UROGENITAL TRAUMA

Analysis of urologic complications after radical hysterectomy
Likic IS, Kadija S, Ladjevic NG, Stefanovic A, Jeremic K, Petkovic S, Dzamic Z
Institutes of Gynecology and Obstetrics, Clinical Centre of Serbia, Belgrade, Serbia
Am J Obstet Gynecol. 2008; 21. [Epub ahead of print]

• Objective: Injuries of the ureter or bladder or development of vesicovaginal and ureterovaginal fistulas are the most serious complications in gynecological surgery.
• Study Design: This study included 536 women who underwent radical hysterectomy because of invasive cancer of the cervix uteri.
• Results: During the surgery the ureter was injured in 1.32% of cases, whereas the percentage of bladder injuries was 1.49. In the early postoperative period vesicovaginal or ureterovaginal fistulas appeared in 2.61% and 2.43% of cases, respectively.
• Conclusion: The stage of the disease, obesity, diabetes, and postoperative surgical infection acted as predisposing factors of the urinary tract complications.
  
  
• Editorial Comment
  Lower urinary tract injury during gynecologic surgery is relatively uncommon. Bladder injuries are the predominant iatrogenic urologic injury. Bladder injuries are usually recognized and repaired immediately, and potential complications are typically minor. Ureteral injuries, however, are typically recognized in a delayed fashion and have the potential to be life threatening, or result in permanent kidney damage or nephrectomy.
  Iatrogenic ureteral injuries are a potential complication of any open or endoscopic pelvic operation. Gynecologic surgery accounts for roughly 75% of all iatrogenic ureteral injuries, with the remaining occurring during colorectal, general, vascular, and urologic surgery. The ureter is injured in roughly 0.5-2% of all hysterectomies and routine gynecologic pelvic operations and in about 2-10% of all radical hysterectomies. Likic et al. report a lower rate of ureteral injury of only 1.32%, but this reported decline over the years is due to improved patient selection, surgery limitation to mostly low-stage disease, decreased use of preoperative radiation, and modifications in surgical technique that limit extreme skeletonization of the ureter. Of iatrogenic ureteral injuries from gynecologic surgery, roughly 50% are from radical hysterectomy, 40% from abdominal hysterectomy, and < 5% from vaginal hysterectomy. All gynecologic ureteral injuries occur to the distal third of the ureter. Ureteral injuries during laparoscopic gynecologic surgeries typically occur during laser ablative endometriosis surgery or laparoscopic assisted vaginal hysterectomy. In gynecologic surgery, bladder injury most commonly occurs during abdominal hysterectomy. The bladder can be injured at four specific sites, on incising the parietal peritoneum, entering the vesicouterine fold, separating the bladder from the uterine fundus, cervix, or upper vagina, entering the anterior vagina, or on mobilizing or suturing the vaginal vault. If a bladder injury is noted at this time, it can usually be easily managed by a 2 or 3 layer closure. Retrograde bladder filling with blue colored saline facilitates bladder injury diagnosis. Undiagnosed intraoperative injuries to the bladder typically present days to weeks after surgery. In patients with prior pelvic irradiation, fistulas can present months to even years after hysterectomy.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA
E-mail: brandess@wudosis.wustl.edu