Bladder and Ureteric Injury

Detection & Management

Dr. Raguram Ganesamoni
MS, MRCS (Glasg), MCh (Uro), Fellow Endourology
Consultant Urologist & Andrologist
Lifeline Hospital, Adoor
Introduction
Urinary tract injury the most common major complication

Unfortunately, many urinary tract injuries are not recognized

at the time

Significant morbidity to patient; can lead to litigation

Objectives
Knowledge of pelvic anatomy and risk factors

Meticulous technique (training)

Use of intraoperative aids

Prompt detection and repair

 Risk Factors for Injury

Endometriosis
Cancer
Adhesions (surgery/infection/inflammation/radiation)
Severe genital organ prolapse
Obesity
Pregnant uterus
 Bladder Injury
50-80% of iatrogenic injuries

Incidence range from 0.02% to 8.3%

Most common - dissection of bladder from cervix

Suprapubic insertion of Veress needle or a trocar

LAVH

Unsafe electrosurgery
 Intraoperative Recognition

About half of bladder injuries remain unrecognized

during the primary operation

Intraoperative recognition and repair

reduce morbidity
less likely to lead to litigation
Visual inspection of Urinary Tract
Diagnostic Findings:
Urine in the operative field
Defect in the bladder
Bladder catheter or mucosa exposed

Suspicious findings:
Blood in the bladder catheter (esp, if ongoing)
Gas in the urine or bladder catheter
 Measures for intraoperative recognition of injury

Intravesical instillation Saline, Methylene blue, Sterile

infant formula

Cystoscopy
Management of bladder injury
Suturing in one or two layers using a 2-0 or 3-0 absorbable
suture

Purse string or figure of 8 suture for small defect

Injuries involving the trigone

Avoid ureters & urethra
Ureteral stents must be inserted

Thermal injury 5 mm debridement

Management of bladder injury
Single or dual bladder drainage

Anticholinergics/Antibiotics

Bladder drainage for 2-3 weeks

Cystogram before removal

Up to 5% can still form a fistula

Postoperative Recognition
Suprapubic pain

Haematuria/Oliguria

Leakage of urine per vagina

Abdominal distention/ileus

Thermal injuries present late

Delayed Management
Cystoscopic examination/ CT Cystogram
Conservative vs Surgical repair
 Ureteric Injury
Incidence < 1% to 2 %

The most common sites of ureteric injury

pelvic brim
lateral to the cervix

Electrocautery 1/4th of ureteric injuries

Unconscious acceleration of surgery, judgement error

Higher the BMI, closer the ureter to cervix (12% - < 0.5 cm)
Prevention
Preoperative MR or CT Urogram in complex cases

Ureteric catheterization (Plain, IRIS, Uriglo, ICG with Infrared)

Intraoperative localization - peristalsis

Ureterolysis

Ureteroscopy
Infrared Illumination System
(IRIS)
Indocyanine Green (ICG)
 ICG
Abnormal Ureteric
Course viability
Intraoperative Recognition
Transection the most common Types of Ureteric
Only a third are recognized intraoperatively Injury
Cystoscopy - rules out only complete Angulation
obstruction Crush
Ligation
Retrograde ureterogram (Fluoro) Thermal
Stenting Laceration
Ureteroscopy Transection
Resection
Postoperative Recognition
Key Principle High index of suspicion

Delayed recovery
Flank pain and ank tenderness
Haematuria/oliguria
Watery vaginal leak
Ascites/Ileus

Thermal injury - delayed necrosis/stula (10 -14 days)

Postoperative Recognition
Ultrasonogram

CT urogram

Antegrade ureterogram

Cystoscopy with retrograde pyelogram

DTPA Scan
Ureteroureterostomy
Psoas Hitch
Boari Flap
 Take home messages
Adequate knowledge, training, technique

Preoperative planning and intraoperative aids

Prompt recognition and repair

Vigilance in postoperative period

Focus on what to preserve, not what to remove