CASE REPORT
IATROGENIC INJURIES OF THE URINARY TRACT IN WOMEN UNDERGOING
PELVIC SURGERIES
Padmasri R1, Jnaneswari T.L2, Rupa S. Iyengar3, Urvashi Bhatara4, Priyadarshini B5
HOW TO CITE THIS ARTICLE:
Padmasri R, Jnaneswari TL, Rupa S. Iyengar, Urvashi Bhatara, Priyadarshini B. “Iatrogenic injuries of the urinary tract
in women undergoing pelvic surgeries”. Journal of Evolution of Medical and Dental Sciences 2013; Vol2, Issue
49, December 09; Page: 9476-9480.
ABSTRACT: Iatrogenic injury to the urinary tract during Obstetric and Gynaecologic surgery can be
a source of significant morbidity. Urologic injury during pelvic surgery is primarily a matter of
prevention; should it occur however prompt recognition and appropriate management are essential.
The most commonly injured organs are the bladder, ureter and urethra. Whenever anticipated, prior
delineation of the course of the pelvic ureter by exposing its course and frequent visualisation
throughout the surgery prevents most of the injuries. Three different cases of iatrogenic injuries at
different sites in the urinary tract are presented here and their preventive and treatment aspects are
discussed.
KEY WORDS: Urinary tract, trauma, stent, cystoscopy
INTRODUCTION: Few complications of gynaecologic surgery create more anxiety and medico-legal
concerns than lower urinary tract injuries. The anatomic proximity of the reproductive and lower
urinary tracts predisposes them to iatrogenic trauma during obstetric and gynaecological surgery.
Bladder is the most common urologic organ injured during surgery. An incidence of 1.8% of bladder
injuries during LSCS has been reported [1]. Though incidence of ureteral injuries is almost similar in
abdominal and vaginal hysterectomy, hardly one third of them are recognised intra operatively. This
leads to renal damage in 25% of such cases resulting in morbidity and mortality. Obstetrics and
Gynaecologic surgeries account for more than 60% of urologic injuries, higher than the urologist or
the general surgeon. To decrease the rate of morbidity, the gynaecologist surgeon must be able to
anticipate the potential apparition of a specific urologic lesion, based on the risk factors of the
patient, so that he/she can then prevent the iatrogenic trauma [2]. A series of three cases with
urologic injuries is discussed below.
CASE 1: A 42 year old parous lady presented with symptoms of dysmenorrhoea, increased
frequency of micturition and occasional retention of urine. She was found to have a large posterior
wall cervical fibroid (10x8x6 cm) indenting the posterior bladder wall. She was posted for total
abdominal hysterectomy. During surgery, uterus was highly vascular, leading to lot of haemorrhage,
resulting in blind clamping. There was difficulty in clamping lower pedicles, with clamps being
applied lateral to the tumour. After hysterectomy, it was found that the ureter on the left side had
been transected with urine spurting out. Cystoscopy revealed that the ureter on the right side was
included in the last ligature. Both ureters were stented and end to end anastomosis of the ureters
was done. [Fig 1]
CASE 2: A 17 year old girl with primary amenorrhoea was diagnosed as having vaginal agenesis. She
was posted for reconstructive surgery of the vagina. Dissection during surgery resulted in
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CASE REPORT
inadvertent injury to the trigone of the bladder. The injury was closed with cystoscopic visualisation
and temporary ureteral stenting.
CASE 3: A 37 year old multigravida with term pregnancy presented with severe pregnancy induced
hypertension with intrauterine foetal death. She had a previous caesarean section. She was induced
with prostaglandin gel and then augmented with oxytocin. When uterus suddenly relaxed she was
suspected of having a uterine rupture. During surgery, the bladder was found to be densely
adherent. The baby was extracted with help of a single forceps blade (vectis) resulting in a tear in
the fundus of the bladder. [Fig 2] Vesicorrhaphy was done. Continuous bladder drainage was kept
for 14days.
DISCUSSION: Although most cases of ureteral injury occur in patients without significant risk
factors, the incidence of urinary tract injuries increases in patients with prior pelvic operations,
extensive endometriosis, inflammatory bowel disease, pelvic inflammatory disease, and in patients
with extensive neoplasms causing distortion of normal surgical planes [3]. Mechanisms of injury to
the ureter include crushing, ligation, transection (partial/complete), angulation, ischaemia and
resection [4]. Ureteric injuries usually involve the pelvic ureter. The common sites of injury are
ovarian vascular pedicle at infundibulo-pelvic ligament, the ureteric relation with the uterine artery,
where it crosses under the artery, cardinal ligament tunnel, dorsal to the infundibulo -pelvic
ligament near or at the pelvic brim, vaginal fornices and lateral rectal pedicles. An excretory
urogram in difficult cases such as pelvic adhesions, endometriosis, large pelvic tumours and radical
surgeries is a primary preventive measure. This along with preliminary finger dissection and
identification of ureter, per operative ureteral catheterization and avoiding blind clamping during
surgery help to reduce injuries. Ureter identification during a surgical procedure has been reported
to range from an invasive procedure to a very minimal surgical procedure. Prophylactic ureteral
catheterization may reduce the chance of a ureter injury. Until recently, ureter identification would
consist of placement of catheters that could only be detected by palpation either by hand or
laparoscopic instrument. Then came the use of visual identification of the ureters with lighted
ureteral stents during gynaecologic procedures. As it causes transient haematuria and infrequent
reflux anuria, it’s not used nowadays [5]. Ureteral stent placement to localize the ureters during
operations is an invasive procedure. The non invasive novel technique of gamma probe localization
of the ureters by using technetium Tc 99m-labeled diethylenetriaminepentaacetic acid ((99m) TcDTPA) administered intravenously before localization is being considered by some [6]. Ureteral
imaging using Methylene blue near infrared (MB NIR) fluorescence provides sensitive, real-time,
intraoperative identification of the ureters during open and laparoscopic surgeries[7]. Post
hysterectomy cystoscopy done routinely, especially in difficult cases, with the identification of the
ureteric jets of urine help in recognising most of the ureteric injuries other than thermal injuries
which take about seven days to manifest. Recognition of ureteral injury during surgery and
immediate repair is ideal and a secondary preventive measure. Usually an ureteroureterostomy in
upper one third injuries or an ureteroneocystostomy with a Boari flap or psoas hitch, if required, for
a tension free anastomosis, in middle third and lower one third, respectively, is carried out. [8]
In the second case the preventive aspect focuses on imaging modalities. Imaging assists in
identifying the distances between vagina, rectum and bladder. Trans rectal ultrasonography
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CASE REPORT
provides an accurate map of the pelvic organs showing the precise distances between the urethra
and bladder anteriorly, rectum posteriorly, retrohymenal fovea caudally, and pelvic peritoneum
cranially. Transrectal ultrasonography produces a picture that corresponded perfectly with the real
anatomical situation [9]. Transperineal sonography is used to determine the length of a low lying
obstruction. The distance between the perineal surface and the caudal aspect of the distended
vagina can be measured with electronic callipers on the transperineal sonograms. This information
is useful when planning reconstructive surgeries [10]. Transperineal or translabial sonography can
be used where vaginal access is difficult. Sonocolpography is another technique for preoperative
assessment, using a vaginal balloon and transabdominal ultrasonography. This is done by pushing
the balloon maximally inward and determining the ability of the echoes of the vaginal pouch to
accommodate the balloon to stretch and to cross over the defect. This cross-over test can also
anticipate the need for surgery [11]. Magnetic resonance imaging (MRI) is the diagnostic tool in
partial or complete vaginal agenesis. It’s advisable to take time for pre-operative assessment during
vaginal surgeries since injuries usually involve the base of bladder with trigone and ureters.
Whenever the trigone of the bladder is injured, prophylactic ureteral stenting must be done to
prevent fistula formation, as was done in our case.
With liberalization of indications for caesarean section it is now the most common surgical
procedure performed on women worldwide. Hence, the incidence of bladder injuries during
caesarean section has risen. Bladder injury during caesarean section may occur by failure to empty
the bladder pre op, inadequate bladder flap reflection or extension of the incision into vagina [12].
Previous caesarean section, stage of labour and station of the head being other aetiological factors.
Techniques of caesarean section continue to be revised. A recent evidence based study says the
creation of bladder flap during the surgery is not required [13]. If the uterine incision is made
slightly above the vesicouterine peritoneal fold, the loose connective tissue between the uterus and
the urinary bladder allows spontaneous descent of the bladder [14]. This could be a double edged
sword, inadvertently increasing the risk of injury. The single blade of forceps, used as a vectis, for
extraction of foetal head, as in this case, can cause lateral and vertical extensions and bladder injury.
Fundal, anterior wall and intraperitoneal injuries should be surgically repaired on identification.
Extra peritoneal injuries of bladder need not be repaired and tend to heal by themselves. The altered
colour of the urine in the urobag is a significant sign in identifying ureteric injuries. Posterior wall of
bladder should always be checked for integrity of trigone and proximity of ureters. Since in our case
it was a tear in fundus of bladder, repair was done by primary surgeon, as there was no ureteric
injury. Cystoscopy, retrograde cystography or computed tomographic (CT) cystography will aid in
identification of site of injury, CT being the gold standard in delayed identification [15]. Cystotomy
when adequately repaired is not associated with any complications.
CONCLUSION: The proximity of the female genital and lower urinary tracts naturally results in a
degree of structural and functional interdependence. Traditional boundaries between some areas of
surgical specialisation need to be reduced with cross boundary training like cystoscopy. The
technology exists today to essentially prevent injuries to the lower urinary tract and should be used
in any surgical procedure where the potential for lower urinary tract injury exists. A surgeon with
no complications is the one who doesn’t operate! Despite such precautions injuries do occur and
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CASE REPORT
immediate recognition and prompt treatment goes a long way in reducing the morbidity. The
Gynaecologists need to be “ureter conscious” and “bladder savvy”.
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CASE REPORT
Fig 1 - Cystoscopic ureteric stenting of right
ureter
Fig 2 - Single blade of outlet forceps being
used as vectis to extract foetal head
4.
AUTHORS:
1. Padmasri R.
2. Jnaneswari T.L.
3. Rupa S. Iyengar
4. Urvashi Bhatara
5. Priyadarshini B.
PARTICULARS OF CONTRIBUTORS:
1. Associate Professor, Department of Obstetrics
& Gynaecology, Sapthagiri Institute of Medical
Sciences and Research Centre, Bangalore.
2. Assistant Professor, Department of Obstetrics
& Gynaecology, Sapthagiri Institute of Medical
Sciences and Research Centre, Bangalore.
3. Professor and HOD, Department of Obstetrics
& Gynaecology, Sapthagiri Institute of Medical
Sciences and Research Centre, Bangalore.
5.
Assistant Professor, Department of Obstetrics
& Gynaecology, Sapthagiri Institute of Medical
Sciences and Research Centre, Bangalore.
Assistant Professor, Department of Obstetrics
& Gynaecology, Sapthagiri Institute of Medical
Sciences and Research Centre, Bangalore.
NAME ADRRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Padmasri R.,
No. 3, Flat No. 002,
“Renaissance Nest”, 17th A Cross,
11th Main, Malleshwaram,
Bangalore – 560055, Karnataka State, India.
Email – drpadmasuraj@gmail.com
Date of Submission: 15/11/2013.
Date of Peer Review: 16/11/2013.
Date of Acceptance: 25/11/2013.
Date of Publishing: 03/12/2013
Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 49/ December 09, 2013
Page 9480