A Review on the Etiology, Prevention, and Management of Ureteral Injuries During Obstetric and Gynecologic Surgeries

Indocyanine Green for Assessment of Ureteral Vascularity Can Reduce the Rate of Ureteral Complications in Patients Undergoing Extended Hysterectomy

Objectives: This study aimed to evaluate the effectiveness of using indocyanine green (ICG) for assessing ureteral vascularity to reduce ureteral complications in patients undergoing extended hysterectomy for deep endometriosis or oncological indications. Methods: A retrospective-prospective cohort study was conducted at the Centre of Gynecology in Opole, Poland, involving 555 patients who underwent hysterectomy from 2020 to 2023. Patients were categorized based on the Querleu-Morrow classification. ICG was used intraoperatively for vascular assessment in patients with deep endometriosis undergoing wide ureter dissection typical of Type C hysterectomy. Results: Ureteral complications occurred in 12 (2.2%) patients, with a significantly lower complication rate in those who underwent ICG testing (1.7%) compared to those who did not (22.7%, p = 0.001). Prophylactic double-J stenting further reduced the risk of complications. Conclusions: The use of ICG for intraoperative assessment of ureteral vascularity significantly reduces the risk of ureteral complications in complex hysterectomies. Further studies are needed to confirm these findings.

Management of urological injuries following gynecologic and obstetric surgery: A retrospective multicenter study

OBJECTIVE

Urinary system injuries may occur iatrogenically during some surgical procedures especially gynecological and obstetrical surgeries. Unfortunately, these injuries can lead to serious complications in patients. In this multicentric study, we aimed to review and report our experiences and results of urinary tract injuries identified during gynecological and obstetrical surgery.

METHODS

We included women with urinary tract injuries during gynecological and obstetrical surgeries between January 2018 and October 2023 at four centers. Detailed data collected include patient demographics, surgical details, injury characteristics, diagnostic and treatment methods, timing of injury diagnosis and management reports of the patients. The incidence of bladder and ureter injuries was evaluated and the rate of intraoperative urological consultations was recorded.

RESULTS

In a total of 328 patients with a median age of 47 years (24-90), urinary tract injuries were diagnosed, including 227 (69.2%) iatrogenic bladder injuries (IBI) and 101 (30.8%) iatrogenic ureteral injuries (IUI). These injuries were diagnosed in 299 patients (91.2%) during surgery and in 29 patients (8.8%) after the surgical procedure. We observed intraoperative detection rates of 71.9% for IBI and 28.1% for IUI. IBI (71.9%) was diagnosed significantly more frequently than IUI (28.1%) (p=0.001). Cesarean section resulted in significantly more frequent IBI, whereas tumor debulking surgeries resulted in more IUI (n=52, 56.5%) than the other types of procedures (p<0.001).

CONCLUSION

Our study provides a comprehensive overview of iatrogenic urological injuries during gynecological and obstetrical surgeries. Although the bladder is the most frequently injured organ during gynecological and obstetric surgeries, early diagnosis and urological intervention are mandatory to prevent delayed complications. Surgeons must have a thorough understanding of the pelvic anatomy and appropriate surgical techniques to prevent iatrogenic injuries during surgery and ensure timely diagnosis and treatment of urinary tract injuries.

Postoperative Complications and Factors Associated with Surgical Site Infection at Muhimbili National Hospital, Dar es Salaam, Tanzania: A cross-Sectional study

Background

Postoperative complications are a leading cause of morbidity and mortality to surgical patients. Different complications are encountered in clinical practice, however surgical site infection (SSI) appears to be the most common. To date, limited published information is known pertaining to the patterns of postoperative complications and factors associated with SSI among patients operated on in other hospitals in Tanzania and referred to Muhimbili national hospital for further management. Therefore, the purpose of this study was to identify patterns of postoperative complications and factors associated with SSI among the study participants.

Methods

This was a hospital based cross-sectional study conducted at Muhimbili national hospital from August 2022 to January 2023, which included 181 patients. Obtained data was analysed using frequency tables, Pearson Chi-squared test and binary logistic regression model, at a level of significance of <0.05.

Results

One hundred eighty one (181) patients were included in this study, of whom 113(62.4%) were females; median age was 39 years. Cigarette smokers and alcohol consumers were 42(23.2%) and 90(49.7%) respectively. Diabetic patients were 8(4.4%), 35(19.3%) were HIV positive and 52(28.7%) had hypertension. Patients whose diagnosis was related to general surgery accounted for 50.2%, whereas 30.9% were obstetric cases. Patients who had undergone Caesarean section were 45(24.9%), whereas 20(11%) patients had undergone total abdominal hysterectomy. Bowel resection and primary anastomosis included 16(8.8%) patients and perforated peptic ulcer repair 8(4.4%) patients. Patients with infected peritoneal collection were 34(18.8%), postpartum haemorrhage 18(9.9%) and bowel perforation 10(5.5%). Patients who had undergone relaparotomy as part of treatment were 70(38.7%), whereas 30(16.6%) patients with SSIs were treated by serial wound dressing and 26(14.4%) patients were admitted and nursed in intensive care unit. None of the factors was found to have a statistically significant association with SSI.

Conclusions

There is a large proportion of patients suffering from postoperative complications after gastroenterology and obstetric surgeries; and of all complications encountered in this study; SSI was the most common contributing 52%, followed by gastrointestinal complications at 31%. Despite the fact that multiple factors were associated with SSI, none of them was found to be statistically significant.

Urinoma Masquerading as Post-hysterectomy Hematoma: The Role of Accurate Diagnosis and Imaging-Guided Intervention

Although rare, ureteric injuries can occur during gynecological surgical interventions, and their diagnosis can be challenging, especially when delayed. If left untreated, missed ureteric injuries can lead to severe complications, including prolonged hospitalization, sepsis, renal damage, and potentially even loss of the affected kidney. We present a unique case of a urinoma caused by bilateral ureteric injuries following abdominal hysterectomy, which was initially misdiagnosed as an intraperitoneal hematoma. However, further radiological investigations enabled accurate diagnosis without the need for exploratory laparotomy, demonstrating the importance of thorough evaluation for all possible complications in patients presenting with post-operative issues. In cases of pelvic collections of unclear origin or ureteric injury, a computed tomography (CT) scan is the gold standard diagnostic modality, providing precise diagnosis and expedited management.

2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery

Iatrogenic urinary tract injury (IUTI) is a severe complication of emergency digestive surgery. It can lead to increased postoperative morbidity and mortality and have a long-term impact on the quality of life. The reported incidence of IUTIs varies greatly among the studies, ranging from 0.3 to 1.5%. Given the high volume of emergency digestive surgery performed worldwide, there is a need for well-defined and effective strategies to prevent and manage IUTIs. Currently, there is a lack of consensus regarding the prevention, detection, and management of IUTIs in the emergency setting. The present guidelines, promoted by the World Society of Emergency Surgery (WSES), were developed following a systematic review of the literature and an international expert panel discussion. The primary aim of these WSES guidelines is to provide evidence-based recommendations to support clinicians and surgeons in the prevention, detection, and management of IUTIs during emergency digestive surgery. The following key aspects were considered: (1) effectiveness of preventive interventions for IUTIs during emergency digestive surgery; (2) intra-operative detection of IUTIs and appropriate management strategies; (3) postoperative detection of IUTIs and appropriate management strategies and timing; and (4) effectiveness of antibiotic therapy (including type and duration) in case of IUTIs.

Urological procedures performed by gynecologists: Activity profile in a gynecological surgery department, 10-year observation cohort

INTRODUCTION

The proximity of the urinary tract to the female genital tract explains its possible involvement in pelvic gynaecological cancer or deep endometriosis. Surgical treatment is aimed at improving overall survival and recurrence-free survival of patients, as well as restoring normal anatomy and functional integrity depending on the pathology. These operations are accompanied by significant post-operative complications. Thus, the urological procedures performed must be rigorously justified, and the different resection and reconstruction techniques adapted to the pathology and the level of infiltration.

OBJECTIVE

To describe the activity profile, over the last ten years, of a gynaecological surgery department in terms of urological procedures in the management of patients with deep endometriosis and pelvic carcinology.

STUDY DESIGN

This is a monocentric retrospective observational study, including all patients who underwent a urological procedure by a gynaecological surgeon only, as part of the management of pelvic gynaecological cancers or deep endometriosis, at the University Hospital Centre (CHU) of Strasbourg, between January 1st 2010 and April 31st 2021. The variables studied were early postoperative complications, the rate of surgical reintervention, operating time, length of hospital stay, the need for peri-operative drainage or transfusion, and post-operative functional disorders.

RESULTS

A total of 86 patients were included, 27 in the pelvic gynaecological cancer group and 59 in the deep endometriosis group. 61.6% of patients received uretero-vesical catheterization, 60.5% partial cystectomy, 10.5% psoic bladder ureteral reimplantation, and 3.5% trans-ileal Bricker skin ureterostomy. The mean operating time was 316 min in the pelvic gynaecological cancer group and 198.9 min in the deep endometriosis group. The average hospital stay was 11.5 days, 22.3 days for patients treated for pelvic cancer and 6.3 days for those treated for endometriosis. The rate of minor post-operative complications was 8.2% of cases, and major post-operative complications 17.4% of cases, the majority of which were in the gynecological cancer group. There were no cases of intra- or early post-operative death. Early postoperative urinary complications affected 14.0% of the total patients, mostly in the gynaecological cancer group with 33.3% of patients, but only 5.1% of patients in the deep endometriosis group. The total reoperation rate within 60 days postoperatively was 15.1%, 40.7% for patients treated for gynaecological cancer and 3.4% for those treated for deep pelvic endometriosis. The rate of reoperations for urinary complications was 11.6% of total patients, or 76.9% of total reoperations. 15 patients received labile blood products intra- or postoperatively, 11 in the pelvic gynaecological cancer group and 4 in the endometriosis group.

CONCLUSION

Our overall results appear comparable to those reported in the literature and are particularly satisfactory in terms of post-operative complications after partial cystectomy in the management of deep endometriosis compared to other gynaecological departments. This work encourages us to continue and improve the training of gynaecological surgeons in terms of multidisciplinary surgical procedures, including urological ones, to obtain a global vision of the pathology and to allow an optimal quality of care for the patients.

BF2-Azadipyrromethene Fluorophores for Intraoperative Vital Structure Identification

A series of mono- and bis-polyethylene glycol (PEG)-substituted BF2-azadipyrromethene fluorophores have been synthesized with emissions in the near-infrared region (700-800 nm) for the purpose of fluorescence guided intraoperative imaging; chiefly ureter imaging. The Bis-PEGylation of fluorophores resulted in higher aqueous fluorescence quantum yields, with PEG chain lengths of 2.9 to 4.6 kDa being optimal. Fluorescence ureter identification was possible in a rodent model with the preference for renal excretion notable through comparative fluorescence intensities from the ureters, kidneys and liver. Ureteral identification was also successfully performed in a larger animal porcine model under abdominal surgical conditions. Three tested doses of 0.5, 0.25 and 0.1 mg/kg all successfully identified fluorescent ureters within 20 min of administration which was sustained up to 120 min. 3-D emission heat map imaging allowed the spatial and temporal changes in intensity due to the distinctive peristaltic waves of urine being transferred from the kidneys to the bladder to be identified. As the emission of these fluorophores could be spectrally distinguished from the clinically-used perfusion dye indocyanine green, it is envisaged that their combined use could be a step towards intraoperative colour coding of different tissues.

Compartment syndrome secondary to intra-operative IV methylene blue extravasation to detect ureteral injury

Compartment syndrome of the extremities is a rare but potentially devastating condition. We herein report a case of a 53-year old female with an unusual case of hand compartment syndrome and fasciitis secondary to methylene blue (MB) extravasation to detect urinary tract injury intraoperatively. This was recognized immediately and fasciotomy was performed. Features of this case are discussed together with its implications. Despite MB's long history of use, few adverse events of an accidental extravasation have been reported.