What is the management approach for a female patient of reproductive or post-menopausal age with a history of stress urinary incontinence and possible previous pelvic surgeries who experiences ureter bleeding after transobturator taping (TOT) surgery?

Management of Ureter Bleeding After Transobturator Taping Surgery

Immediate recognition and urgent intervention are critical: if ureteral injury with bleeding is confirmed after TOT surgery, the patient requires immediate urologic consultation for potential surgical repair or ureteral stenting, as ureteral injury—though rare with transobturator approaches—can lead to significant morbidity including ureteral obstruction, urinoma formation, and potential loss of renal function if not promptly addressed.

Initial Assessment and Recognition

Early postoperative communication is essential to identify complications. The AUA/SUFU guidelines emphasize that physicians or designees should communicate with patients in the early postoperative period to assess for significant voiding problems, pain, or unanticipated events, and patients experiencing these outcomes should be seen and examined immediately 1.

Key Clinical Indicators of Ureteral Injury:

• Flank pain (ipsilateral to the injured ureter) 1
• Hematuria (gross or microscopic) 1
• Fever and signs of urinoma or infection 1
• Decreased urine output or anuria (if bilateral or solitary kidney) 1
• Persistent vaginal fluid leakage (suggesting ureterovaginal fistula) 1

Understanding the Risk Context

Ureteral injury is exceptionally rare with transobturator approaches compared to retropubic procedures. The AUA guidelines document that ureteral injury rates are approximately 11% for laparoscopic retropubic suspensions compared to only 1% for open suspensions, with the transobturator technique specifically designed to avoid the retropubic space and thus minimize bladder and ureteral complications 1. Recent comparative data confirms that TOT procedures have significantly fewer intraoperative complications compared to retropubic TVT (p=0.001, OR: 0.281) 2.

However, vascular complications are more characteristic of TOT procedures. Case reports document injury to branches of the obturator artery during TOT placement, which can cause significant bleeding and hemodynamic instability 3. Pelvic and retropubic hematomas have been reported following TOT procedures 4, 5.

Immediate Management Algorithm

Step 1: Hemodynamic Stabilization

• Assess vital signs and hemodynamic stability immediately 3
• Obtain complete blood count to assess for anemia and need for transfusion 3, 5
• Establish large-bore IV access and initiate fluid resuscitation if hypotensive 3

Step 2: Diagnostic Imaging

• Obtain CT scan with IV contrast (CT urography) to evaluate for:

  • Ureteral injury or obstruction 1
  • Urinoma formation 1
  • Pelvic hematoma location and size 4, 5
  • Active contrast extravasation indicating ongoing bleeding 3, 4

• Pelvic ultrasound may be used initially if CT is not immediately available, though it is less sensitive for ureteral injury 5

Step 3: Urgent Urologic Consultation

All suspected ureteral injuries require immediate urologic evaluation 1. The consulting urologist should assess for:

• Need for cystoscopy with retrograde pyelography to definitively identify the site and extent of ureteral injury 1
• Ureteral stent placement as initial management for partial injuries or to temporize complete injuries 1
• Percutaneous nephrostomy if retrograde stenting is not possible 1

Definitive Management Based on Injury Type

For Confirmed Ureteral Injury:

• Immediate surgical repair is indicated for complete transection or significant devascularization 1
• Ureteral stenting with delayed repair may be appropriate for partial injuries recognized postoperatively 1
• The synthetic mesh should be removed if it is directly involved in or contributing to the ureteral injury 1

For Vascular Injury with Hematoma:

• Conservative management is appropriate for stable patients with contained hematomas without active bleeding 4, 5
• Interventional radiology consultation for angiographic embolization is indicated for hemodynamically unstable patients with active arterial bleeding 3
• CT-guided drainage may be necessary for large symptomatic hematomas 4

Critical Pitfalls to Avoid

Do not delay imaging or consultation based on "watchful waiting" in the setting of concerning symptoms. Early intervention may ameliorate potential complications, and patients may suffer unnecessarily if appropriate assessment is not performed 1.

Do not assume all postoperative bleeding is from expected surgical sites. While bladder injury occurs in approximately 6% of midurethral sling procedures 1, ureteral injury—though rare with TOT—requires different management and can lead to permanent renal damage if missed 1.

Do not attempt to manage suspected ureteral injury without urologic expertise. The AUA guidelines emphasize that synthetic sling surgery is contraindicated in patients with intraoperative urethral injury, and similar principles apply to ureteral injury requiring specialist management 1.

Follow-Up Considerations

Patients with unfavorable outcomes require additional follow-up beyond the standard six-month postoperative visit. The AUA/SUFU guidelines recommend that patients should be seen and examined within six months postoperatively, with assessment including physical examination of all surgical sites, evaluation for mesh extrusion, and post-void residual measurement 1.

Long-term renal function monitoring is essential after ureteral injury, with repeat imaging (renal ultrasound or CT) at 3-6 months to ensure resolution of hydronephrosis and preserved renal function 1.