Urinary tract injuries in laparoscopic gynaecological surgery; prevention, recognition and management

Abstract

Key content Injury of the urinary tract is the most common major complication of gynaecological laparoscopic surgery. Injury to either bladder or ureter results in significant morbidity for the patient and may lead to litigation. Knowledge of pelvic anatomy, training and meticulous technique are of paramount importance in reducing the incidence of urinary tract injury. Ideally an injury should be identified and repaired during the primary operation, but vigilance in the immediate postoperative period may result in early recognition and intervention. Learning objectives To understand the common risk factors of urinary tract injury at laparoscopy. To learn strategies to prevent injury where possible. To learn strategies for intraoperative and postoperative recognition and repair of such injuries. To understand the significance of multi‐disciplinary management of such injuries. Ethical issues Limited evidence shows that laparoscopic hysterectomy may carry a higher risk of urinary tract injury compared with abdominal hysterectomy. Should patients be counselled accordingly?

Urinary Tract Injuries in Laparoscopic Hysterectomy: A Systematic Review

“…We read with interest the review by Minas et al 1 and wish to comment on the subject of ureteric injury.…”

The diagnosis and management of ureteric injury after laparoscopy

“…Computer Tomography (CT) scans does not benefit to evaluate ureter injury, whereas a CT with delayed contrast would help in detect the injury [29,30].…”

“…The recommended amount of time for which the ureter should be stented in such cases, varies in the literature and case reports between 2 to 6 weeks [27,29,36]. Laceration is a partial opening of the ureter, which includes pinpoint defects and wider openings.…”

A Case of Iatrogenic Ureter Injury: Recent Diagnostic and Treatment Methods

“…If the ureteral orifices are visible on cystoscopy, presence of urinary flow therein may indicate at least absence of obstruction yet cannot exclude other types of injuries. Outflow of blood or air (in laparoscopic operations) from the orifice during cystoscopy are indirect findings of injury (9). If postop ureteral injury is suspected, urinomas, abscess formations and hydronephrosis may be detected by USG and/or contrast-enhanced CT, whereas CT urography may contribute to localization of the injury.…”

“…In minor injuries (clamp crush, needle injuries, etc. ), conservative treatment may be applied unless there is suspicion of ureter vitality and leak, and presence of peristalsis (9). As for injuries due to ligation and other basic injuries, stenting should be preferred to avoid potential stenosis and leaks (10,11).…”