Hassan Morsi MD MRCOG
Consultant Obstetrician & Gynaecologist
Special Interest: Minimal Access Surgery
Dudley Hospitals NHS Foundation Trust
Honorary Senior Clinical Lecturer, University of Birmingham
United Kingdom
“I do not see any mode of certainty providing against the
mischance of dividing one or both ureters. I fear that, with all
possible care, it is an
accident which may occasionally be unavoidable”.
Sir Thomas Spencer Wells 1882
President of the RCS
First surgeon to successfully perform an ovarian cystectomy
Would there be any experienced gynaecological surgeon who has not
injured the urinary tract at some time during pelvic surgery in his
career?
I have always been obsessed with reducing ureteral injuries.
Most are not identified or even suspected without cystoscopy, even if
the surgeon is visually able to identify the ureters.
Normal peristalsis may occur in a damaged ureter.
Harry Reich 3, 2003, 32-40
Laparoscopic Hysterectomy in current gynaecological practice
Reviews in Gynaecological Practice
Urinary;
Morbidity
Chronic infection
Strictures
Calculi
Urinary incontinence / fistula
Loss of kidney
Disability
High risk of litigation
Referral to urology; loss of contact
TRIAD
Bowel;
Vascular;
Mortality
Mortality
Parpala-Spårman T et al; 2008, Scand J Urol Nephrol, reviewed 20 years;
ureteric injuries with laparoscopic surgery
50
11%
40
Gynaecological
procedures
30
10
0
Surgical
procedures
25%
20
64%
5
28
39
(1986 - 1992)
(1993- 1999)
(2000 - 2006)
Urological
procedures
Makinen 2001; Finnish study; 10110 hysterectomies, RR 7.2 ureteral injuries
with laparoscopic versus abdominal hysterectomy
Medical Negligence claims over 30 years: 70/year 1974, 5965/year 2003
Cost over 30 years: 1 million to 446 million £
“Culture of compensation”, ‘for every accident someone is at fault, every
injury someone is to blame, for every accident someone has to pay’.
Harkki-Siren 1998; Bleeding (57%)
Enlarged uterus (24%), endometriosis, adhesions, obesity
‘Difficulty during surgery’; bladder injury in 53% LH, 37% of TAH
40% - 50% of all ureter injuries; no identifiable predisposing
factors; ‘routine surgery’
Harkki-Siren 1999; all gynae laparoscopies; urinary injury
2.5/1000.
Total major complications reduced (4.9% to 2.3% over 3 years)
Ureteral complications remained static at 1% of laparoscopic
hysterectomies.
Inherent nature / intrinsic nature ? ....apologetic/guilty surgeon
Learning curve ?
Surgical expertise; lower in university hospitals (0.9% vs 2.6%)
33%
Laparoscopic
Open
56%
Injury was in most cases located in the lower ureter (89%).
Diagnosis; usually delayed (in 79%), with a median time to diagnosis of 6 days.
Urinary tract injury in Gynaecological laparoscopic surgery; 0.3% - 4% (LAVH
0.49%, TLH 4%)
The risk of injuries especially to the ureter, is
increased with the laparoscopic approach.
lack of tactile sensations;
decreased mobility for manipulation;
reduced visual field, depth perception &
panoramic view
reluctance of the gynecologist to gain entry into
the retroperitoneal space;
suboptimal knowledge of pelvic anatomy;
reliance on hemostatic energy devices and
stapling tools (not commonly used in open
surgery); Baggish 2010 – 67% of ureteral injuries
due to stapling, harmonic, tissue sealing devices
Ureter and bladder are always
anatomically close to major vasculature
that is cut in major gynaecologic surgery
Urinary tract injury in gynaecologic surgery
commonly ends in litigation
Medical negligence or unavoidable
complication ?
Litigation Rate
Urinary tract injury
56%
Other complications
23%
Favourable legal outcome
Intraoperative recognition
82%
Postoperative recognition
60%
Gilmour; 2005, Obstet Gynecol
Patients
Total (%) Bladder (B)
Injury (%)
Ureter (U) Detected
Injury (%) before
cystoscopy
(%)
Detection
rate after
cystoscopy
(%)
Vakili 2005 471
4.8
3.6
1.7
U 12
B 35
96
Ibeanu
2009
4.3
2.9
1.8
U7
B 37
97.4
839
Gilmour 1999; 11.5% of ureteral injuries and 51.6% of bladder injuries
detected intraoperatively without cystoscopy
Ibeanu; 2009, Obstet Gynecol; 75% of urinary tract injury were unsuspected
prior to cystoscopy
Baggish; 2010, Journal Gyneco Surgery; over 24 years, 75 cases of urinary
tract injury in gynecologic laparoscopy cases ; only 27% diagnosed intraoperatively,
50% in the late postoperative period
Dwyer; 2010, Int Urogynecol J
Advantages
Disadvantages
Early diagnosis/repair
Time
Other bladder pathology
Cost (Visco 2001; cost effective if
ureteral / bladder injury is > 1.5% - 2%)
Educational
Morbidity
If routine; quick, efficient
Lack of training (easy, straightforward)
Baggish 2010;
“2 patients had kidney loss……
There is no better case example for the proponents of timely diagnosis
(liberal use of cystoscopy)
and timely treatment than this sort of catastrophe”
Negligence: failure to act as a reasonably well qualified doctor
would have acted under similar circumstances
Not Negligent: body of fellow practitioners would have acted in
the same way in the same situation then not negligent
“Reasonable clinical practice”....variations in clinical
practice....Clinical Practice guidelines based on expert opinion,
clinical research (NICE, RCOG, NHMRC)....will provide answers in
court
4 questions:
Operation performed to adequate standard
Urinary tract injury; is it a recognised complication even with careful
technique
When should it be detected; intraoperatively or was the delay
reasonable (bladder injuries more likely to be recognized than ureteral
injuries without cystoscopy). Most injuries are still diagnosed
postoperatively (only 1 in 3 bladder injuries, 1 in 10 ureter injuries are
diagnosed intraoperatively without cystoscopy)
Would the outcome be different if detected intraoperatively (at present
most gynaecologists do not perform cystoscopy even in difficult surgery)
therefore not negligent as not widely accepted practice but could be
seen as an unavoidable complication
Dwyer; 2010, Int Urogynecol J
ACOG; 1997, at the conclusion of any pelvic procedure
both ureter & bladder should be inspected to confirm
their integrity
ACOG; 2007, cystoscopy to rule out cystotomy and
intravesical or intraurethral suture or mesh and to
check bilateral ureteral patency during or after certain
procedures……those procedures with relatively high
risk of these complications (1-2%) may benefit from
cystoscopy.
Linda Brubaker 2009 Obstet Gynaecol; hysterectomyassociated urinary tract injury is a preventable
morbidity; more palatable to incorporate cystoscopy
instead of suffering medicolegal action
Prevention of injury
Early recognition
If we assume it is unavoidable in some cases,
then early recognition becomes an obvious
choice especially with increased emphasis on
patient safety
Good data supports routine cystoscopy
following major laparoscopic surgery (Ko 2008,
Vakili 2005, Gustilo-Ashby 2006)
100% detection rate ureteral injury
94% detection of bladder injury
Negative predictive value; 99.8%
One injury missed, presented with VVF; tissue
ischaemia/necrosis (Fasolino 2002; 2 VVF after
LH despite normal cystoscopy
Thermal injuries to ureter; later onset
Iatrogenic ureteral injuries have increased markedly
during the past two decades.
Gynaecological laparoscopic procedures account for
more than half of the injuries, and the most common
location is the lower ureter.
To improve the management of ureteral injury there
must be a high index of suspicion, especially in
laparoscopic operations.
Universal cystoscopy with indigocarmine dye increases
the detection rates, avoids diagnostic delay
“Never Events” Would you leave out a
swab or instrument count ? “Time out” is
a risk management requirement.
It is ultimately a surgeon’s individual
decision – remember your patient’s safety
depends on your decision
Selective cystoscopy = low % of patients
will leave theatre with an untreated lower
urinary tract injury
“should or could the urinary tract injury
have been detected intraoperatively to
avoid further complications and delayed
corrective surgery ?”