Urinary Tract Injury During Gynecologic Surgery Case File

Urinary Tract Injury During Gynecologic Surgery Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 27

A 42-year-old G3P3003 woman is in lithotomy position to undergo a total laparoscopic hysterectomy for a symptomatic 14-week leiomyomatous uterus. Her medical, surgical, and gynecologic histories are unremarkable except for a history of three cesarean sections. An umbilical incision is made with easy entry through the fascia for placement of a Hassan trocar. Several thin filmy adhesions are noted and taken down. The hysterectomy is then started by identifying and ligating the uterine-ovarian ligaments and round ligaments with a tissue sealing device using thermal energy. Upon creation of the bladder flap, the bladder is noted to be adherent to the lower uterine segment. This is taken down sharply with some difficulty.

Once the uterine arteries are skeletonized bilaterally, they are ligated using the tissue sealing device. When the pedicle is divided, it appears that the device has moved and brisk bleeding is noted from what appears to be the right uterine artery pedicle. The pedicle is quickly grasped and an absorbable suture is used to ligate the area of bleeding. The rest of the hysterectomy is then performed up to amputation of the cervix from the vagina without difficulty. During closure of the vaginal cuff, the bladder is noted to be in close proximity to the suture line of the cuff closure.

➤ Where are potential points of injury to the urinary tract during this hysterectomy?

➤ What are possible complications of unrecognized injury?

➤ What is the next step in management of this patient?

ANSWERS TO CASE 27:

Urinary Tract Injury During Gynecologic Surgery

Summary: This is a 42-year-old G3P3003 woman with three prior cesarean section deliveries and a 14-week leiomyomatous uterus who is undergoing a total laparoscopic hysterectomy. During surgery, further ligation by suture was required at the right uterine artery pedicle to obtain hemostasis. The bladder was also adherent to the lower uterine segment and cervix. During closure of the vaginal cuff, the suture line was noted to be in close proximity to the bladder.

➤ Points of injury: The bladder is at risk during creation of the bladder flap as well as closure of the vaginal cuff. The ureter is at greatest risk during ligation of the ovarian and uterine vessels. In this case, the ovarian vessels were not at risk as the uterine-ovarian ligament was divided. However, when dividing the uterine artery, further ligation was required to achieve hemostasis.

➤ Unrecognized injury: Unrecognized injuries to the bladder could result in urinoma formation, urinary peritonitis, or vesicovaginal fistulas. With foreign bodies present, the bladder is at risk for bladder calculi and recurrent infections. Unrecognized injury to the ureter could also result in urinoma formation as well as hydronephrosis and loss of renal function caused by ureteral stricture or ligation.

➤ Next step: Cystourethroscopy with intravenous indigo carmine is a minimally invasive diagnostic method to ensure ureteral patency and absence of bladder wall injury from cystotomy or foreign body (suture, mesh, etc). When thermal energy is used, injury to the urinary tract may present in a delayed fashion. Careful dissection of the ureter would also need to be performed to evaluate the distance of the suspected site of injury from the point of application of thermal energy.

ANALYSIS

Objectives

1. Know the possible complications to the urinary tract during gynecologic surgery.
2. Know the indications for cystourethroscopy in gynecologic surgery.
3. Know the parts that comprise a cystourethroscope and appropriate uses of these parts for intraoperative use during gynecologic procedures.

Considerations

This is a 42-year-old woman with three prior cesarean sections who is undergoing a total laparoscopic hysterectomy for a symptomatic 14-week leiomyomatous uterus. There was significant difficulty developing the bladder flap and vesicovaginal space. Additionally, incomplete ligation of the right uterine artery pedicle required further lateral suture ligation deeper into the surrounding tissue. Finally, the bladder was noted to be in close proximity to the suture line during vaginal cuff closure. These events have led the right ureter and bladder to be placed at significant risk for injury. The retroperitoneal space may be opened at the time of surgery to allow identification of the ureter and its course to assure the surgeon of ureteral patency. Near the area where the uterosacral ligament inserts into the uterus, the ureter may be as close as 0.9 ± 0.4 cm from the cervical portion of the uterosacral ligament.1 Cystoscopy provides an easy, less invasive method to check the patency of the ureter at the ureteral orifice in the bladder. It is especially helpful in cases where there is no abdominal access during surgery or in those patients with multiple adhesions or poor exposure that lead to a difficult retroperitoneal dissection. The bladder is also at risk for cystotomy during a difficult sharp dissection from the lower uterine segment and vagina which may not have been readily identifiable. If bladder fibers are immediately adjacent to the cuff closure, visual inspection alone may not be sufficient to recognize if the suture line incorporates bladder tissue. Cystourethroscopy allows for close inspection of integrity of the bladder lumen, presence of foreign bodies, and ureteral patency.

APPROACH TO

Ureteral Injury

DEFINITIONS

BRIDGE: The portion of the cystourethroscope that connects the sheath to the telescope and often contains one or more operative ports.

INDIGO CARMINE: A substance that is injected, usually intravenously, which colors the urine blue to aid in identification of the ureteral orifices and diagnosis of ureteral obstruction.

SHEATH: The portion of the cystourethroscope which is introduced into the urethral meatus and contains ports for distending media.

TELESCOPE: The portion of the cystourethroscope that contains the lens and eyepiece.

CLINICAL APPROACH

Cystourethroscopy

History

In 1805, Bozzini was the first to describe cystoscopy of the female bladder.2 Several modifications were made over the nineteenth century. In 1894, Kelly described a different technique that is well known. The cystoscope used was a hollow tube that used gas to distend the bladder. The patient was placed in a knee-chest position while cystoscopy was performed using a head mirror to channel light for visualization.3 Since the advent of fiber optics, many changes have been made to the original models.

The Instrument

The cystourethroscope may either be a flexible scope or rigid scope. The flexible cystoscope is a single unit scope with the tip ranging from 15- to 18-Fr in diameter. A lever near the viewing lens allows the tip to be deflected up to 290 degrees in a single plane. The optics and light source are made of fiberoptic bundles that allow the device to function when bent.4

In contrast, the rigid cystoscope is composed of a lens, bridge, and sheath (Figure 27–1) which allow different parts to be interchanged, depending on the need of the operator. The sheath usually contains two ports for inflow and outflow of distending media. Normal saline is commonly used for diagnostic cystourethroscopy whereas glycine or sorbitol is often used when electrocautery is used. Typical sizes range from 17 to 23 Fr. Often 17 Fr is preferred for diagnostic cystourethroscopy since the smaller size facilitates passage of the scope through the urethral meatus.

The bridge functions to connect the sheath to the telescope. Bridges also contain one or more ports allowing for the passage of distending media, ureteral catheters, or other working instruments for operative cystoscopy. Often during ureteral catheterization, difficulty may be encountered in finding the right angle to easily access the ureteral orifice. Use of an Albarrán bridge may facilitate catheterization by adjusting an external knob that deflects the tip of the catheter downward at the end of the sheath. This bridge also helps to stabilize the ureteral catheter in the working channel.

Similar to the other parts of the cystourethroscope, telescopes also are available in different models with each having a different viewing angle. The most common angles are 0, 15, 30, and 70 degrees. Often a 30-degree telescope will suffice for examination of the bladder and urethra as well as such operative procedures as ureteral catheterization and intraurethral bulking. If difficulty is encountered when trying to visualize the entire bladder, a 70-degree telescope will improve visualization. Similarly, a 0- or 15-degree

Figure 27–1. A. Sheath; B. bridge; C. telescopes; D. light source; E. tubing for distending media.

telescope will improve visualization of the urethra during diagnostic or operative procedures. The telescope also has a coupling for the light source, and a camera may be attached to the eyepiece to display the picture on a monitor.

Indications

The role of cystourethroscopy has become so important that an ACOG committee opinion has been issued, describing its role in the use of general obstetrician-gynecology practice. In the committee opinion, it is suggested that general obstetrician-gynecologists can perform cystourethroscopy for diagnostic and a few operative procedures.5 Specifically, the most important indications listed are to rule out cystotomy and intravesical and intraurethral foreign bodies such as mesh and suture (Figure 27–2) as well as ensure ureteral patency. Other indications would include any symptoms or diseases related to the lower urinary tract. Surgical procedures such as the tension-free vaginal tape (TVT) procedure, Burch colposuspension, and high uterosacral

Figure 27–2. Cystoscopy was performed and reveals TVT mesh in the lumen of the urethra.

ligament suspension require intraoperative cystourethroscopy whereas McCall culdoplasty, colpocleisis, and advanced or difficult laparoscopic and vaginal procedures may be other indications.5 Although not listed in the above procedures, cystourethroscopy is also helpful in ruling out intraoperative injury to the bladder and urethra with other mid-urethral slings, bladder neck slings, and mesh placed into the vesicovaginal space.

When performing cystoscopy, it is important to visualize the entire bladder mucosa and urethra. It is helpful in holding the camera in the proper orientation while the telescope is rotated by the light source to change the angle as the entire scope is moved. Performing a bladder survey helps to rule out other conditions such as cystitis, polyps, and suspected carcinoma. When surveying the urethra, there should be inflow of distending media to obtain a complete circumferential view.

Indigo Carmine Dye

This text focuses on the use of indigo carmine, as other more advanced techniques of detecting ureteral obstructions such as ureteral stenting and retrograde pyelography are beyond the scope of this chapter. Indigo carmine is available in one ampule of 5 mL containing 40 mg of indigotindisulfonate sodium which becomes a deep blue solution when mixed in water. It is largely excreted by the kidneys usually within 10 minutes of injection intravenously and can be seen jetting from the ureteral orifice (Figure 27–3). Intramuscular injection can be performed but requires larger quantities and additional time for excretion.

Figure 27–3. Indigo carmine spilling from the ureteral orifice.

Indigo carmine is contraindicated in patients with a prior adverse reaction to its use. Weak ejection of blue dye from the ureteral orifice does not necessarily rule out a partial obstruction that may need further evaluation.6

Rates of Injuries

Since hysterectomy is one of the most common surgical procedures performed on women, Vakili et al. performed a prospective study examining the rate of urinary tract injury at the time of hysterectomy by using universal cystoscopy.7 With 471 patients enrolled, they had a 1.7% rate of ureteral injury and 3.6% rate of bladder injury. Ureteral injury was found to be significantly higher at the time of prolapse surgery whereas bladder injury was significantly higher when concurrent anti-incontinence procedures were performed. The most important aspect of this study is that only 12.5% of ureteral injuries and 35.3% of bladder injuries were diagnosed prior to cystoscopy. The authors concluded that the overall rate of injury to the urinary tract during hysterectomy was 4.8%, and prolapse and anti-incontinence procedures increased this risk. In the authors’ opinion, the use of cystoscopy should be considered with hysterectomy.7

In a retrospective review by Gustilo-Ashby et al., 700 consecutive patients were reviewed to determine the incidence of ureteral obstruction during vaginal surgery for pelvic organ prolapse specifically. Their surgeries consisted of uterosacral ligament suspension, proximal and distal McCall culdoplasty, anterior colporrhaphy, and colpocleisis. In their study, 5.3% of patients had no spillage from one or both ureters with a false-positive and false-negative cystoscopy rate of 0.4% and 0.3%, respectively. Intraoperative cystoscopy had a sensitivity of 94.4% and specificity of 99.5% for ureteral injury, making it a valuable diagnostic test in this review.8

Comprehension Questions

27.1 A cystoscopy is performed after a routine abdominal hysterectomy. Which of the following statements is the best rationale for the cystoscopy?

A. Cystoscopy allows for ensuring that no sutures perforated the bladder.

B. Cystoscopy allows for inspection of bladder endometriosis.

C. Cystoscopy allows for placement of stents after hysterectomy.

D. Cystoscopy allows for inspection of ureteral injury.

27.2 A 44-year-old woman is noted to have a possible ureteral injury. Cystoscopy is contemplated. Which of the following is the best adjuvant to assist in the interpretation of the cystoscopic findings?

A. IV radio opaque dye

B. IV indigo carmine

C. Methylene blue in the bladder

D. Saline in the cul-de-sac

27.3 A 30-degree rigid cystoscope is placed into the bladder, but the entire bladder is difficult to visualize. Which of the following is the best method to address this problem?

A. Change to a 0-degree cystoscope.

B. Change to a 70-degree cystoscope.

C. Change to a flexible cystoscope.

D. Document what is visualized and stop the procedure.

ANSWERS

27.1 D. In studies, only 12.5% of ureteral injuries were discovered prior to cystoscopy after hysterectomy. Thus, routine cystoscopy can allow for discovery of unsuspected ureteral injury Although it is valid to use cystoscopy to examine the bladder for sutures, this complication is less common during a routine uncomplicated hysterectomy.

27.2 B. Indigo carmine is concentrated in the kidneys and excreted into the bladder. Cystoscopy allows inspection of the ureteral orifices to see if there is efflux of urine through both ureteral openings.

27.3 B. The 70-degree cystoscope allows for inspection of the entire bladder when the 30-degree cystoscope may be insufficient to visualize the entire bladder.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ The cystourethroscope is composed of a sheath, bridge, and telescope.

➤ Lenses with different angles may assist in evaluating the bladder and urethra.Lenses of 0, 15, and 30 degrees are commonly used to evaluate the urethra whereas 30- and 70-degree lenses are commonly used to evaluate the bladder (Level B).

➤ Cystourethroscopy aids in the detection of urinary tract injuries, especially when concomitant prolapse and anti-incontinence procedures are performed (Level B).

➤ Use of indigo carmine intravenously given 10 minutes prior to cystourethroscopy may aid in locating the ureteral orifices and detect ureteral obstruction (Level B).

➤ The ureteral orifices are most easily found by locating the intertrigonal ridge which is an elevation of the bladder mucosa just proximal to the urethral-vesical junction (Level B).

➤ In patients with significant prolapse, placement of a sponge stick into the vagina may restore anatomy sufficiently to aid in identification of the ureteral orifices (Level C).

➤ Overdistending the bladder may make it more difficult to locate the ureteral orifices (Level B).

➤ When passing ureteral catheters, an Albarrán bridge may facilitate passage of the ureteral catheter into the orifice (Level C).

REFERENCES

1. Buller JA, Thompson JR, Cundiff GW, et al. Uterosacral ligament: description of anatomic relationships to optimize surgical safety. Obstet Gynecol. 2001;97: 873-879. 

2. Bozzini P. Lichtleiter, eine erfindung zur anschung inerer theile, und krukheiten nebst abbildung. J Pract Arzeykunde. 1805;24:107. 

3. Kelly HA. The direct examination of the female bladder with elevated pelvis: the catheterization of the ureters under direct inspection, with and without elevation of the pelvis. Am J Obstet Dis Wom Child. 1894;25:1-9. 

4. Cundiff GW, Bent AE. Cystourethroscopy. In: Bent AE, Cuniff GW, Swift SE, et al., eds. Ostergard’s Urogynecology and Pelvic Floor Dysfunction. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003. 

5. American College of Obstetricians and Gynecologists. The role of cystourethroscopy in the generalist obstetrician-gynecologist practice. ACOG Committee Opinion No. 372. Obstet Gynecol. 2007;110:221-224. 

6. American Regent, Inc. Indigo Carmine. http://www.americanregent.com/documents/ Product27PrescribingInformation.pdf. Accessed August 12, 2010. 

7. Vakili B, Chesson RR, Kyle BL, et al. The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy. Am J Obstet Gynecol. 2005;192:1599-1604. 

8. Gustilo-Ashby AM, Jelovsek JE, Barber MD, et al. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol. 2006;194:1478-1485.

HomeGynecologic Surgery Case FileUrinary Tract Injury During Gynecologic Surgery Case File