useful initial test to identify hydronephrosis.
This is becoming another useful test with an increase in the widespread availability of CT scanning. It has the advantage of showing clear anatomical relationships as well as the site of any injury.
Intravenous urography (IVU) is useful in the investigation both of ureteric fistulae and of ureteric obstruction. The urinary tract is outlined by radio-opaque dye and the site of leakage or obstruction of urine can be identified. Small fistulae may not be identified by this approach.
This manoeuvre is both therapeutic and diagnostic. Percutaneous nephrostomy is carried out under an ultrasound or X-ray control. Using local anaesthesia, a catheter is passed through the skin and into the renal pelvis or ureter (percutaneous nephrostomy). This allows drainage of the kidney, and prevents further renal damage. Contrast medium can then be injected through the catheter (antegrade pyelography), and this gives further information on the extent of ureteric damage.
Treatment of Ureteric Injury
When ureteric injury is diagnosed, the principle of treatment, in the first instance, is to relieve the ureteric obstruction, thus preventing back pressure on the kidney and subsequent renal necrosis. Clearly, if both ureters have been damaged, and renal compromise/failure is already apparent, consideration should be given to renal dialysis. The following manoeuvres may be useful in the short term:
In the longer term, formal repair of the ureter is necessary, and this may be achieved using one of the techniques outlined above. It should be emphasised again that these techniques are outside the areas of expertise of most gynaecologists.
Bowel injury
Serosal abrasions should be assessed and repaired where appropriate, particularly when it is a diathermy injury. Injuries involving the muscularis or both the muscularis and the mucosa should also be repaired.
For colonic injury, the lack of a preoperative bowel prep is not an indication for colostomy. After the bowel is repaired, the abdomen is copiously irrigated. Occasionally, a segment of the bowel must be resected, and if reanastomosis is performed, routine care can resume. If bowel reanastomosis cannot be performed due to extensive injury or pathology (i.e. dense adhesions or inflammatory changes), a diverting colostomy may be required.
Fistula formation
Urinary fistula
(L. fistula: a pipe) It is a pathological connection between the urinary tract and an adjacent structure through which urine escapes. A fistula between the bladder base and the vagina is the condition that is most often seen.
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