Urological injuries

UROLOGICAL INJURIES

DR.LALITHA

UROLOGIST & UROGYNECOLOGIST

YASHODA HOSPITALS

INTRODUCTION

• URINARY TRACT INJURIES ARE NOT UNCOMMON

• INCREASED INCIDENCE WITH LAPAROSCOPIC SURGERIES

• DEVASTATING TO THE PATIENT

UROLOGICAL INJURIES

• BLADDER INJURY

• URETERIC INJURIES

• EITHER DURING CAESAREAN OR HYSTERECTOMY

CLINICAL PRESENTATION

• DEPENDS ON THE TIME OF DETECTION

• EARLY POST-OP• BLADDER – HEMATURIA• URETER – LOIN PAIN, FEVER,

ABDOMINAL DISTENSION• ANURIA – RARE- BILATERAL URETERS

URINARY FISTULAE

• MOST DEVASTATING CONSEQUENCE

• INJURY UNDETECTED INTRAOP OR EARLY POSTOP

• OR• FAILED PRIMARY REPAIR• OR

CO-EXISTING INJURY MISSED INTRAOP

TYPES OF URINARY FISTULAE

• POST HYSTERECTOMY• V V F• URETERO-VAGINAL FISTULA• POST CAESAREAN• VESICO-UTERINE FISTULA• URETERO-UTERINE FISTULA

VESICO-VAGINAL FISTULA

• MOST COMMONLY SEEN FISTULA• CONTINUOUS LEAKAGE OF URINE

WITHOUT NORMAL VOIDING

• PARADOXICAL INCONTINENCE WITH SMALL VVF

URETERO-VAGINAL FISTULA

• 0.5% FOLLOWING VAGINAL HYST.

• 1% FOLLOWING OPEN ABDOMINAL HYST.

• 2-3% WITH LAP HYSTERECTOMY

URETERO-VAGINAL FISTULA

• PRESENTS WITH PARADOXICAL INCONTINENCE

• URINE LEAK PER VAGINA WITH NORMAL VOIDING

• 1 WEEK – 10 DAYS POST-OP

VESICO-UTERINE FISTULA

• UNDETECTED BLADDER INJURY DURING A CAESAREAN SECTION

• PRESENTS WITH URINE LEAK THRU CERVIX

• CYCLICAL HEMATURIA WITHOUT ANY URINARY LEAK--

MRI PELVIS—POST CAESAREANFISTULA BETWEEN BLADDER DOME AND UTERUS

MR

MRI UROGRAM SHOWING NORMAL UPPER TRACTS WITH VESICO-UTERINE FISTULA

VESICO-UTERINE FISTULA

• TREATMENT

• TRANSPERITONEAL REPAIR WITH OMENTAL INTERPOSITION

• HYSTERECTOMY REQUIRED IN SOME CASES

RGP SHOWING URETERO-UTERINE FISTULA

IVP TOTAL URETERIC OBST. FOLLOWING LSCS

IVP – LEFT URETERO-UTERINE FISTULA

URETERO-UTERINE FISTULA

• RAREST FORM OF URINARY FISTULA

• 0.02% FOLLOWING CAESAREAN

• MORE COMMON ON LEFT SIDE• DUE TO DEXTRO-ROTATION • BLIND ATTEMPT AT HEMOSTASIS

URETERO-UTERINE FISTULA

• CLINICAL PRESENTATION

• LOIN PAIN, FEVER• URINE LEAK THRU CERVIX• NORMAL VOIDING

PREVENTION OF BLADDER INJURIES

• FOCUS ON 3 AREAS

• OPENING THE PERITONEUM• FULL BLADDER• PREVIOUS SURGERY • MOBILIZING THE BLADDER OFF THE

UTERUS• CLOSURE OF UTERUS OR VAULT

PREVENTION OF URETERIC INJURIES

• IDENTIFY HIGH RISK CASES• PID,ENDOMETRIOSIS, OVARIAN

TUMORS,BROAD LIG. OR CERVICAL FIBROID

• PREOP-IVP• INTRAOP STENTING• AVOID SKELETONIZING THE URETERS

DIAGNOSIS

• BEST TIME TO DETECT IS DURING SURGERY

• HIGH INDEX OF SUSPICION

• WHEN IN DOUBT – CALL A UROLOGIST

BLADDER INJURIES

• CHECK FOR INTEGRITY BY FILLING SALINE

• ANY BLADDER REPAIR – POST OP INDWELLING CATHETERIZATION

• DON’T HESITATE TO PUT AN SPC WHEN INJURY IS EXTENSIVE

URETERIC INJURIES

• HIGH INDEX OF SUSPICION

ANY DIFFICULT DISSECTION

CYSTOSCOPY AND RGP UNDER FLOROSCOPY

WHEN IN DOUBT, SAFER TO STENT

POST-OP URINE LEAK

• WHAT NEXT?

• DIAGNOSIS – TYPE OF FISTULA• HISTORY – TOTAL / PARADOXICAL• EXAM.- LEAK P/V OR PER URETHRA

DIAGNOSIS OF TYPE OF FISTULA

USG -• VVF / VESICO-UTERINE FISTULA

NORMAL KIDNEYS

BLADDER MAY BE EMPTY

• UVF / URETERO-UTERINE FISTULA

HYDRONEPHROSIS

DIAGNOSIS

• IVP

URETERIC FISTULAE

HYDRONEPHROSIS & HYDRO-URETER

VVF- CYSTOGRAM PHASE

URINE LEAK INTO VAGINA

DIAGNOSIS [ contd]

• CYSTOSCOPY AND RGP• V V F SITE

SIZE

NUMBER

PROXIMITY TO ORIFICES

ANY INFLAMMATION

RGP- EXACT SITE OF URETERIC INJURY

DIAGNOSIS

CT UROGRAM / MRI

• FOR POST CAESAREAN LEAKS

VESICO-UTERINE FISTULA

URETERO-UTERINE FISTULA

TREATMENT

• VVF - CONSERVATIVE

• SURGICAL OPTIONS

VAGINAL

ABDOMINAL – TRANSVESICAL

TRANSPERITONEAL

LAPAROSCOPIC

TREATMENT

VESICO-UTERINE FISTULA

TRANSPERITONEAL REPAIR

OMENTAL INTERPOSITION

MAY NEED HYSTERECTOMY

URETERIC INJURIES

• TREATMENT OPTIONS BASED ON• TIME OF DETECTION• SITE OF INJURY• NATURE OF INJURY• UNILATERAL / BILAT.

URETERIC INJURIES

TREATMENT OPTIONS

URETEROSCOPIC STENTING

END-TO-END ANAST.

RE-IMPLANTATION

DIRECT

PSOAS-HITCH

BOARI’S FLAP