What is the management of urinary tract injury during gynecologic surgery?

Management of Urinary Tract Injury in Gynecologic Surgery

Immediate Intraoperative Recognition and Management

When a urinary tract injury is identified during gynecologic surgery, immediate repair should be performed in hemodynamically stable patients, as this approach results in superior outcomes with minimal long-term morbidity compared to delayed recognition. 1

Detection Methods During Surgery

• Cystoscopy with retrograde pyelogram is the gold standard for intraoperative detection of urinary tract injuries, though it requires hemodynamic stability, proper patient positioning, and specialized equipment including a mobile C-arm machine 1

• Alternative detection methods when cystoscopy is unavailable include intravenous indigo carmine injection (visualize dye efflux from ureteral orifices), direct ureteral inspection, or retrograde ureteral catheterization 1

• Direct visual inspection of ureters during laparotomy is mandatory in high-risk cases when preoperative imaging was not obtained 1

• Intraoperative single-shot IVP cannot reliably exclude ureteral injury and should not be used as the sole diagnostic method 1

Immediate Repair Strategies by Injury Type

Ureteral Injuries

• Contusions with impaired urine flow require ureteral stenting as initial management 1

• Partial ureteral lacerations should be repaired primarily with double-J stent placement in stable patients at the time of laparotomy 1

• Complete ureteral transections in the distal third should be managed with ureteral reimplantation into the bladder (ureteroneocystostomy) 1

• Upper and middle third complete transections require ureteroureterostomy (end-to-end anastomosis) with stent placement and, when possible, coverage with peritoneum or other tissue 1

• All ureteral repairs must include stent placement to optimize healing 1

Bladder Injuries

• Intraperitoneal bladder rupture requires immediate surgical exploration and primary repair with two-layer closure using absorbable suture material 1

• Laparoscopic repair of isolated intraperitoneal injuries is acceptable in hemodynamically stable patients without other indications for laparotomy 1

• Extraperitoneal bladder injuries can be managed non-operatively with urethral or suprapubic catheter drainage for at least 5 days, unless they are large, involve the bladder neck, or are associated with vaginal/rectal injuries 1

• Complex extraperitoneal ruptures (bladder neck injuries, injuries associated with vaginal or rectal injuries) must be surgically explored and repaired 1

• Urinary drainage with urethral catheter alone (without suprapubic catheter) is mandatory after surgical bladder repair in adults, maintained for 7-14 days 1

Damage Control Scenarios

When patients are hemodynamically unstable or have multiple life-threatening injuries, adopt a "drain now, fix later" approach:

• For ureteral injuries: Ligate the proximal ureteral stump to prevent uroperitoneum, then place percutaneous nephrostomy postoperatively with delayed definitive repair 1

• For bladder injuries: Perform urinary diversion via bladder drainage and perivesical drainage, with delayed definitive repair 1

• Conversion from laparoscopic to open approach is recommended when the surgeon lacks expertise in minimally invasive repair or when injuries are complex 1

Delayed/Postoperative Recognition and Management

Approximately 50-70% of urinary tract injuries are missed intraoperatively, requiring postoperative diagnosis and management. 1, 2

Clinical Presentation and Diagnosis

• Suspect delayed IUTI with: Flank pain, abdominal distension, peritonitis, fever, sepsis, unexplained tachycardia, decreased urine output, or fluid from surgical drains 1

• Biochemical markers include elevated serum creatinine, increased peritoneal fluid creatinine (peritoneal fluid creatinine > serum creatinine confirms urine leak), elevated C-reactive protein, and decreased renal function 1

• CT urography with both nephrographic and excretory phases is the gold standard for postoperative diagnosis, enabling simultaneous evaluation of bladder and ureters 1

• CT cystography (requires bladder distention with >300 mL diluted contrast) has 85-100% accuracy for bladder injuries 1

Postoperative Management by Injury Type

Ureteral Injuries

Postoperatively diagnosed ureteral injuries should be treated as soon as possible to avoid complications and sepsis. 1

• Partial ureteral transections: Attempt retrograde or anterograde ureteral stent placement as first-line treatment 1

• If stenting fails or is impossible: Place percutaneous nephrostomy with delayed surgical repair 1

• Complete ureteral transections diagnosed within one week: Consider immediate repair if the patient is being re-explored for other reasons or if the injury is near a surgically closed viscus 1

• Complete transections diagnosed after one week: Percutaneous nephrostomy followed by delayed surgical repair (ureteroureterostomy for upper/middle third, ureteroneocystostomy for distal third) 1

• Catheterization failure rate is approximately 65.9% in postoperatively diagnosed injuries, necessitating surgical re-exploration 2

Bladder Injuries

• Isolated uncomplicated intraperitoneal bladder injuries without infection or ileus: Non-operative management with urinary catheter for at least 7 days 1

• Intraperitoneal injuries with signs of infection or sepsis: Immediate operative repair to prevent progression 1

• Uncomplicated extraperitoneal injuries: Bladder decompression with indwelling urinary catheter for at least 5 days 1

• Patients unfit for surgery: Bilateral nephrostomy combined with urinary catheterization 1

• Percutaneous peritoneal drainage can be added as adjunctive treatment for intraperitoneal perforations 1

Critical Pitfalls and Prevention Strategies

High-Risk Scenarios Requiring Heightened Vigilance

• Highest risk procedures: Rectal cancer surgery (7.1/1,000), diverticular disease (2.9/1,000), inflammatory bowel disease 1

• Patient risk factors: Previous pelvic surgery, neoadjuvant radiotherapy, visceral obesity, locally advanced cancers, severe endometriosis, distorted anatomy 1, 3, 4

• Surgical risk factors: Conversion from laparoscopic to open, increased operative complexity, T4 cancers, adhesions 1

Common Pitfalls to Avoid

• Never assume absence of hematuria excludes ureteral injury - ureteral injuries frequently present without hematuria 1

• Do not rely on intraoperative single-shot IVP as it cannot reliably exclude injury 1

• Avoid delayed recognition - injuries recognized intraoperatively have significantly better outcomes than those diagnosed postoperatively (98.4% vs. 65.9% success with initial management) 1, 2

• Do not attempt conservative management of bladder neck injuries - these require surgical repair 1

• Avoid prolonged attempts at minimally invasive repair if surgeon lacks expertise - convert to open approach 1

Prevention Strategies

• Preoperative CT with excretory phase in high-risk patients to identify anatomical variations and plan surgical approach 1

• Routine ureteral identification during left-sided colorectal/gynecologic surgery is considered mandatory by 83.7% of surgeons 1

• Visual inspection of trocar insertion sites in laparoscopic surgery to detect bladder injuries (only 1 in 6 recognized intraoperatively without inspection) 1

• Higher surgical volume and experience directly correlate with lower complication rates 5, 4

Follow-Up and Long-Term Management

• CT scan with delayed phase imaging is the method of choice for follow-up of bladder and ureteral injuries 1, 6

• Cystography before catheter removal after bladder repair (typically 7-14 days postoperatively) 1

• Ureteroscopy or urethrogram for follow-up of urethral injuries 1, 6

• Long-term morbidity is minimal when injuries are recognized early and managed by experienced teams 2

• No relapses occur with appropriate initial management 2