Urologic and Gastrointestinal Injuries
Kristy K. Ward
While urological and bowel injuries are very rare during caesarian section, a busy obstetrician will encounter a few such injuries and should be prepared. It is most important that the obstetric surgeon can quickly identify these injuries intraoperatively and call for assistance from a specialist. Intraoperative diagnosis and treatment are the key to quick patient recovery.
All obstetricians are familiar with the intimate relationship of the bladder and distal ureters to the uterus (Figure 9-1). While the pregnant uterus usually holds the bowel out of the operative field, adhesive disease can pull the bowel into the pelvis and increase the risk of injury. Fortunately, urologic and gastrointestinal injuries occur during less than 1% of cesarean deliveries.1
BLADDER INJURY
Bladder injury is the most common injury associated with cesarean section and is still fortunately very rare. Bladder injuries often occur at the bladder dome and are more difficult to repair if they occur at the trigone of the bladder (Figure 9-2). Incidence of bladder injury with cesarean sections is estimated to be between 0.052% and 0.8%. Repeat cesarean section is the greatest risk factor for injury. There is also increased risk of bladder injury when performing hysterotomy on a laboring uterus. Bladder injury can also occur during peritoneal entry, bladder flap creation, hysterotomy, lysis of adhesions, or during attempted hemorrhagic control.2,3
Assessment for Bladder Injury
If bladder injury is suspected, the bladder must be carefully visually inspected to evaluate for any visible tears.
If no tears are visualized, leakage should be assessed by backfilling the bladder with a colored fluid. Normal saline tinted with methylene blue can be used, but sterile baby formula is usually readily available on the OB floor and also works well.
When performing this intraoperatively, a nurse or assistant disconnects the Foley catheter under the drape and then uses a large syringe to fill the bladder which usually requires at least 180 mL or more to see distention of the bladder. Remember to clamp the Foley tubing or the fluid will run out of the bladder.
Leakage is confirmed when colored fluid is seen in the abdominal cavity.
 FIGURE 9-1 Female anatomy (sagittal section) showing proximity of uterus, bladder, rectum, and ureters. (Reprinted with permission from Olinger AB. Human Gross Anatomy. Philadelphia: Wolters Kluwer; 2016.) |
 FIGURE 9-2 Parts of the urinary bladder of the female (coronal section). (Reprinted with permission from Olinger AB. Human Gross Anatomy. Philadelphia: Wolters Kluwer; 2016.) |
Repair of Injury to the Dome of the Bladder
Injury to the dome of the bladder heals well with repair and bladder rest. The dome of the bladder can be repaired by the obstetrician with absorbable suture.
The first layer should reapproximate the mucosa in a running fashion.
A second imbricating layer should then be performed in the serosal layer in a running fashion.
The bladder should be backfilled to assess leakage as described above. Any areas of leakage should be oversewn.
The patient keeps the Foley catheter in place for 1 week, after which a voiding trial can be completed in the office.
Repair of Injury to the Trigone of the Bladder
Injury to the trigone of the bladder requires repair by a surgeon with urologic training.
Careful ureteral reassessment is needed before, during, and after the repair to assure patency.
Options for ureteral evaluation include injections of intravenous endocardial mean to allow visualization of urine exhalation from the ureteral orifices or placement of ureteral stents.
The urologist or urogynecologist may decide to place pelvic drains to evaluate for leakage. The output from the drains is tested for creatinine; if the creatinine of the fluid is greater than serum creatinine, this suggests urine is leaking into the abdomen.
The patient retains the Foley catheter in place for 1 week.
A voiding cystourethrogram is usually ordered prior to removing the Foley to confirm the injury has healed.
URETER INJURY
Ureteral injury should always be evaluated and repaired by a surgeon with urological training. The repair of ureteral injury is dependent on the type and location of the injury. The majority of ureteral injuries encountered during obstetric cases occur near where the uterine artery crosses the ureter. The two most common injuries result from the ureter being kinked by suture placement too close the ureter or by the ureter being
mistakenly tied in an attempt to ligate the uterine artery. The method of repair for ureteral injury depends on the level of the injury (below the pelvic brim, mid-ureter, or proximal ureter) (Figure 9-3). Repair techniques include reimplantation, end-to-end reanastomosis, and anastomosis of the injured ureter to the normal one.
mistakenly tied in an attempt to ligate the uterine artery. The method of repair for ureteral injury depends on the level of the injury (below the pelvic brim, mid-ureter, or proximal ureter) (Figure 9-3). Repair techniques include reimplantation, end-to-end reanastomosis, and anastomosis of the injured ureter to the normal one.
 FIGURE 9-3 Course of the ureter and injury locations and types of repair (ureteropelvic junction, proximal and mid-ureter, distal ureter). (Reprinted with permission from Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 7th ed. Philadelphia: Wolters Kluwer; 2014.) |
Assessment for Ureteral Injury
The obstetrician should carefully trace the ureter along its course to identify a site of injury, and cystoscopy should be performed to see if there is reflux from the ureteral orifices bilaterally.
Intravenous dye or mannitol distension of the bladder should be used for better visualization of the ureteral efflux.
If the bladder is filled with colored fluid prior to cystoscope insertion, irrigation should be performed.4
Indigo carmine was one of the most commonly used intravenous materials to evaluate ureteral flow but is no longer manufactured. Intravenous sodium fluorescein will adequately tint the urine to allow visualization of efflux.
Procedure for Repair of Injury to Ureter
If the suture does not involve the ureter and can be removed, the suture should be removed and cystoscopy performed to evaluate ureteral efflux.
Note that crush-and-burn injuries of the ureter may take a few days before showing disturbances in urine flow. If there is concern, a urologic specialist should be consulted to evaluate for stent placement.
If still no ureteral efflux, consult urology or urogynecology to attempt to insert a stent. If the stent can be passed, the urologist will advise on how long the stent should remain in place and if any other intervention is needed.
If the stent cannot be inserted, further evaluation is needed to find and remove the cause of the blockage. In cases where this cannot be done (such as a hemostatic stitch in an unstable patient), the patient may need a temporary percutaneous nephrostomy with repair at a later date.
Procedure for Cut or Damaged Ureter
If the ureter has been cut or damaged, it will likely require reimplantation. A defect that still allows adequate ureteral length may be able to be repaired with reimplantation ureteroneocystostomy alone (Figure 9-4).
Technique for Ureteroneocystostomy
Open an incision into the bladder and insert the ureter (view Figure 9-4A).
The ureter is transected and brought through a small cystotomy above the trigone (Figure 9-4B).
The ureter is then tunneled between the serosa and muscularis and brought through another incision on the interior of the bladder (Figure 9-4C).
The ureter is then sutured open inside the bladder, and a stent is placed to allow healing (Figure 9-4D).
Repair of Larger Ureteral Injury
If there is not enough ureteral length to allow repair without tension, a Boari flap and/or psoas hitch may be necessary. A Boari flap increases the bladder height to allow reimplantation of the ureter into the bladder. In the psoas hitch procedure, the bladder is mobilized to the ureter and sewn to the psoas tendon to allow tension free ureteral reanastomosis.
 FIGURE 9-4 A-D, Ureteroneocystostomy. Injury of the ureter near the trigone may be able to be reimplanted into the bladder. A, Open an incision into the bladder and insert the ureter. B, Create a distal incision in the mucosa of the bladder and tunnel to the inserted ureter. C, Bring the ureter through the tunnel. D, Suture the ends of the ureter to the mucosa and place a stent. (Reprinted with permission from Presti JC Jr, Carroll PR. Intraoperative management of the injured ureter. In: Schrock TR, ed. Perspectives in Colon and Rectal Surgery. St. Louis, MO: Quality Medical Publishing; 1988. ©Thieme Medical Publishers.) |
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