INTRODUCTION — Urinary tract injury is a known complication of gynecologic surgery. Intraoperative identification of injury permits prompt repair and potentially lessens postoperative sequelae including patient morbidity and cost. Delayed diagnosis of urinary tract injuries can result in complications beyond the site of the injury, such as genitourinary fistula formation, renal injury, sepsis, and death [1].
The evaluation and management of urinary tract injury in gynecologic surgery are reviewed here. Prevention of urinary tract injury and issues related to urinary tract injuries during advanced gynecologic surgery and obstetric procedures are reviewed separately.
●(See "Urinary tract injury in gynecologic surgery: Epidemiology and prevention".)
●(See "Cesarean birth: Surgical technique", section on 'Bladder flap'.)
●(See "Operative vaginal birth", section on 'Maternal complications'.)
INCIDENCE OF URINARY TRACT INJURY WITH GYNECOLOGIC SURGERY — The incidence of urinary tract injury varies by type of gynecologic surgery and by the detection method used. (See "Urinary tract injury in gynecologic surgery: Epidemiology and prevention".)
INTRAOPERATIVE FINDINGS AND EVALUATION
Screening for injury with routine cystoscopy — The routine use of intraoperative cystoscopy (complete term cystourethroscopy) to screen for urinary tract injury in women undergoing major gynecologic surgery is a topic of debate [2-6]. Visualization of the urinary tract is routinely performed during gynecologic surgery. In addition, cystoscopy can be performed routinely (ie, for all women) or selectively (ie, based on patient risk factors or intraoperative concerns).
Our approach — We suggest intraoperative use of cystoscopy in addition to visual inspection of the urinary tract, rather than visual inspection alone, for women undergoing surgical treatment of urinary incontinence or anterior or apical pelvic organ prolapse [3,7,8]. We also perform intraoperative cystoscopy for women undergoing hysterectomy (any route) or those undergoing oophorectomy who have risk factors for ureteral injury (eg, endometriosis, history of pelvic irradiation or laparoscopic hysterectomy). Surgeons are encouraged to have a low threshold for performing cystoscopy at the time of hysterectomy, but the decision to do so is surgeon-dependent [3,4]. (See "Urinary tract injury in gynecologic surgery: Epidemiology and prevention" and "Perioperative patient care issues in female pelvic reconstructive surgery", section on 'Intraoperative cystourethroscopy'.)
Although the value of routine cystoscopy per case may be low, the value of routine cystoscopy per surgeon may be high. Over time, as a surgeon accumulates more experience in easy and difficult cases, the immediate feedback provided by cystoscopy about urinary tract integrity (secondary prevention) can help the surgeon develop a better awareness of risk that can alter the planning of future cases (primary prevention). Thus, while universal cystoscopy is not required, surgeons early in their career might wish to adopt an initial policy of universal cystoscopy to become skilled at the technique and interpretation of findings, and to recognize any inadvertent ureteral bladder injuries in their early operative practice (secondary prevention). As these surgeons accumulate experience and thus better awareness, insight, and intuition about intraoperative challenges and pelvic anatomy that increase risks of injury (primary prevention), a policy of selective cystoscopy may be adopted.
Potential benefits — Routine intraoperative cystoscopy, compared with selective cystoscopy, has been proposed to reduce the incidence of unrecognized urinary tract injury during surgery and thereby reduce patient morbidity and cost associated with delayed diagnosis and repair [9-13]. Delayed recognition and repair are associated with greater morbidity [1,12,14].
Routine intraoperative cystoscopy increases the detection rate of urinary tract injury up to fivefold compared with not using cystoscopy [2], in part because most ureteral injuries are not typically detected by visual inspection alone [9,15]. In a systematic review of 79 retrospective and prospective studies, the proportion of ureteric and bladder injuries detected increased to nearly 95 percent with routine cystoscopy compared with detection rates of 18 and 79 percent without routine cystoscopy, respectively [2]. However, the rates of 30-day delayed lower urinary tract injury do not appear to differ among women receiving selective or no cystoscopy at the time of benign hysterectomy [16].
Routine cystoscopy as a screening tool after all major gynecologic procedures, especially hysterectomy, remains difficult to evaluate for clinical significance and cost-effectiveness because of the low rate of injuries. It has been estimated that a trial would require approximately 25,500 women in each arm for 80 percent power to detect a difference between one and two injuries per 1000 surgeries [2].
Potential concerns — Barriers to general gynecologic surgeons implementing routine cystoscopy after hysterectomy include concerns about increased costs and lack of training with equipment and interpretation of findings [17]. Concerns associated with implementation of routine cystoscopy include detection of clinically insignificant injuries, false-positive findings, complications, increased costs, and lack of demonstrable benefit in the postoperative period. Minor urinary tract injuries, such as an absorbable suture in the bladder, can resolve without harm. The incidence of asymptomatic undetected urinary tract injuries is not known. However, the concern for over-detection of minor injuries does not appear warranted based on prospective studies demonstrating the majority of injuries diagnosed with routine cystoscopy are clinically significant ureteral transection or kinking [9,15]. Additionally, the risk of false positive findings appears to be low. In a prospective study of nearly 840 women, cystoscopic examination revealed abnormal ureteral efflux (sluggish or absent flow), but no detectable injury, in 2 percent of women [9]. In all women with abnormal flow, the urine flow rate normalized after the patient received a bolus of intravenous fluid, with or without the addition of a diuretic. Although many gynecologists are not trained to perform cystoscopy, it is easily learned. The cystoscopy complication rate is low [12,18]. (See "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions", section on 'Procedure' and "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions", section on 'Complications'.)
The increased cost of routine cystoscopy is frequently cited as a reason to use the technique only selectively [5]. Increased cost is incurred by training gynecologists to perform cystoscopy, using additional equipment and operating room time, and evaluating or treating injuries that would have healed spontaneously [15]. Despite these additional cost sources, a decision-tree analysis concluded that selective cystoscopy, performed at the time of benign hysterectomy if the concern for injury risk was above a cutoff threshold, was the most reasonable strategy [13]. Cost-effectiveness assessment is further complicated by the fact that both costs and injury rates for procedures vary across institutions and regions, and therefore the breakpoint for the cost versus benefit of routine cystoscopy will differ by setting.
Lastly, although routine cystoscopy is associated with improved intraoperative detection of ureteral and bladder injuries, a subsequent decrease in postoperatively detected injuries has not yet been demonstrated when intraoperative cystoscopy is routinely used. In a systematic review of 79 retrospective and prospective studies, there was no difference in the postoperative detection rates for ureteral and bladder injuries between the groups with and without routine cystoscopy [2]. The most likely explanation for no difference is that postoperatively detected injuries were underreported, injuries detected with routine cystoscopy would have resolved spontaneously, or a combination of both.
Intraoperative evaluation
Our approach — Our practice is to use sodium fluorescein as a first-line agent to screen for ureteral integrity. If we do not see one or both ureteric jets after approximately 5 to 10 minutes, we perform a ureteric catheterization, although supporting data are lacking. We assemble a 21-French cystoscope, deflector bridge, and 5-French ureteric catheter. We then introduce the 5-French ureteric catheter into the ureteric orifices that are not effluxing urine and ensure that the catheter easily glides up at least 17 cm. We then remove the catheter and complete the surgical case. Applying this second intraoperative maneuver with ureteric catheterization helps resolve any intraoperative cystoscopies that may be a false positive for a ureteric injury. If the ureteric catheter cannot be advanced or if we have other concerns for ureteral injury, we explore the course of the ureter from an abdominal approach.
Role of intravesical contrast or fluid — Administration of agents that color the urine can be used to assess the integrity of the lower urinary tract. Although cystoscopy can be performed without the use of a marker dye to stain the urine, the ureteral jets can be difficult to visualize, particularly in patients with dilute urine. In contrast, leakage of dye into the operative field confirms the presence of a bladder or ureteral defect and helps to pinpoint its location as well as enables identification of the ureteral jets. The absence of the appearance of dye does not exclude injury since dye may be sequestered (eg, in the retroperitoneum) or an injury other than a laceration may have occurred (eg, thermal injury).
Dye can be administered through several routes:
●Intravesical contrast or fluid – Either intravesical dye or distending media can aid visualization of the ureteral jets or bladder injury. Although methylene blue (two to three drops diluted in saline) has traditionally been used for intravesical distention, drug availability is now limited. As an alternate, sterile infant formula can be used to distend the bladder and is commonly available in obstetric operating rooms (no dilution required) [19,20]. Intravesical dye is primarily for suspected bladder injury; ureteral injuries proximal to the bladder may not be revealed.
Alternately, some clinicians prefer intravesical instillation with mannitol solution as an aid to visualize ureteral jets. In an unblinded trial of 131 women undergoing gynecologic surgery, surgeons rated mannitol bladder distension as providing the best visualization, ease of use, and overall satisfaction when compared with oral phenazopyridine, intravenous sodium fluorescein, and normal saline [21]. No adverse events were reported in any of the arms, including for postoperative urinary tract infection. In contrast, a prior study reported that use of 50 percent dextrose solution for bladder instillation was associated with increased rates of postoperative urinary tract infections [22].
●Intravenous
•Sodium fluorescein (0.25 mL or 25 mg of 10 percent solution is administered intravenously and colors the urine fluorescent yellow [23]. Our practice is to dilute 1 mL of 10 percent sodium fluorescein in 9 mL of normal saline and administer 1 mL (10 mg) intravenously. Bright fluorescent yellow urine is easily seen from patent ureteral orifices [24]. If the bladder is full of the bright yellow urine, it may need to be rinsed to better visualize the contrast when evaluating ureteric integrity. Administration of a fluid bolus or placing the patient in reverse Trendelenburg position speeds the flow of dye; a diuretic (eg, intravenous furosemide 20 mg) may be used in patients who have no renal compromise. From ophthalmologic literature (where intravenous doses are typically 500 mg), frequency rates were 1:63 for moderate adverse reaction, 1:1900 for severe adverse reaction, and 1:222,000 for death [25]. Anaphylactic reaction has been described in a patient receiving a 25 mg intravenous dose to facilitate cystoscopy [26]. Thus, although rare, sodium fluorescein should not be administered to patients with any prior allergic reaction to it and should be administered with caution to patients with a history of anaphylactic reactions [26].
•Indigo carmine (2.5 mL of a 0.8 percent solution) has traditionally been used to color the urine blue. However, manufacture of the product was discontinued in 2015 due to a shortage of raw material [27]. Indigo carmine should not be given to patients with a history of anaphylaxis to sulfa medications, since indigo carmine may cross-react with sulfa [28].
●Oral – For surgeries with planned cystoscopy, the patient can take 100 to 200 mg of oral phenazopyridine approximately one hour before surgery [29]; dose selection in determined by availability. One study has reported that phenazopyridine colors the urine reddish-orange. As the drug is cleared by the kidneys, it is not given to patients with renal insufficiency. While oral vitamin B has been described to color urine, its use with cystoscopy is limited because the change in urine color is inconsistent [30].
Alternate agents to detect ureteral efflux have included cystoscopic dextrose in sterile water (D10 or D50) and intravenous methylene blue. We do not use cystoscopic D10 because it has been associated with nearly double the incidence of postoperative urinary tract infections compared with cystoscopic normal saline [31]. Methylene blue is not used intravenously to color urine because a cumulative dose >7 mg/kg can result in methemoglobinemia in susceptible individuals. (See "Methemoglobinemia".)
Following intravenous or oral administration of dye, colored urine will be visible in the operative field if a defect is present, in addition to appearing in the bladder catheter collection system. Output of colored urine signifies only that at least one ureter is functioning but does not indicate which ureter may be patent. Failure to visualize colored urine in the output of the bladder catheter after administering a dye suggests occlusion of both ureters. Marked delay between drainage from one ureter or obvious differences in the amount of dye seen coming from each ureter suggests partial obstruction.
Administration of a fluid bolus or placing the patient in reverse Trendelenburg position may speed the flow of dye, or a diuretic (eg, intravenous furosemide 20 mg) may be used in patients without renal compromise. In a trial comparing time to confirmation of ureteral patency in women receiving furosemide or placebo, women receiving furosemide had ureteral patency confirmed faster (86.5 versus 165 seconds), but the time difference of just over a minute is of unclear clinical benefit [32].
Visual inspection of the urinary tract — Intraoperative evaluation is warranted any time there is a finding suggestive of urinary tract injury or clinical concern. When using an abdominal or laparoscopic surgical approach, the first step in the evaluation of suspected injury is visual inspection to assess the integrity of the bladder and ureters and the nature and severity of injury [33]. If an injury is identified, complete evaluation of the urinary tract is still performed as the contralateral ureter or bladder may also have been injured. Bladder injury is more likely than ureteral injury to be diagnosed using visual inspection [2,9,34,35]. In a prospective study over 800 women who underwent hysterectomy, visual inspection detected 38 percent bladder injuries versus 7 percent of ureteral injuries [9].
Findings that are diagnostic for urinary tract injury include seeing urine in the operative field, a defect in the ureter or bladder such as transection or laceration, or the bladder catheter or mucosa in the operative field. Findings suggestive of urinary tract injury include blood in the bladder catheter (particularly if it is ongoing); the ureter in close proximity to a clamp, suture, or staple; and gas in the urine or bladder catheter during laparoscopic surgery. Ongoing hematuria is more suggestive of injury than blood that clears rapidly from the urine. Transient bleeding can result from minor trauma during urinary tract manipulation (eg, insertion of the bladder catheter, pressure from retractor) and typically clears. If hematuria persists, further evaluation for a urinary tract injury is performed.
Observing the ureter for peristalsis is used to identify the ureter, but it is not a valid test for ureteral integrity. In a retrospective study in which women undergoing total abdominal hysterectomy were evaluated with intraoperative cystoscopy, peristalsis was present in five of six women with ureteral injury [35]. Full evaluation of a ureter may require further dissection of the ureter. Whether to perform this ureteral dissection initially or defer dissection and evaluate the urinary tract integrity at a later time during surgery (eg, with cystoscopy) is based upon the surgeon's preference and skills. The techniques for dissection to avoid injury to the ureters and bladders are described separately. (See "Urinary tract injury in gynecologic surgery: Epidemiology and prevention", section on 'Surgical technique'.)
During vaginal surgery, all pedicles and the anterior vaginal wall should be inspected for possible areas of impingement upon urinary tract structures. It is not possible to inspect the bladder or ureters directly when using a vaginal approach.
Cystoscopy — Intraoperative cystoscopy is performed to evaluate bladder injury (eg, perforation, bleeding, suture or staple) and confirm urine efflux from both ureteral orifices. Absence or abnormal flow (delayed or sluggish) from one or both ureters warrants further evaluation for ureteral transection or obstruction. Blood coming from a ureteral orifice can also point to ureteral injury and must be investigated. However, cystoscopy does not detect all ureteral injuries; partial ureteral obstruction or transection or thermal injuries may be missed [36]. The procedure for diagnostic cystoscopy is reviewed separately. (See "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions".)
Circumstances may arise where a patient undergoing an open procedure in the dorsal supine position is considered at risk for bladder or ureteral injury and cystoscopy is considered. While one option is to re-position and drape the patient in lithotomy position and then proceed, transvesical cystoscopy is another option. A 70 or 30 degree cystoscope can be placed through the dome of the bladder in the operative field and the opening tied with a purse-string suture. Alternately, a simple incision can be made into the dome of the bladder and direct inspection performed.
Another option is to position patients in the dorsal lithotomy position before abdominal surgery and use lithotomy stirrups that can adjust from a low to high position plus a self-retaining retractor that does not interfere with elevating the upper thigh. We routinely perform all major abdominal gynecologic and urogynecologic procedures with the patient in low lithotomy boot-type (eg, Yellofin) stirrups and use a self-retaining abdominal retractor (eg, Bookwalter retractor (figure 1)) to allow us easy access for cystoscopy when needed. (See "Urinary tract injury in gynecologic surgery: Epidemiology and prevention", section on 'Preoperative planning' and "Urinary tract injury in gynecologic surgery: Epidemiology and prevention" and "Perioperative patient care issues in female pelvic reconstructive surgery", section on 'Intraoperative'.)
Ureterography — A ureteral defect can be diagnosed with intraoperative contrast studies (eg, retrograde ureterography or intravenous pyelography). Extravasation of contrast confirms a ureteral defect.
POSTOPERATIVE FINDINGS AND EVALUATION — The most important principle of postoperative diagnosis of urinary tract injury is to have a high index of suspicion, since early symptoms and signs may be subtle. Any suspicion of injury should be promptly investigated. Early diagnosis facilitates management of the injury and speeds recovery [1].
Urinary tract injuries are distressing for patients. The attending gynecologic surgeon should stay involved with the patient's care, assisting with explaining upcoming procedures, test results, and providing the patient opportunity to ask about the details and circumstances around the intraoperative injury, even when the patient is referred for surgical repair by another surgeon.
Clinical manifestations — The presentation of a urinary tract injury after gynecologic surgery depends upon the underlying pathology and how much time has passed since surgery.
Urinary tract injuries that are not recognized intraoperatively are most likely to present within the first two weeks after surgery, but some cases present later. Gynecologic surgeons need to ensure that these early presentations, often with subtle symptoms and signs, are recognized, thereby allowing diagnosis and management. As an example, in a series of 136 ureteral injuries, 17 were discovered intraoperatively, 50 were discovered within a week of surgery, 47 within one month, and 17 greater than one month after surgery [37]. In five patients, damage was not noted until two years after the surgery [37]. During the first 14 days after surgery, signs and symptoms that should prompt evaluation for urinary tract injury include [33,38]:
●Leakage of urine from the vagina or abdominal incision
●Unilateral or bilateral flank pain
●Hematuria
●Oliguria
●Anuria
●Abdominal pain or distension
●Nausea with or without vomiting
●Ileus
●Fever
Symptoms coincide with the location and type of injury. Obstruction or laceration of the urinary tract are the most common mechanisms of injury. A combination of obstruction and a laceration in the urinary tract may present with a combination of signs and symptoms. There can also be more than one area injured, including a combination of ureteral and bladder injuries. Coincident urinary tract infection often increases the acuity of the presentation and the severity of illness. Intraperitoneal leakage of infected urine or a combination of urinary tract obstruction and infection can lead to severe and quick compromise in a previously healthy adult.
Complete ureteral obstruction may present with ipsilateral flank pain within 24 hours after surgery. However, many patients may present with pain in other locations or may be asymptomatic. Postoperative analgesics may also mask the pain. Due to these variations in the presentation, clinicians should be vigilant regarding symptoms that suggest ureteral obstruction. Stasis of urine can predispose to pyelonephritis. Partial ureteral obstruction may be asymptomatic, but may progress over time to complete obstruction and result in loss of function in the ipsilateral kidney. Such loss of function may remain silent or be discovered at some point during investigations for other health conditions. (See "Clinical manifestations and diagnosis of urinary tract obstruction (UTO) and hydronephrosis".)
A ureteral or bladder defect with leakage of urine into the peritoneal cavity may present as abdominal pain and ascites. Peritonitis may develop and irritation of the bowel from the urine usually results in ileus. Leakage of urine from the vagina or abdominal incision in the immediate postoperative period after hysterectomy is likely due to drainage of a peritoneal collection of urine. The time course of development of vesicovaginal or ureteral vaginal fistula ranges from days to weeks. Copious serosanguinous drainage from an incision may also signify wound dehiscence. (See "Complications of abdominal surgical incisions", section on 'Fascial dehiscence'.)
In the retroperitoneum, a collection may develop into a urinoma; the patient may become febrile due to infection and inflammation associated with this process. Based on the urinary tract anatomy, a retroperitoneal collection is typically due to a ureteral, rather than bladder injury.
Hematuria may be apparent immediately after the bladder catheter is removed, but this should clear shortly after removal. If bleeding persists or appears remote from the removal of the catheter, urinary tract injury should be suspected. Anuria signifies bilateral ureteral obstruction or transection or other structural or intrinsic renal process (eg, renal failure) and requires immediate evaluation. Oliguria can occur in the setting of ureteral obstruction, but it is not a specific sign because there are other postoperative causes for oliguria after surgery (eg, fluid shifts to the interstitial space).
Postoperative evaluation — The diagnosis of postoperative urinary tract injury is made using cystoscopy or imaging studies of the urinary tract. The patient's symptoms and results of physical examination and laboratory studies also contribute to the choice of diagnostic study and identification of other complications associated with the injury (eg, renal insufficiency, urinary tract infection).
Physical examination — Vital signs are taken to assess hemodynamic stability and whether the patient is febrile. The urine output for the previous 24-hour period is calculated and the urine inspected for hematuria. The abdomen is assessed for signs of peritonitis, ascites, and the presence of bowel sounds. Following abdominal surgery, the integrity of the abdominal incision(s) is evaluated. A pelvic examination is conducted to rule out a pelvic mass or tenderness and leakage of urine from the vaginal incision(s). The back is examined for costovertebral tenderness.
Laboratory evaluation — Serum electrolytes, blood urea nitrogen (BUN), and creatinine are measured.
Bilateral ureteral obstruction results in acute renal failure (acute kidney injury). Unilateral complete obstruction is accompanied by a transient minimal increase in creatinine as the other kidney compensates for the loss of function in the contralateral kidney. A case control study of 15 women with unilateral ureteral obstruction after gynecologic surgery reported that the increase in creatinine from the postoperative value was significantly higher in women with obstruction compared with age- and procedure-matched controls [39]. For the women with ureteral obstruction, at 36 to 48 hours after surgery, the mean increase from the preoperative creatinine was 0.8 mg/dL above the preoperative value (range for women with obstruction: 0.3 to 1.4 mg/dL versus controls: -0.2 to 0.3 mg/dL).
Urinalysis is sent to assess for infection and hematuria, a urine culture is sent if the results suggest infection. Alternatively, a urine culture should be sent without obtaining a urinalysis if the patient is at high risk of infection or if infection is suspected.
If uroperitoneum (ie, urinary ascites) is suspected, some clinicians obtain a biochemical analysis of the peritoneal fluid by performing paracentesis or sending fluid from an intraperitoneal drain (eg, Jackson-Pratt drain). The results from such testing do not provide direct evidence of urinary tract injury, and confirmation may still be needed with more definitive testing (eg, cystoscopy with intravenous indigo carmine, imaging studies).
Evidence regarding the diagnosis of uroperitoneum is limited to older case reports and small case series. As an example, a 1999 case series of 20 women followed postoperatively after radical hysterectomy reported mean normal values for urea nitrogen (peritoneal: 10 mg/dL; urine: 469 mg/dL) and creatinine (peritoneal: 0.9 mg/dL; urine: 141 mg/dL) [40]. By contrast, in patients with liver cirrhosis, BUN and creatinine concentrations are similar in ascites and serum [41]. The values for uroperitoneum will be similar to urine rather than serum (or peritoneal fluid, which has values similar to serum) [40,42,43].
If peritoneal fluid is sent for biochemical analysis, the BUN and creatinine of the peritoneal fluid needs to be measured and compared with the patient's serum and urine levels. The results are interpreted as follows:
●Similar values in serum and ascitic fluid (or lower levels in ascitic fluid) is reassuring for the absence of uroperitoneum. However, the patient should be evaluated further if urinary tract injury is still suspected (eg, ureteric obstruction without uroperitoneum). In addition, if significant non-urine ascites is present, the patient may need to be further evaluated for other etiologies. (See "Evaluation of adults with ascites".)
●If BUN and creatinine are normal in the serum and elevated to a level similar to urine in the ascitic fluid, urinary tract injury is likely, but the patient still requires testing with cystoscopy and/or imaging for confirmation.
●If the values are elevated in both serum and ascitic fluid, this may represent both acute renal failure and uroperitoneum possibly from urinary tract injury. This result warrants further evaluation of renal function and cystoscopy and/or imaging to further evaluate for urinary tract injury. (See "Assessment of kidney function".)
Because measuring BUN and creatinine in peritoneal fluid is an indirect test for urinary tract injury with unknown specificity and sensitivity, if a urinary tract injury is suspected, we use more direct diagnostic tests (ie, cystoscopy and imaging).
Cystoscopy — Cystoscopy is performed to assess for bladder injury and evaluate ureteral function. (See 'Cystoscopy' above.)
Imaging studies — Bladder injury can be evaluated with a cystogram if cystoscopy cannot be performed; however, a cystogram can detect a laceration or large foreign body, but not more subtle findings (eg, a transmural suture or attenuation of the bladder mucosa). When ureteral injury is suspected, ultrasonography can be helpful as an initial test to assess for hydronephrosis or to exclude a retroperitoneal collection. We follow this with computed tomography with renal contrast or cystoscopy with retrograde intravenous pyelography, depending on test availability.
Once a diagnosis of ureteral injury is suspected or confirmed, a retrograde pyelogram can give more information regarding the precise location of the injury. Depending upon the skills and experience of the urologist, ureteral double-J stenting during the retrograde pyelogram as a first-line treatment may manage the injury and avoid the need for more invasive surgery, especially in cases of ureteric obstruction in the postoperative period without large lacerations [44]. Nephrostomy tube insertion by an urologist or interventional radiologist is another approach to initial management of an acute injury.
If a retroperitoneal, pelvic, or abdominal urinoma is suspected, ultrasonography is the initial imaging study of choice. Further clarification of the location of a fluid collection can be evaluated with computed tomography or magnetic resonance imaging.
Evaluation of patients with urinary tract obstruction or genitourinary fistula is discussed separately. (See "Clinical manifestations and diagnosis of urinary tract obstruction (UTO) and hydronephrosis" and "Urogenital tract fistulas in females", section on 'Cystoscopy and imaging studies'.)
MANAGEMENT — Urinary tract injury recognized during surgery should be treated intraoperatively rather than delaying until after surgery or performing a second procedure.
Antibiotic prophylaxis — Most surgeons do not administer additional antibiotic prophylaxis when a urinary tract injury occurs, whether it is recognized intra- or postoperatively. Urinary tract injury is most likely to occur in major gynecologic procedures for which routinely used antibiotic prophylactic agents (cephalosporins, gentamicin, or fluoroquinolones) (table 1) cover the enteric gram-negative bacilli that comprise most urinary tract pathogens. There are no high-quality data that address this issue. In our practice, if a patient in whom a urinary tract injury occurs has clinical signs suggestive of a urinary tract infection (cloudy urine output from the bladder catheter, malodorous urine, or bladder mucosa that appears inflamed on cystoscopy), we send urine culture during surgery and treat empirically for a urinary tract infection until the culture results are received.
A bladder catheter is used for several days or weeks in many women following a urinary tract injury. Based upon high-quality data, prophylactic antibiotics to prevent urinary tract infection are not required in this setting. (See "Catheter-associated urinary tract infection in adults", section on 'Prevention'.)
Ureteral injury — Repair of ureteral injuries often involves ureteral stenting or advanced surgical repair.
The exception to this is the ligation or kinking of a ureter with a suture. In such cases, the suture is removed and the integrity of the ureter is inspected. Cystoscopy is performed to verify ureteral function. If the efflux from the ureter is absent or abnormal, a surgeon with experience with urinary tract injury, typically a urologist or urogynecologist, should be consulted intraoperatively. If there is doubt regarding the integrity of the ureter, a ureteral stent may be necessary [10]. (See "Placement and management of indwelling ureteral stents" and "Surgical repair of an iatrogenic ureteral injury".)
Injuries such as transection or other types of extensive damage (eg, crush injury, thermal damage) may require reanastomosis or ureteroneocystostomy [10]. Repair of such injures is usually performed by a urologist or other surgical specialist. (See "Surgical repair of an iatrogenic ureteral injury".)
Bladder injury — The approach to repair of a bladder injury depends upon the site, type, and severity of injury. Potential sites of injury to the bladder include the dome, supratrigonal area, trigone, and below the trigone.
Treatment of thermal bladder injury varies depending upon the extent of injury. This type of injury should be managed by a clinician experienced with thermal urinary tract injury, typically a urologist.
Bladder dome — When recognized intraoperatively, dome or supratrigonal injuries are usually repaired with excellent results. Delayed identification and repair of injury to the bladder dome are more difficult. If the injury noted is an accidentally placed suture or staple, the foreign material is removed. The bladder should then be re-inspected after removal to confirm no tear has occurred. Similarly, mesh tapes may be inadvertently inserted into the bladder.
Repair of cystotomy limited to the bladder dome is a straightforward procedure in most patients, but should only be performed by a surgeon with experience with this type of repair. Bladder injury in women in whom primary closure is difficult (eg, vaginal surgery or history of pelvic irradiation) or which is not a simple cystotomy requires intraoperative consultation with an advanced gynecologic or urologic surgeon with skills in these more complicated repairs.
●Management – Management of a bladder dome cystotomy depends upon the size of the defect. Minimal defects in the bladder dome (eg, a <2 mm injury from pneumoperitoneum needle during laparoscopic surgery) can be managed expectantly. Very small injuries (eg, <1 cm) may either be repaired or managed by leaving the bladder catheter in place for five to seven days, followed by a cystogram to confirm closure. All other cystotomies should be repaired.
●Cystotomy repair – The repair should be delayed until all other surgical dissection is completed, since other injuries may occur. The repair is a one- or two-layered running closure with absorbable suture. We use an absorbable synthetic suture (eg, polyglactin or poliglecaprone). We use one layer for a small cystotomy (eg, <2 cm) or two layers for larger cystotomies. When there are more than one cystostomy in close proximity to each other and well away from the bladder trigone, an option is to incise the small defects to combine them into a single defect before beginning the repair. When the repair is completed, the closure should be tested to see if it is water-tight by instilling dye into the bladder catheter. Additionally, we evaluate the closure with cystoscopy, taking care to not over distend the bladder nor traumatize the suture line with the cystoscope.
The bladder will re-epithelialize within three to four days and will regain its normal strength after 21 days [45-47]. We usually leave the bladder catheter in for 5 to 14 days, depending on the size and location of the defect. Some clinicians obtain a cystogram to confirm the injury has healed before removing the catheter, especially for larger cystotomies [48]. In our practice, we perform cystogram prior to catheter removal if we have concerns about tissue healing (eg, tenuous repair or irradiated tissue) or if the catheter is being removed early (<7 days) per patient request. Prophylactic antibiotics are not required for these women. (See 'Antibiotic prophylaxis' above.)
For all cystotomies where prior anti-incontinence procedures were performed, prior to removing the bladder catheter, we instill approximately 300 mL of sterile water, withdraw the bladder catheter, and ensure the patient can void without leaving behind a large residual. (See "Perioperative patient care issues in female pelvic reconstructive surgery", section on 'Catheter removal and voiding trial'.)
Bladder trigone — Injuries to the trigone or below the trigone may involve the ureters or urethra and are more difficult to repair than dome or supratrigonal injuries. Exposure and suturing of this area are difficult, particularly during abdominal or laparoscopic procedures. This is because the trigone includes the ostia of the ureters and urethra and is located in the inferior and posterior aspect of the bladder.
When an injury to the trigone occurs, the integrity of the ureters and urethra must be assessed. Ureteral stent placement may be required. Repair of the bladder defect and other injuries must be performed by an advanced gynecologic or urologic surgeon.
Neurogenic bladder dysfunction — Postoperative bladder dysfunction is a common complication of gynecologic surgery. In a prospective series of 284 women who underwent gynecologic surgery, the incidence of postoperative urinary retention was 9 percent [49]. Women with postoperative urinary retention are treated with bladder catheterization. In our experience, normal bladder function will return within several days in most patients. Because of this small risk of short-term bladder dysfunction, we check a postvoid residual (PVR) in these patients after their catheter removal by instilling (retrograde) a known volume into the bladder and then either confirming that the voided volume is the same as that instilled or that the PVR is minimal with a bladder scanner. (See "Postoperative urinary retention in females", section on 'Retrograde voiding trial'.)
Chronic postoperative neurogenic bladder dysfunction can result from procedures that involve extensive dissection and mobilization of the bladder. This type of complication is more likely following extensive perivesical dissection. Radical hysterectomy, for example, interrupts parasympathetic and sympathetic innervation due to resection of the uterosacral and cardinal ligaments. Operative trauma may result in edema and hematoma formation that affects the bladder's functions of urine collection and micturition.
Management of neurogenic bladder dysfunction is discussed separately. (See "Acute urinary retention".)
Urethral injury — Urethral injury following pelvic surgery most commonly occurs during surgery for pelvic organ prolapse or urinary incontinence. This is discussed separately (see "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Urethral injury' and "Surgical management of stress urinary incontinence in females: Transobturator midurethral slings", section on 'Bladder or urethral injury'). Urethrovaginal fistula is most commonly associated with anterior colporrhaphy or obstetric forceps rotations. (See "Urogenital tract fistulas in females", section on 'Urethrovaginal fistulas'.)
Postoperative management — Upon postoperative diagnosis of a urinary tract injury, initial priorities include relieving renal obstruction, treating infection, and stopping urine leakage. In some cases, obstruction or leakage can be managed with ureteral stents, a minimally invasive procedure. Otherwise, surgical exploration is required for repair of the injury. If definitive repair must be delayed, temporary measures (eg, nephrostomy) may be necessary. Ureteral stenting and surgical repair of the urinary tract should be performed by a surgeon with experience with these procedures, often a urologist or urogynecologist. Repair of genitourinary fistula is discussed separately. (See "Urogenital tract fistulas in females", section on 'Management'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery" and "Society guideline links: Genitourinary tract trauma in adults".)
SUMMARY AND RECOMMENDATIONS
●Intraoperative identification of urinary tract injury during gynecologic surgery permits prompt repair. Delayed diagnosis of urinary tract injuries may result in genitourinary fistula formation, severe renal complications, sepsis, and death. (See 'Introduction' above.)
●Urinary tract injury may be seen grossly during surgery or may be suspected if the ureter or bladder are noted in close proximity to a clamp, suture, or staple, or if urine or the bladder catheter are seen in the operative field. (See 'Visual inspection of the urinary tract' above.)
●Methods for intraoperative assessment for urinary tract injury include visual inspection, cystoscopy, and ureterography. (See 'Intraoperative evaluation' above.)
●We suggest intraoperative use of cystoscopy in addition to visual inspection of the urinary tract rather than visual inspection alone for women undergoing surgical treatment of urinary incontinence or anterior or apical pelvic organ prolapse (Grade 2B). We also perform intraoperative cystoscopy for women undergoing laparoscopic hysterectomy or those undergoing oophorectomy who have risk factors for ureteral injury (eg, endometriosis, history of pelvic irradiation laparoscopic hysterectomy). Surgeons are encouraged to have a low threshold for performing cystoscopy at the time of hysterectomy, but the decision to do so is surgeon dependent. (See 'Screening for injury with routine cystoscopy' above.)
●We suggest a dilute solution of sodium fluorescein to facilitate ureteral patency while performing cystoscopy to evaluate lower urinary tract integrity. In cases with marked delays in ureteric jet identification, in order to resolve whether this is a false-positive cystoscopy, we suggest assembling a rigid 21-French cystoscope, deflector bridge, and sliding a ureteric catheter up at least 17 cm prior to other more complicated maneuvers or tests.
●Performing universal cystoscopy early in one's surgical career, with decreasing usage to selective cystoscopy as surgical experience, insight, and awareness increases, may be one option for surgeons to adopt to decrease morbidity and mortality from unrecognized urinary tract injuries. (See 'Our approach' above.)
●Signs and symptoms of urinary tract injury during the first two weeks after surgery may include: leakage of urine from the vagina or abdominal incision, flank pain, hematuria, oliguria, anuria, abdominal pain or distension, nausea, vomiting, ileus, and fever. (See 'Clinical manifestations' above.)
●Obstruction or laceration of the urinary tract are the most common mechanisms of injury. More than one injury may be present, including a combination of obstruction and laceration. Coincident urinary tract infection often increases the acuity of the presentation and the severity of illness. (See 'Clinical manifestations' above.)
●The diagnosis of postoperative urinary tract injury depends upon the clinical scenario but can be made using cystoscopy or imaging studies of the urinary tract. (See 'Postoperative evaluation' above.)
●Urinary tract injury recognized during surgery is best treated intraoperatively. Upon postoperative diagnosis of an injury, the first priorities are to treat infection, relieve renal obstruction, and stop urine leakage. (See 'Management' above.)
●Repair of ureteral injuries often involves ureteral stenting or advanced surgical repair, including ureteral reanastomosis or ureteroneocystostomy. (See 'Ureteral injury' above.)
●The approach to repair of a bladder injury depends upon the site, type, and severity of injury. Injuries to the trigone are the most difficult to repair. (See 'Bladder injury' above.)
