Diagnosis and Management of
Urologic Injuries in Gynecologic
Surgery
Marisa Adelman, MD
Assistant Professor
Dept. Obstetrics & Gynecology
Incidence
• Hysterectomy (meta-analysis)
– Overall urologic injury: 73/10,000 (0.73%)
– Bladder injury: 5-66/10,000 (0.05-0.6%)
– Ureteral injury: 2-40/10,000 (0.02-0.4%)
• 19.7% repeat surgical rate with injury
• 3.4% vesicovaginal fistula rate with injury
• 2.4% ureterovaginal fistula rate with injury
Adelman MR, Bardsley TR, Sharp HT. J Minim Invas Gyn, 2014.
Incidence
• Adnexectomy:
– Ureteral injury: 0.1%
• Pelvic organ prolapse:
– Ureteral injury: up to 11%
• Slings:
– Bladder injury:
• TVT: 3-9%
• TOT: 0.5%
Prevention and Detection
• Bladder injury:
84.2% with delayed injury require reoperation
• Ureteral injury:
60.7% with delayed injury require reoperation
• Intraoperative recognition and primary repair:
– Decreases secondary surgical procedures
– Decreases morbidity: fistula and loss of renal function
Dissection of the ureter
• Selective dissection:
– Presence of adhesions
• Endometriosis
• Prior surgery
• Pelvic radiation
– High-risk procedures
• Malignancy
• Fibroids near ureter
• Routine dissection:
– Results in bleeding
– Can obscure anatomy
– Can obscure tissue planes
Bladder distension
• Bladder is insufflated
with liquid or C02
• Typical volume is 200250 mL
• Laparoscopic guidance.
Cystourethroscopy
• Routine use recommended by ACOG for:
– All prolapse and incontinence procedures with a 1-2%
risk of injury to the urogenital tract:
• TVT
• Burch colposuspension
• High uterosacral ligament vaginal vault suspension
– High-risk procedures which may benefit:
• McCall culdoplasty
• Colpocleisis
• Advanced vaginal and laparoscopic procedures
• When injury rate exceeds 2% in hysterectomy
– Cost-effective to perform routinely
Cystourethroscopy
• IV indigo carmine:
– Evaluate for ureteral kinking or transection
 Following suspension procedures
 Following difficult dissections
– Alternatives:
• Oral phenazopyridine
• Sodium fluorescein
Universal preoperative stenting:
Why consider it?
• Cost of an undiagnosed ureteral injury
requiring readmission and repair:
– 1.72 times cost if repaired at time of injury
– 2.29 times cost if no injury
Schimpf MO, et al. BJOG, 2008.
Universal stenting?
• 12 year prospective randomized trial of >3,000
patients undergoing major Gyn surgery:
– Universal stenting: 19 ureteral injuries
– No stenting: 17 ureteral injuries
• Decision analysis:
– At a ureteral injury rate of 3.2%, universal stenting
becomes minimally cost-saving.
Chou MT, et al. Urogynecol J Pel, 2009.
Universal stenting
• The cost savings depends upon the injury rate
 Minimal benefit at common levels
• Does not prevent injuries
• May aid in recognition
 Limited data to support
• Selective use may help identify the course of
the ureter.
Prophylactic stenting
Prudent if extensive devascularization suspected:
• Ureterolysis
• Thermal injury
Indocyanine green
• Can be injected into the ureter
• Fluoresces in response to near-infrared laser
• Utilized in a variety of specialties:
– Optho: retinal angiography
– CV: Cardiac function testing
– General surgery: intraoperative tissue viability
Role of Urologists
• 13,010 OB/Gyn procedures
 98 consultation requests
 29 for preoperative ureteral stents
 69 cases of suspected injury
• 32 bladder injuries
28 Dx’ed by operating OB/Gyn
23 to the dome, 9 to the posterior wall**
• 11 ureteral injuries
1 Dx’ed by operating OB/Gyn
Tx’ed with stenting, repair, and reimplantation**
Hammad FT, et al. Int Urogynecol J, 2010.
Intraoperative diagnosis
Postoperative diagnosis
Symptoms of Urologic Injury
Cystotomy or ureteral
defect
Ureteral obstruction
Fistula formation
Intraureteral or intravesicle
mesh
Profuse drain output
Flank or abdominal pain
Urinary incontinence
Hematuria
Profuse wound leakage
Anuria
Watery vaginal discharge
Dysuria
Ileus
Recurrent urinary tract infection
Fever
De novo urinary urgency
Peritonitis
Urge incontinence
Hematuria
Pelvic pain
Cystography
• Cystogram:
– Plain film with instillation of radiocontrast
– Information on integrity and contour
• Voiding cystogram
– Provides real-time information as the patient voids.
– May demonstrate extravasation or ureteral reflux
• CT cystogram
– Addition of radiocontrast in the bladder prior to
performance of a CT.
Cystography
Urography/pyelography
• Intravenous pyelography (IVP)
– Plain film x-rays following IV contrast administration.
– Can identify stricture or obstruction.
– Provides information on functionality.
• Retrograde pyelography
– Performed under fluoroscopy with cystoscopy
– Contrast media is injected into the ureters
• CT IVP
• MRI IVP
Pyelography
Ultrasonography
• Non-specific
• Can visualize:
– Hydronephrosis
– Ureteral jetting
– Free fluid/ascites
• Identifies need for
additional imaging.
Choice of postoperative imaging
High suspicion
Bladder injury
Cystogram or
CT cystogram
Urinary tract
injury suspected
Renal, pelvic, and
bladder ultrasound
ultrasound
Ureteral injury or
unknown location
CT IVP or retrograde
pyelogram
Low suspicion
Hydronephrosis
and/or absent
ureteral jets
Ascites and/or
fluid collection
Suspect obstruction
Suspect leak
(bladder and/or ureteral)
CT IVP or retrograde
pyelogram
CT IVP +/- CT cystogram
Cystoscopy with
retrograde pyelogram
if non-diagnostic
Diagnosis of a fistula
• Suspected based on urinary pattern alterations:
– Total urinary incontinence  vesicovaginal fistula
– Normal voiding with vaginal leakage  ureterovaginal fistula
• Confirmed with in-office testing:
– Oral phenazopyridine prior to the study
– Instillation of dilute indigo carmine or methylene blue into the
bladder
– Tampon placed in the vagina
• Localized with imaging:
– Cystoscopy  vesicovaginal
– IVP  ureterovaginal
– MRI  Small or in close approximation to trigone
Management: Bladder injuries
• Dome
– <2 mm: no repair, no prolonged drainage
– >2 mm, <1 cm: drainage for up to 7 days
– 1-2 cm: single layer absorbable suture
– >2 cm: double layer absorbable suture
• Foley drainage for 5-14 days, depending upon extent.
– Multiple small cystotomies:
• May be connected
• Repaired as a single cystotomy.
Management: Bladder injuries
• Trigone:
– May occur with injury to the ureters and urethra
• Integrity of these structures must be assessed
– Exposure may be difficult
– Should involve someone with
advanced urologic training.
Role of cystography
• Repair of simple defect: may not need
cystogram prior to removing Foley.
• Repair of complex defect: should obtain
cystogram prior to removing Foley.
• Time to bladder healing varies
– If treating a 3-9 mm defect with drainage alone,
perform cystogram prior to removing Foley.
Management: Ureteral injuries
• Kinking:
– Remove suture to relieve kinking and obstruction
• Ligation and crush:
– Can cause devascularization
– Remove stitch and assess viability
– Stent for minor damage
– Resect + anastomose or reimplant for major damage
Stents and drains
• Role of stents:
– Promote healing
– Prevent extravasation
– Prevent stricturing
• Role of drains
– Keep anastomosis dry
– Inform when leaking
Management: Ureteral injuries
• Laceration:
– <1/2 diameter of ureter
 Repair over a stent
 Interrupted dissolvable sutures
 Drain placement
– >1/2 diameter of ureter
 Treat like a transection
Management: Ureteral injuries
• Transection
– Goals of repair:
• Adequate debridement
• Tension-free
• Watertight
– Repair by location:
• Distal 1/3: Reimplantation +/- psoas hitch
– Anastomosis acceptable if injury accessible
• Mid 1/3: Anastomosis or reimplantation + boari flap
• Proximal 1/3: Anastomosis or reimplantation + boari flap
Management: Ureteral injuries
• Thermal:
– Stent for minor damage
– Resect + anastomose or reimplant
– Omental flap for vaginal incision or concomitant
bowel injury in close proximity
Ureteral repair follow-up
• Foley catheter
– Remove 1-2 weeks postoperatively
 Following cystogram confirmation of no leak
• Ureteral stent
– Remove 1-2 months postoperatively
Followed by cystogram or IVP to assess the anastomotic site
• Long-term function
– Appropriate kidney function and absence of a stricture
should be assessed at 3-6 months and 12 months
 Can be done with IVP, renal ultrasound, and serum creatinine
Fistula management
• Primary Tx: drainage
– VVF: Foley catheter
– UVF: Ureteral stent
• Secondary treatment: surgical repair
– VVF: incise epithelium around fistula  mobilize tissue 
excise fistulous tract  close defect in layers  confirm
water-tight bladder repair avoid overlapping suture
lines.
– UVF: incise above fistula  reimplant ureter  ligate
distal portion of ureter near fistula.
References
• Adelman MR, Bardsley TR, Sharp HT. Urinary tract injuries in
laparoscopic hysterectomy: a systematic review. Journal of
minimally invasive gynecology. Jul-Aug 2014;21(4):558-566.
• Brummer TH, Jalkanen J, Fraser J, et al. FINHYST, a prospective
study of 5279 hysterectomies: complications and their risk factors.
Human reproduction (Oxford, England). Jul 2011;26(7):1741-1751.
• Lafay Pillet MC, Leonard F, Chopin N, et al. Incidence and risk factors
of bladder injuries during laparoscopic hysterectomy indicated for
benign uterine pathologies: a 14.5 years experience in a continuous
series of 1501 procedures. Human reproduction (Oxford, England).
Apr 2009;24(4):842-849.
• Ibeanu OA, Chesson RR, Echols KT, Nieves M, Busangu F, Nolan TE.
Urinary tract injury during hysterectomy based on universal
cystoscopy. Obstetrics and gynecology. Jan 2009;113(1):6-10.
References
• Schimpf MO, Gottenger EE, Wagner JR. Universal ureteral stent
placement at hysterectomy to identify ureteral injury: a decision
analysis. BJOG : an international journal of obstetrics and
gynaecology. Aug 2008;115(9):1151-1158.
• Chou MT, Wang CJ, Lien RC. Prophylactic ureteral catheterization in
gynecologic surgery: a 12-year randomized trial in a community
hospital. International urogynecology journal and pelvic floor
dysfunction. Jun 2009;20(6):689-693.
• O'Hanlan KA. Cystosufflation to prevent bladder injury. Journal of
minimally invasive gynecology. Mar-Apr 2009;16(2):195-197.
• Siddighi S, Yune JJ, Hardesty J. Indocyanine green for intraoperative
localization of ureter. American journal of obstetrics and
gynecology. Oct 2014;211(4):436.e431-432.
References
• Lee Z, et al. Urology 2013; 82:729-33.
• Hammad FT, AlQaiwani KM, Shirodkar SS. The role of urologists in
the management of urological injuries during obstetric and
gynaecologic surgery. International urogynecology journal. Oct
2010;21(10):1237-1241.
• El-Tabey NA, Ali-El-Dein B, Shaaban AA, et al. Urological trauma
after gynecological and obstetric surgeries. Scandinavian journal of
urology and nephrology. 2006;40(3):225-231.