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Avoiding lower urinary tract injury

OBG Manag. 2005 September;17(9):38-52

Urogynecologists discuss the rising injury rate, the reasons behind it, and techniques for safe and successful pelvic surgery.

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References

1. Karram MM, Segal JL, Vassallo BJ, Kleeman SD. Complications and untoward effects of the tension-free vaginal tape procedure. Obstet Gynecol 2003;101:929-932.

2. Rooney C, Crawford A, Vassaco B, Kleeman S, Karram M. Is cesarean section a risk factor for incidental cystotomy at the time of hysterectomy? Am J Obstet Gynecol. In press.

3. Samson JA. Ligation and clamping of the ureter as complications of surgical operations. Am Med. 1902;4:693.-

4. Wiskind AK, Thompson JD. Should cystoscopy be performed at every gynecologic operation to diagnose unsuspected ureteral injury? J Pelvic Surg. 1995;1:134-137.

5. St. Martin EC, et al. Ureteral injury in gynecologic surgery. J Urol. 1953;70:51-57.

6. Conger K, Beecham CT, Horrax TM. Ureteral injury in pelvic surgery: current thought on incidence, pathogenesis, prophylaxis and treatment. Obstet Gynecol. 1954;3:343-357.

7. Mann WJ, Arato M, Patsner B, et al. Ureteral injuries in an obstetrics and gynecology training program: etiology and management. Obstet Gynecol. 1988;72:82-85.

8. Stanhope CR, Wilson TO, Utz WJ, Smith LH, O’Brien PC. Suture entrapment and secondary ureteral obstruction. Am J Obstet Gynecol. 1991;164:1513-1519.

9. Vakili B, Chesson RR, Kyle BL, et al. The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy. Am J Obstet Gynecol. 2005;192:1599-1604.

10. Harris RL, Cundiff GW, Theofrastous JT, Yoon HW, Bump RC, Addison WA. The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery. Am J Obstet Gynecol. 1997;177:1367-1369.

11. Gill EJ, Elser DM, Bonidie MJ, Roberts KM, Hurt WG. The routine use of cystoscopy with the Burch procedure. Am J Obstet Gynecol. 2002;186:1108.-

12. Kwon CH, Goldberg RO, Koduri S, Sand PK. The use of intraoperative cystoscopy in major vaginal and urogynecologic surgeries. Am J Obstet Gynecol. 2002;187:1466-1471; discussion 1471-1472.

13. Tulikangas PK, Weber AM, et al. Intraoperative cystoscopy in conjunction with anti-incontinence surgery. Obstet Gynecol. 2000;95(6 Pt 1):794-796.

Fast Track

Most injuries occur during straightforward hysterectomies—Geoffrey Cundiff, MD

If the lower urinary tract is evaluated only when injury is suspected, a good number of injuries will be missed—Geoffrey Cundiff, MD

After abdominal surgery, assess the urinary tract via suprapubic telescopy or high extraperitoneal cystotomy—Mickey Karram, MD

Very little or no education is provided in preventing lower urinary tract injury—Alfred Bent, MD

Routinely mobilize the bladder flap using sharp dissection—never blunt dissection—Alfred Bent, MD

IN THIS ARTICLE

3 ways to prevent injury at abdominal hysterectomy
Protective tactics during vaginal hysterectomy
To safeguard the ureter, follow its course

OUR EXPERT PANELISTS

Moderator Mickey Karram, MD, Director of Urogynecology, Good Samaritan Hospital, Cincinnati, and Professor of Obstetrics and Gynecology, University of Cincinnati.
Matthew Barber, MD, MHS, Section of Urogynecology and Reconstructive Pelvic Surgery, Departments of Obstetrics & Gynecology and Urology, Cleveland Clinic, Cleveland.
Alfred Bent, MD, Head, Division of Gynecology, Department of Obstetrics and Gynecology, Dalhousie University, IWK Health Center, Halifax, Nova Scotia.
Geoffrey Cundiff, MD, Professor of Obstetrics and Gynecology, Johns Hopkins University, Baltimore.

Unfortunate but true: Many complications of pelvic surgery involve injury to the lower urinary tract—and many of these injuries go undetected and increase the patient’s risk of serious morbidity and the physician’s chances of being sued.

Even more unfortunate: These injuries are on the rise, thanks to the proliferation of anti-incontinence surgeries, greater use of laparoscopy, and the need for increasingly complex vaginal dissection.

Fortunately, most lower urinary tract injuries can be avoided, or at least detected early, and this discussion centers on techniques to accomplish those goals and ensure bladder integrity and ureteral patency.

The rising injury rate

There appear to be more injuries to the lower urinary tract arising from pelvic surgery. Why do you think that is?

BARBER: I think the increase is due to the increasing popularity of midurethral slings, such as the tension-free vaginal tape (TVT). With these blind retropubic procedures, the risk of bladder injury is approximately 5%, which is considerably higher than in most other procedures we perform.¹

Fortunately, the negative consequences of placing the TVT trocar into the dome of the bladder are minimal, since the trocar can be removed and placed in the appropriate location without the need for bladder repair and without causing long-term bladder dysfunction.

KARRAM: The higher rate of injury also may be linked, in part, to greater use of energy sources during laparoscopic surgery. Over the past 2 years, we have seen numerous cases of delayed injury to the lower urinary tract or bowel secondary to thermal damage from energy devices including electrosurgical instruments and ultrasonic shears.

BARBER: I think there is an increase in lower urinary tract and ureteral injury because of the rising popularity of operative laparoscopy. Lower urinary tract injury is certainly more common with laparoscopic hysterectomy than with abdominal or vaginal hysterectomy.

Increase has no single cause

BENT: There may be a small increase overall in lower urinary tract injury during pelvic surgery, since we now do more procedures that require complicated vaginal dissection and exploration of tissue planes in close proximity to the ureters. This has increased the rate of ureteral injuries.

There also have been a few more urethral injuries, again related to tension-free suburethral slings, most often involving the transobturator approach.

KARRAM: The higher rate of cesarean sections also plays a role. Many women undergoing hysterectomies have had 1 or more cesarean deliveries. We recently completed a study that shows that cesarean section is an independent risk factor for cystotomy at the time of hysterectomy.²

Unfortunately, many surgeons still use aggressive blunt dissection when they attempt to mobilize the bladder off the uterus—whether a hysterectomy is being performed abdominally or vaginally. This can lead to inadvertent entry into the bladder. For this reason, sharp dissection should always be used.

CUNDIFF: Based on my reading of the literature, the incidence of operative injury to the lower urinary tract during gynecologic surgery in general has not changed noticeably since Samson reviewed the subject in 1902³—although gynecologic surgery is the leading cause of such injuries and the leading cause of litigation against gynecologists.⁴

Most injuries involve hysterectomy

CUNDIFF: Most injuries occur during straightforward hysterectomies. Estimates of the prevalence of ureteral injury range from 0.4% to 2.4%.^5-8 Since most studies estimating prevalence have not evaluated the lower urinary tract in the whole study population, they may underestimate true prevalence. However, a recent study by Vakili and colleagues⁹ included universal endoscopy of all patients undergoing hysterectomy and reported rates of ureteral injury (1.7%) and bladder injury (3.6%) similar to those of less rigorous studies.

Avoiding lower urinary tract injury

References

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