Video Clips on DVD
- 5-1
Suprapubic Catheter Placement
- 5-2
Closed Technique for Suprapubic Catheter Placement
- 5-3
Suprapubic Catheter Placement (Intentional Cystotomy)
- 5-4
Transvaginal Cystotomy Repair
- 5-5
Transvaginal Vesicovaginal Fistula Repair
- 5-6
Transvaginal Vesicovaginal Fistula Repair 2
- 5-7
Abdominal Repair of Vesicovaginal Fistula
- 5-8
Attempted Vaginal Vesicovaginal Fistula Repair with Conversion to Abdominal Repair
- 5-9
Repair of Vesicouterine Fistula
- 5-10
Vaginal Hysterectomy with Entry into the Anterior Cul-de-Sac
- 5-11
Abdominal Hysterectomy with Development of the Vesicouterine Space
Introduction
Hysterectomy is second only to cesarean delivery as the most frequently performed major surgical procedure for women of reproductive age in the United States where approximately 600,000 hysterectomies are performed annually. Approximately 20 million U.S. women have had a hysterectomy; moreover, by age 60, one third of all women will have a hysterectomy. Because of the intimate anatomic relationship between the genitourinary tract in the female pelvis, gynecologic surgery is the most common cause of injury to the urinary tract, accounting for 75% of all injuries. The bladder is the most common site of urinary tract injury, with 0.2% to 2.5% of injuries occurring during hysterectomy. Symmonds noted that 75% of more than 800 fistulas managed over 3 decades occurred after hysterectomy, with 50% of those occurring after simple hysterectomy.
The Finnish Hospital Discharge Register, which collects information on all surgical procedures, noted 82 injures to the bladder in more than 62,000 hysterectomies (0.13%) with an incidence of 1.3 per 1000 procedures. Bladder injuries are most common after laparoscopic hysterectomy, followed by total abdominal hysterectomy; rarely do bladder injuries occur after vaginal or supracervical hysterectomy. Problems noted during these cases in decreasing order consisted of bleeding, difficulty in separating the bladder from the uterus, enlarged uteri, adhesions, and obesity. However, in only 37% of these injuries is one of these risk factors noted. Recognition of the bladder injury during the primary procedure is most commonly seen in supracervical hysterectomy and laparoscopic hysterectomy, whereas a delay in diagnosis is seen in the majority of cases involving a total abdominal hysterectomy ( Table 5-1 ). A systematic review using MEDLINE entries from January 1966 to May 2004 on rates of urinary tract injury from gynecologic surgery notes that the use of routine intraoperative cystoscopy increases the identification rate of bladder injury during laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy from 6.4 in 1000 surgeries to 29.2 in 1000 surgeries. The clinical significance of this increased detection is not clear because it is not known whether missed injuries may have remained asymptomatic and resolved on their own. However, it is noted that bladder injuries seem to be more readily diagnosed at the time of surgery when routine intraoperative cystoscopy is used.
| LH (n = 2741) | TAH (n = 43,149) | SAH (n = 10,854) | VH (n = 5636) | |
|---|---|---|---|---|
| Bladder * | 18 (6.6) ‡ | 9 (0.2) ‡ | 3 (0.3) ‡ | 0 |
| Fistula † | 6 (2.2) ‡ | 45 (1.0) ‡ | 0 | 1 (0.2) ‡ |
| Total | 24 (8.9) ‡ | 54 (1.3) ‡ | 3 (0.3) ‡ | 1 (0.2) ‡ |
| Injury recognized at time of surgery | 14 (58%) | 2 (4%) | 2 (66%) | 0 |
* Simple perforations repaired with sutures.
† Vesicovaginal fistula after bladder perforation.
Overview of Preoperative Workup of Patients Undergoing Pelvic Surgery
Prevention of injury or management of a postoperative complication begins with a complete history and physical examination. Review of previous genitourinary complaints, previous operations, review of operative notes, and current symptoms and pathology will guide the surgeon in selecting appropriate testing for diagnosis and proper planning for any surgical intervention.
Clinical and laboratory evaluation begins with urinalysis and culture with determination of bacterial susceptibilities if infection is present. Urine cytology may be obtained when a neoplastic condition is suspected. Once infection is ruled out, the initial evaluation of the bladder is cystourethroscopy—an invaluable surgical procedure that all pelvic surgeons should master. A rigid or flexible fiberoptic cystoscope is used to examine the urethra and bladder lumen. The indications for cystourethroscopy are both diagnostic and operative for symptoms and disease related to the lower urinary tract. Diagnostic cystourethroscopy can be (1) used as part of an evaluation of abnormal symptoms, signs, or laboratory findings; (2) used intraoperatively during gynecologic or urogynecologic surgery to rule out bladder, urethral, or ureteral trauma; and (3) used as part of staging or surgery for gynecologic malignancy.
Uroradiologic evaluation of the bladder is done in conjunction with cystourethroscopy and physical examination to evaluate more complex disease involving the bladder. If a complex fistula is suspected that may involve the ureter, bladder, and/or vagina, or if abnormal filling defects are seen at cystoscopy, radiographic imaging may be useful in identifying the lesion and may help guide the appropriate surgical approach. Intravenous pyelography (IVP) has been the initial evaluation used most often for imaging the upper tracts in patients with urologic diseases and for helping to identify fistulas. However, with advances in technology, the IVP has been replaced in most centers with computed tomography urography (CTU) and magnetic resonance urography (MRU) for identifying genitourinary tract disease. CTU is the application of multidetector row helical volumetric CT evaluation of the urinary tract. In CTU, the renal parenchyma, urothelium, and integrity of the viscus system can all be evaluated at a single comprehensive examination.
MRU is another alternative to conventional imaging of the urinary tract. Using either heavy T2-weighted pulse sequences or gadolinium-enhanced T1-weighted sequences, MRU has potential to detect, localize, and characterize genitourinary tract abnormalities. MRU is best used in patients with renal insufficiency or when intravenous contrast is otherwise contraindicated. Choice of testing may depend on the individual center’s capability and expertise. In these circumstances, it is recommended to discuss the case with a radiologist to help guide which test may be most beneficial depending on the differential diagnosis.
Suprapubic Catheter Placement
View DVD: Videos 5-1 and 5-2
5-1: A 63-year-old G4 P3013 presented for surgical correction of pelvic organ prolapse with anterior, apical, and posterior wall prolapse past the hymen. Vaginal repair with a high uterosacral apical suspension, anterior colporrhaphy, and posterior colpoperineorrhaphy were planned. Suprapubic catheter placement is shown.
5-2: A 54-year-old underwent a vaginal prolapse repair with placement of a midurethral sling. She will have a catheter placed.
Procedure Steps
A delay of normal voiding is expected following reconstructive surgery, so suprapubic catheters are commonly placed during surgery. Suprapubic catheters are thought to improve patient comfort and ease of nursing care; however, the real advantage is that they allow patients to control voiding trials. Patients are able to attempt voiding normally through the urethra and avoid the need for repeated transurethral catheterizations or the need for self-intermittent catheterization. Suprapubic catheters can be inserted using an open or closed technique. Open techniques are used at the time of abdominal surgery when an intentional cystotomy can be made.
Open insertion begins with a stab incision made through the skin in the desired location of the catheter placement. If a Foley catheter is used, a curved clamp or right-angle forceps is passed from the undersurface of the rectus muscle and fascia and then out the stab wound. The Foley is then pulled through the wound and placed through the cystotomy and then the cystotomy is closed in two layers around the catheter ( Fig. 5-1 ). If an intentional cystotomy has not been used, a stab wound can be placed in the extraperitoneal dome of the bladder, the catheter is placed directly into the bladder, and a 2-0 chromic pursestring suture is placed and tied around the catheter.
Closed insertion can be performed using a variety of catheters and is commonly done after vaginal procedures. The patient is placed in the Trendelenburg position to facilitate cephalad movement of bowel, and the bladder is filled with at least 500 mL of normal saline or until the bladder can be palpated abdominally. A stab incision is made no more than 3 cm above the pubic symphysis. The trocar is inserted through the stab incision in the skin directed retropubically through the fascia and into the bladder. Once return of clear fluid is noted, the balloon is inflated and the trocar is removed. The catheter is secured in place. This technique can be facilitated with cystoscopy at the time of trocar passage; however, this does not ensure avoidance of bowel injury.
Other techniques include the use of a perforated urethral sound or Lowsley retractor transurethrally into the bladder. The tip is directed anteriorly into the bladder dome and the abdominal wall is tented upward. A suprapubic stab wound is made over the tented tissue and the catheter is secured to the sound and pulled backward through the bladder; the balloon is inflated and secured in place.
Intentional Cystotomy
View DVD: Video 5-3
This 43-year-old patient presented with a vesicovaginal fistula after undergoing an abdominal hysterectomy elsewhere. She will have a suprapubic catheter placed, via an intentional cystotomy, at the time of fistula repair.
Procedure Steps
Intentional cystotomy and repair is an invaluable tool to use during an abdominal procedure if there is concern about bladder injury; when there is need to evaluate the bladder mucosa or patency of the ureter with the need to place an indwelling ureteral stent; or when anatomy is distorted by disease. Performing a cystotomy to assist in dissection of the bladder can help identify surgical planes and aid in developing the retropubic space and vesicovaginal space, and in locating the ureters and ureteral orifices.
The most accessible and least dependent portion of the bladder is the extraperitoneal portion of the bladder dome ( Fig. 5-2 ). The surgeon can pull the Foley balloon up into the dome of the bladder to help with identification. Cautery or sharp dissection is used until the bladder is penetrated. The use of Allis clamps helps maintain traction and countertraction to aid in proper dissection. Once the bladder is entered, a 4- to 5-cm incision in the dome allows adequate access to visualize the interior of the bladder and allow palpation to help dissection in the appropriate planes, if needed ( Fig. 5-3 ). To close the bladder, 2-0 chromic suture is used in a two-layer closure. The first layer is a continuous suture that approximates the vesical mucosa ( Fig. 5-4 ); the second layer is placed to imbricate the muscular portion of the wall of the bladder. The length of bladder drainage after cystotomy depends on the position and extent of the cystotomy. In general, high extraperitoneal cystotomies in a nondependent portion of the bladder require very little drainage time, whereas low intraperitoneal cystotomies in a dependent portion of the bladder usually require 10 to 14 days of bladder drainage.
Repair of Bladder Laceration
View DVD: Video 5-4
A 56-year-old G3 P3003 who presented for symptomatic pelvic organ prolapse with anterior, apical, and posterior vaginal wall prolapse had the following pelvic organ prolapse–quantification (POP-Q) score: Aa +2, Ba +2, C −1, D 0, Ap 0, Bp 0. During dissection of the anterior vaginal epithelium off the underlying bladder connective tissue, an incidental cystotomy was made and identified at the time of injury. She will undergo a transvaginal cystotomy repair.
Procedure Steps
Even with sufficient experience, injury to the urinary tract can and does occur. Once the injury is identified, surgeons generally prefer to proceed with the operation in the proper plane of dissection, with the plan that the cystotomy would be repaired after completion of the hysterectomy and during the reconstructive phase of the pelvic repair. If the injury is repaired immediately, the otherwise satisfactory bladder repair could be disrupted during the rest of the dissection necessary for hysterectomy.
In the procedure shown in the video, traction is applied to the vagina to aid in any additional mobilization of the bladder that may be necessary to provide a tension-free closure of the cystotomy. The cystotomy is closed in two separate layers with a 2-0 chromic suture, making sure to start and finish the suture line at least 0.5 cm past the fresh edges of the defect. A second layer is used to imbricate the first layer, again taking care to start and end the suture line distal to the initial layer. If available, the peritoneum can be mobilized to cover the repair for a third layer, or if there is concern about the health of the tissue used, a Martius flap can be mobilized and used to improve healing.
Vaginal Repair of Vesicovaginal Fistula
View DVD: Videos 5-5 and 5-6
5-5: A 58-year-old G1 P1001 underwent a vaginal hysterectomy for symptomatic uterine fibroids. The operative report notes an anterior fibroid in the lower uterine segment, but there is no mention of difficulty developing the vesicovaginal plane. The patient reported that when the catheter was removed the following day, she had urinary leakage. She was reassured and discharged with a course of antibiotics. Her symptoms worsened in the following week and when she was seen for follow-up, a vesicovaginal fistula was suspected and a 3-week course of transurethral catheter drainage was recommended. Upon removal of the catheter, symptoms returned immediately. She will undergo a transvaginal vesicovaginal fistula repair.
5-6: A 44-year-old presented with a persistent vesicovaginal fistula after multiple procedures elsewhere. She will undergo a transvaginal vesicovaginal fistula repair.
Procedure Steps
Timing and approach to repair of vesicovaginal fistulas depends on when the diagnosis is made in relationship to when the injury occurred. Approach to the fistula, either vaginally or abdominally depends on location, complexity, and individual patient and surgeon preferences ( Fig. 5-5 ). If the injury is recognized early, within the immediate postoperative period, an attempt at repair within the first 5 to 7 days appears to be associated with good outcome. Approximately 20% of small bladder injuries heal spontaneously without further operation, so the surgeon should consider splinting the urinary tract with a large-bore Foley to facilitate healing before epithelialization of the aberrant tract occurs. A high index of suspicion along with appropriate testing is needed to make a rapid diagnosis for early return to the operating room. For optimal results when the fistula is discovered later, a delay of 8 to 12 weeks after the initial injury is desirable before initiating repair.
Most surgeons believe that all simple vesicovaginal fistulas should be closed with a primary vaginal approach. The Latzko partial colpocleisis closure, a standard vaginal dissection and excision of the fistula tract with a layered closure, or a combination of the two is the preferred method when exposure is adequate and no complicating circumstances are involved.
A standard closure of a simple vesicovaginal fistula begins with cystoscopy and determination of the proximity of the ureteral orifices to the fistula tract. Indigo carmine can be given intravenously and blue-stained urine excretion can help identify the orifices. If needed, the ureters can be catheterized with temporary or indwelling ureteral stents as directed by the surgeon. A weighted speculum and Deaver retractors are used to gain adequate exposure. Traction sutures or Allis/Kocher clamps may be placed in the lateral quadrants of the vaginal vault to facilitate exposure. Infiltration with saline or a dilute vasoconstricting agent is preferred by some surgeons to help with dissection. An incision is then made approximately 1 cm from the fistula edge circumferentially around the fistula ( Fig. 5-6 ). The vaginal mucosa is mobilized in all directions to ensure a layered and tension-free closure. Latzko did not routinely excise the fistulous tract. Excision may not be necessary on mature fistulas; however, most surgeons believe that on fresh fistulas in the setting of induration or the presence of necrotic tissue, the edges may not heal if the tract is not removed and the fistula closed with healthier tissue. If an older, scarred, and epithelialized fistula tract is not excised, it should be carefully entropionized as Latzko described rather than suturing the edges together. When the tract is excised, a relatively small fistula can turn into a larger one that may put the ureters at risk during closure. After excising the tract, the bladder mucosal edges are approximated with interrupted 2-0 chromic suture, with the surgeon ensuring that the lateral sutures are beyond the fistula tract. A series of imbricating layers are then placed in a similar fashion, inverting the previous suture line ( Figs. 5-7 and 5-8 ). Multiple layers are desirable in most fistula repairs.
