Urinary tract injuries in laparoscopic gynaecological surgery

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 3 – C O R E S U R G I C A L S K I L L S

Urinary Tract Injuries in Laparoscopic Gynaecological Surgery Minas V et al. Urinary tract injuries in laparoscopic gynaecological surgery: prevention, recognition and management. TOG 2014;16:19–28. doi:10.1111/tog.12073

0.02–8.3% <1–2% 91× BLADDER INJURY INCIDENCE URETERIC INJURY INCIDENCE LITIGATION RISK VS OTHER COMPLICATIONS

DO N' T-M IS S FA C TS

  1. Urinary tract injury = commonest major laparoscopic complication; 91× higher litigation risk than other complications

  2. Avoid suprapubic Veress needle insertion (RCOG); insert secondary trocars under direct vision

  3. Retro-pubic (space of Retzius) bladder injury may not leak intraperitoneally – cystoscope if any suspicion

  4. ~50% bladder and ~2/3 ureteric injuries missed intraoperatively; watch catheter bag for gas/blood, check for haematuria

  5. Bladder repair: absorbable 2-0/3-0 suture, watertight, catheter 2 weeks; VVF still occurs in ~5%

  6. Ureteric injury sites: pelvic brim (infundibulopelvic ligament) and lateral to cervix (uterine vessels/uterosacral-cardinal ligaments)

  7. Repair by site: upper third = uretero-ureterostomy; middle third = uretero-ureterostomy/trans-uretero-ureterostomy; lower third = uretero-neocystostomy ± psoas hitch/Boari flap

  8. Up to 25% of unrecognised ureteric injuries → loss of ipsilateral kidney

INJURY SITE VS REPAIR (QUICK RECALL)

Upper third → uretero-ureterostomy Middle third → uretero-ureterostomy / trans-uretero-ureterostomy

Lower third → uretero-neocystostomy ± psoas hitch/Boari flap

ABBREVIATION KEY

LAVH — laparoscopic-assisted vaginal hysterectomy MRI — magnetic resonance imaging

TLH — total laparoscopic hysterectomy CT IVU — CT intravenous urogram

RCOG — Royal College of Obstetricians and Gynaecologists BMI — body mass index

CT — computed tomography VVF — vesico-vaginal fistula

IVU — intravenous urogram

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — 2014;16:19–28. doi:10.1111/tog.12073

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