Injury to the Urinary Organs
The ureter, bladder, and urethra are in an exposed location in classical gynecological operations. Iatrogenic urethra injuries are extremely rare. Bladder and ureter injuries occur more often, depending on the surgeon′s operative experience and on the degree of difficulty of the operation. Very extensive pelvic floor reconstructions, oncological operations, radical hysterectomy, and radical endometriosis surgery are associated with a high risk. Intraoperative injuries should be corrected immediately. Unnoticed injuries, strictures, or thermal injuries, which only become symptomatic later, are more problematic.
Sites of predilection. The most frequent site of bladder injury during abdominal surgery is the roof of the bladder at the site of the peritoneal reflection on the anterior abdominal wall. The injury occurs when the abdomen is entered too far inferiorly or when a laparotomy is incautiously extended downward. Another trouble spot during abdominal surgery is the part of the bladder lying directly next to the cervix, which must be dissected off bluntly. Injuries in this area can also occur during vaginal surgery.
Treatment. Injuries that are sufficiently distant from the ureteral ostia can be managed relatively easily with sutures. When the injuries are close to or involve the ureters, there is a risk of ureter stenosis if they are managed incorrectly. A urological opinion is essential and in extreme cases the ureter even has to be reimplanted.
The closure technique is guided by the thickness of the bladder wall, which varies from patient to patient. Injuries of the muscularis only, without opening of the bladder lumen, are closed with interrupted sutures (PDS, Vicryl, 3–0 or 2–0) and covered by the previously dissected peritoneum as a second layer. The same procedure is recommended for a muscular bladder wall when the lumen is entered. If the bladder lumen has been opened and the bladder wall is thin, the first row of sutures closes the mucosa and muscularis together with a 3–0 inverting, atraumatic, continuous, absorbable suture. The second row of sutures closes the peritoneum. An extramucosal suture is possible and indicated only when the bladder wall is highly muscular. Watertight closure is crucial, and this is achieved in the intraperitoneal part of the bladder by the second row of peritoneal sutures. In any case, the bladder should be drained initially for a certain time by both transurethral and suprapubic catheters, depending on the extent of the bladder injury.