Urologic injuries during gynecologic surgery, a 10-year review

Clinical efficacy of ureteroscopy-assisted laparoscopic ureteroplasty in the treatment of ureteral stricture after pelvic surgery

OBJECTIVE

This study is to investigate the safety and efficacy of ureteroscope-assisted laparoscopic ureteroplasty in treating ureteral stricture after pelvic surgery.

METHODS

A retrospective analysis of the clinical data of 95 patients treated for ureteral stricture at Ganzhou People's Hospital from June 2017 to March 2023 after pelvic surgery. In this group, 49 patients underwent ureteroscope and laparoscopic ureteroplasty under lithotomy position. The control group consisted of 46 patients who underwent simple laparoscopic ureteroplasty in a supine position. Postoperative data from both groups were collected and compared, including operation time, amount of blood loss during surgery, postoperative hospital stay, incidence of complications, success rate of ureteroplasty, and effectiveness of the operation.

RESULTS

The success rate of end-to-end ureteral anastomosis in the observation group was 93.88%, and the operation effectiveness rate was 100%. The success rate in the control group was 78.26% and the operation effectiveness rate was 89.1%.The average operation time and intraoperative blood loss in the observation group were (121.3 ± 44.6) min and (137.5 ± 34.2) ml, respectively, while in the control group they were (151.2 ± 52.3) min and (165.6 ± 45.8) ml, the difference were statistically significant (P < 0.05). The incidence of perioperative complications in the observation group was 2%, significantly lower than that in the control group (19.6%) (P < 0.05).

CONCLUSION

Ureteroscope-assisted laparoscopic ureteroplasty for ureteral stricture after pelvic surgery has the advantages of shortened operation time, increased success rate, and reduced incidence of complications, making it an optional surgical scheme in clinical practice.

Systematic review of urological injury during caesarean section and hysterectomy

INTRODUCTION AND HYPOTHESIS

We aim to review iatrogenic bladder and ureteric injuries sustained during caesarean section and hysterectomy.

METHODS

A search of Cochrane, Embase, Medline and grey literature was performed using methods pre-published on PROSPERO. Eligible studies described iatrogenic bladder or ureter injury rates during caesarean section or hysterectomy. The 15 largest studies were included for each procedure sub-type and meta-analyses performed. The primary outcome was injury incidence. Secondary outcomes were risk factors and preventative measures.

RESULTS

Ninety-six eligible studies were identified, representing 1,741,894 women. Amongst women undergoing caesarean section, weighted pooled rates of bladder or ureteric injury per 100,000 procedures were 267 or 9 events respectively. Injury rates during hysterectomy varied by approach and pathological condition. Weighted pooled mean rates for bladder injury were 212-997 events per 100,000 procedures for all approaches (open, vaginal, laparoscopic, laparoscopically assisted vaginal and robot assisted) and all pathological conditions (benign, malignant, any), except for open peripartum hysterectomy (6,279 events) and laparoscopic hysterectomy for malignancy (1,553 events). Similarly, weighted pooled mean rates for ureteric injury were 9-577 events per 100,000 procedures for all hysterectomy approaches and pathologies, except for open peripartum hysterectomy (666 events) and laparoscopic hysterectomy for malignancy (814 events). Surgeon inexperience was the prime risk factor for injury, and improved anatomical knowledge the leading preventative strategy.

CONCLUSIONS

Caesarean section and most types of hysterectomy carry low rates of urological injury. Obstetricians and gynaecologists should counsel the patient for her individual risk of injury, prospectively establish risk factors and implement preventative strategies.

Can preoperative ureteral stents reduce the incidence of ureteral stricture after radiotherapy in patients with cervical cancer?

Objective

To determine the impact of preoperative stent placement on postradiotherapy stricture rate in patients with cervical cancer after radical resection.

Methods

This study was a retrospective analysis of data collected from 55 cervical cancer patients treated with radiotherapy between June 2016 and June 2020. Patients were divided into the stent and control groups. After 3 months, the stricture rate and the complications related to stent placement between the two groups were compared.

Results

There were 12 (46.2%) and 10 (34.5%) cases of ureteral stricture in the stent (n = 26) and control (n = 29) groups, respectively, three months after the end of radiotherapy. The incidence rates of ureter stricture in the two groups were not significantly different (P = 0.378). Moreover, there were 20 units (38.5%) and 15 units (25.9%) ureteral strictures in the stent and control groups, respectively. No significant difference in the incidence rates of ureteral strictures was found between the two groups (P = 0.157). There were 13 (50.0%) and 10 (34.5%) cases of ureteral stricture in the stent (n = 26) and control (n = 29) groups, respectively, six months after the end of the radiotherapy. The incidence rates of ureter stricture in the two groups were not significantly different (P = 0.244). Moreover, there were 21 units (40.4%) and 15 units (25.9%) ureteral strictures in the stent and control groups, respectively. No significant difference in the incidence rates of ureteral strictures was found between the two groups (P = 0.105). Complications related to stent placement such as urinary tract infections and bladder irritation were statistically significant (P = 0.006 and P = 0.036) between the two groups; while the other complications were not significantly different (P = 0.070, P = 0.092 and P = 0.586).

Conclusions

Ureteral stents may not reduce the incidence of ureteral stricture after radiotherapy in patients with cervical cancer. The stent needs to be replaced regularly, and the complications related to stent placement may occur at any time. Thus, preoperative stent placement should be cautious for the clinical management of cervical cancer patients treated with postoperative radiotherapy.

Intraoperative injuries from abdominopelvic surgery: an analysis of national medicolegal data

Background

Intraoperative injuries during abdominopelvic surgery can be associated with substantial patient harm. The objective of this study was to describe abdominopelvic intraoperative injuries and their contributing factors among medicolegal cases.

Methods

This study was a descriptive analysis of medicolegal matters reported to a national body, with subgroup analyses by type of surgery. We reviewed medicolegal matters involving a population-based sample of physicians who were subject to a civil legal action or complaint to a regulatory authority that was closed between 2013 and 2017 in Canada.

Results

Our analysis included 181 civil legal cases and 88 complaints to a regulatory authority. Among legal cases, 155 patients (85.6%) (median age 47 yr) underwent elective procedures. The most common injury site was the bowel (53 cases [29.3%]). Injuries frequently occurred during dissection (79 [43.6%]) and ligation (38 [21.0%]), were identified postoperatively (138 [76.2%]) and necessitated further surgery (139 [76.8%]). Many patients experienced severe harm (55 [30.4%]) or died (25 [13.8%]). Peer experts in nongynecologic cases were more likely than those in gynecologic cases to include criticisms of a provider in a harmful incident (79 [71.2%] v. 30 [42.9%], p < 0.01). Peer expert criticisms often related to clinical evaluation, decision-making and misidentification of anatomy. Criticisms of nontechnical skills identified documentation and communication deficiencies.

Conclusion

This study confirms the importance of provider and team training to improve clinical evaluation and decision-making, documentation and communication. Effective protocols may help support clinicians in providing safer surgical care.

Pelvic dimension as a predictor of ureteral injury in gynecological cancer surgeries

BACKGROUND

Ureteral injury is an intractable complication in gynecological cancer surgeries. Identifying risk factors can ensure safety of the ureters intraoperatively. A narrow pelvis is known to exert extra difficulties in pelvic surgeries. However, whether pelvic dimension can affect the risk of ureteral injury in gynecological cancer surgeries is poorly understood. We aimed to evaluate the association between pelvic dimension and the risk of ureteral injury during gynecological cancer surgeries.

METHODS

All patients who had undergone gynecological cancer surgeries were searched from January 2011 to July 2017. We included patients with ureteral injury who had available data of abdominal and pelvic computed tomography for measuring pelvic dimensions. Multivariate condition logistic analysis was used to identify the risk factors independently correlated with ureteral injury in gynecological cancer surgeries.

RESULTS

A total of 43 cases with 86 controls were included in this study. We discovered that a longer anteroposterior diameter of the mid-pelvis (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.01-1.13, P = 0.019) and a shorter transverse diameter of the mid-pelvis (OR 0.92, 95% CI 0.86-0.98, P = 0.013) were associated with ureteral injury in gynecological cancer surgeries. In laparoscopic analysis, a longer anteroposterior diameter of the mid-pelvis (OR 1.11, 95% CI 1.00-1.24, P = 0.041) was a risk factor for ureteral injury. In the analysis of open surgery, a longer transverse diameter of the mid-pelvis (OR 0.79, 95% CI 0.66-0.93, P = 0.006) was a protective factor for ureteral injury.

CONCLUSIONS

This study demonstrated that mid-pelvis dimensions were associated with ureteral injury, but the observed differences were too small. In addition, pelvic inlet dimensions did not appear to relate with ureteral injury. Thus, these pelvimetry measures could not be beneficial in assessing the risk of ureteral injury in gynecological cancer surgeries.

Uterine manipulator requirement in laparoscopic surgery of Ectopic Pregnancy

Objective:

The advantages of laparoscopic surgery used in the treatment of ectopic pregnancy is well-known; however, the efficacy of uterine manipulators remains unknown. In this study, we aimed to investigate the efficacy of uterine manipulators in the laparoscopic treatment of ectopic pregnancy.

Methods:

Overall, 118 patients who underwent laparoscopy due to ectopic pregnancy in Department of Obstetrics and Gynaecology at Tepecik Education and Research Hospital between January 2010 and January 2018 and who met the inclusion criteria were included in the study. Groups of patients undergoing surgery with or without the use of a uterine manipulator were compared in terms of demographic data, operative and postoperative results.

Results:

No difference was noted between the groups in terms of age, parity, body mass index, smoking, side of ectopic pregnancy mass, previous operations and pregnancy type. However, the size of ectopic pregnancy mass measured by ultrasonography was significantly larger (p = 0.006) and the operation time was significantly shorter (p<0.001) in the group where uterine manipulators were not used than in the uterine manipulator group.

Conclusion:

We concluded that not using a uterine manipulator in laparoscopic procedures for ectopic pregnancy did not increase operative complications and that operation time was higher in procedures using uterine manipulators.

Bowel and Bladder Injury Repair and Follow-up After Gynecologic Surgery

Bowel and bladder injuries are relatively rare, but there can be serious complications of both open and minimally invasive gynecologic procedures. As with most surgical complications, timely recognition is key in minimizing serious patient morbidity and mortality. Diagnosis of such injuries requires careful attention to surgical entry and dissection techniques and employment of adjuvant diagnostic modalities. Repair of bowel and bladder may be performed robotically, laparoscopically, or using laparotomy. Repair of these injuries requires knowledge of anatomic layers and suture materials and testing to ensure that intact and safe repair has been achieved. The participation of consultants is encouraged depending on the primary surgeon's skill and expertise. Postoperative care after bowel or bladder injury requires surveillance for complications including repair site leak, abscess, and fistula formation.

Laparoscopic Surgery for Ovarian Cyst Infection with Avoidance of Ureteral Injury and Uterine Perforation following Intrauterine Insemination after Abdominal Modified Radical Trachelectomy

Pelvic inflammatory disease (PID) sometimes develops after intrauterine insemination (IUI). We herein present a case of PID which developed after IUI performed after abdominal modified radical trachelectomy (AmRT) and was treated with laparoscopic surgery. To our knowledge, this is the first case report of laparoscopic surgery for PID that occurred after AmRT in Japan. A 39-year-old woman who was diagnosed with cervical cancer stage IA1 with lymphovascular invasion underwent AmRT and pelvic lymphadenectomy. At 3 years and 6 months after the surgery, she had fever and pain in her left lower abdomen 10 days after IUI. She was diagnosed with PID with left ovarian cyst infection and underwent laparoscopic left ovarian cystectomy. Before surgery, bilateral ureteral catheters were inserted because of possible difficulty identifying the ureters. During surgery, severe adhesion was seen in the pelvic cavity. By moving the catheters manually back and forth from outside the body, we were able to identify the ureters visually. A uterine manipulator was inserted during surgery, rather than before surgery, to avoid the risk of uterine perforation. Laparoscopic surgery with ureteral catheters and a uterine manipulator can be applied safely for such cases after AmRT even when severe intraperitoneal adhesion is present.

Anatomical structures at risk using different approaches for sacrospinous ligament fixation

For 50 years now, sacrospinous ligament fixation (SSLF) has been used to treat pelvic organ prolapse consequent on altered integrity of the pelvic myofascial structures. It is usually performed vaginally, but it has recently been performed laparoscopically through either an anterior or a posterior approach, with the broad ligament as a landmark to differentiate the two. In the present study, these two laparoscopic approaches were assessed using Thiel-embalmed cadavers. The anterior and posterior approaches were compared in terms of the closest distance to anatomical structures at risk, including pelvic viscera, the obturator nerve, and vascular structures. The posterior approach was more often closer to the investigated vessels and the rectum. The obturator nerve and the ureter were close to both the anterior and posterior approaches. The urinary bladder was closer using the anterior approach. From an anatomical standpoint, therefore, the anterior laparoscopic approach for SSLF is more likely to cause injury to the urinary bladder, whereas the posterior approach is more prone to causing rectal and vessel injuries. This study illustrates, from a basic science perspective, the importance of combining fascia research, novel endoscopic or minimally invasive surgical exposures informed by anatomy, and contemporary trends in gynecology in order to improve patient outcomes. Clin. Anat. 33:522-529, 2020. © 2019 Wiley Periodicals, Inc.

Bladder and ureteral injuries during benign hysterectomy: an observational cohort analysis in New York State

PURPOSE

Hysterectomy (Hys) is the most common non-urologic surgery associated with iatrogenic genitourinary (GU) injury. We present the largest known population-based evaluation of GU injury related to benign Hys.

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) was queried by ICD-9 and CPT codes. SPARCS for women from 1995 to 2014, who underwent laparoscopic or robotic Hys (minimally invasive surgery = MIS), abdominal Hys (AH), and vaginal Hys (VH) for benign diagnoses. Bladder and ureteral repairs were captured based on the procedure codes. Codes for ureteroneocystotomy (UNC) were compared to any other ureteral repairs, to elucidate injury patterns. Statistical analysis was conducted using Chi squared test, ANOVA, Mann-Whitney test and Poisson Regression and multivariable analysis were performed.

RESULTS

516,340 women underwent Hys for a benign etiology. 69% were AH, 25% VH, and 6% were MIS. 7490 patients (1.45%) had a concomitant GU injury. Compared to VH, MIS and AH were associated with greater odds of bladder and ureteral injury (p < 0.001). MIS and AH, compared to VH, were associated with reduced odds of UNC compared to complex reconstruction (OR 0.27, p < 0.001 and OR 0.12, p < 0.00, respectively). The injured cohort had higher total mean charges ($29,889 vs $15,808) and length of hospitalization (6.32 vs 3.56 days) (p < 0.001).

CONCLUSIONS

Bladder and ureteral injuries during hysterectomy are uncommon in contemporary practice and are lower than historical rates. GU injury increases hospitalization cost. VH is associated with the lowest rate of GU injury, and thus appears to be a valuable approach, when feasible.

The incidence, causes, and management of lower urinary tract injury during total laparoscopic hysterectomy

OBJECTIVES

Determining the incidence and causes of lower urinary tract injury in patients undergoing total laparoscopic hysterectomy and examining the procedures applied for management.

METHODS

Patients who underwent total laparoscopic hysterectomy in a large referral center between 1 January 2015 and 31 October 2017 for benign gynecological reasons were included in the study. Patients who underwent laparoscopic supracervical hysterectomy, laparoscopy-assisted vaginal hysterectomy and robot-assisted laparoscopic hysterectomy were not included in this study. The hospital records of all patients included in the study were examined and the incidence, causes and management of lower urinary tract injuries were reviewed.

RESULTS

Total lower urinary tract injury rate was found as 2.01%, and these injuries were evaluated separately as bladder and ureter injuries. All the bladder injuries had occurred on the posterior wall of the bladder during vesicouterine dissection; six cases were intraoperatively detected and one case was detected on the first postoperative day. Most of ureteral injury cases were detected in the early postoperative period (75%). The rates of previous cesarean section and endometriosis were significantly higher in patients with injury to the bladder and ureter than in the control group (p<0,001). There was no significant difference between the patients with lower urinary tract injury and the control group regarding uterine weight, estimated blood loss, bilateral salpingo-oophorectomy, the presence and location of fibroids, and laparoscopic or vaginal closure of the vaginal cuff.

CONCLUSION

Laparoscopic hysterectomy may be a good option in appropriate patients, but in case of previous cesarean section and endometriosis cases, patients should be informed about the possible complications in detail before the operation and care should be taken during dissection.

[Results of conservative surgical management of ureteral injuries]

INTRODUCTION

The ureter is a retroperitoneal organ. Ureteral injuries are rare, with a prevalence of 0.083% of surgical interventions over 10 years. The objective of this study was to evaluate the surgical management of ureteric injuries according to the time of discovery, their size and their location. We also evaluated the results of this management on the renal repercussion as well as the predictive factors of the severity of the ureteric injuries.

MATERIAL AND METHODS

This was a monocentric retrospective study carried out on the basis of a systematic review of the CHU surgery files.

RESULTS

The average follow-up was 30 months. The average hospital stay was 8 days. Thirty-four patients (73.9%) underwent initial endoscopic management by attempting a double J probe. Only 20 patients received this double J probe and only 11 patients (55%) did not recidivate the ureteral injury with a median duration of maintenance of the double J probe of 90 days (28-240). Thirty-five patients received open surgical management (76.1%). We found 57% ureterovesical reimplantations (n=20), corresponding to pelvic ureteral injuries (n=32). We also found 20% of nephrectomies. No patient had recurrence of the ureteral injury. Eight patients had secondary dilatation of the pyelocalicious cavities (28.57%). The success of surgical treatment was therefore 57%.

CONCLUSION

The management of surgically treated ureter injuries provides good results but remains relatively diversified due to the different lesion levels. It was effective in 57% of cases including nephrectomies as failure of treatment.

LEVEL OF EVIDENCE

4.