Urological injuries in conjunction with gynecologic surgery-10 years' experience

A 10-year evaluation (1983–1992) of 23 patients (mean age 49 years) with urologic injuries in conjunction with gynecologic surgery is presented. There were nine vesicovaginal fistulas, eight ureteral injuries, three bladder lesions, two posterior urethrovaginal fistulas and one vesicocervical fistula. The total incidence of urologic injuries from all major gynecologic operations (n=16 400) was 0.09% and that of abdominal hysterectomies (n=4082) 0.17%. Vesicovaginal fistulas and ureteral injuries comprised two-thirds (17/23) of all injuries. All vesicovaginal fistulas followed abdominal hysterectomy, whereas almost half (3/8) of ureteral injuries were recognized after radical hysterectomy. Of nine vesicovaginal fistulas two were cured by prolonged transurethral catheter drainage: the other seven underwent successful transabdominal repair at first attempt. All the eight ureteral injuries were cured successfully at the first attempt, five of them by ureteroneocystostomy and the others with ureteral stent placement. One of the urethrovaginal fistulas was repaired successfully at the first attempt, the other required a second repair. At follow-up (mean 4 years) all patients were doing well. Urologic injuries after gynecologic surgery are extremely rare (0.09% in our series) but when they occur they can be consistently repaired by modern surgical techniques.Editorial Comment: This report of a 10-year experience with various types of fistula and ureteral injury indicates a very low incidence as well as a very high success rate in their management. Of note is the high frequency of fistulas following urethral diverticulectomy (18%). Care must be taken when closing the anterior vaginal wall in this procedure. There must be no tension and adequately vascularized tissue must be present. The preparation of flaps is usually possible as the dissection of the diverticulum proceeds, with the goal of having enough tissue to allow a vest-over closure in one or two layers. If there is any doubt about the closure a bulbocavernosus fat pad graft should be prepared and placed as an additional layer prior to closure of the vaginal wall.     

The late occurrence of urinary tract damage in patients successfully treated by radiotherapy for cervical carcinoma

Urinary tract complications apparently resulting from radiation therapy for carcinoma of the cervix can occur as long as 30 years after cessation of such treatment. Patients generally present with urinary incontinence and often are treated by standard operative methods that usually are unsuccessful. Incontinence is related to bladder fibrosis, urethral nonfunction and vesicovaginal fistuLa formation, and may be accompanied by bilateral ureteral obstruction. Of 11 patients with late complications of radiotherapy 4 had upper tract deterioration, 4 had vesicovaginal fistulas, 5 had an incompetent urethra aNd 9 had a fibrotic, noncompliant areflexive bladder. Treatment was aimed at providing adequate low pressure storage capacity and consisted of augmentation cystoplasty in 5 patients, repair of the fistula in 4 and correction of urethral dysfunction in 5. Women who complain of incontinence and/or irritable bladder symptoms with a history of radiotherapy for cervical carcinoma should be evaluated for fistuLa formation, urethral incompetence, and detrusor areflexia and fibrosis before treatment is done.     

医原性输尿管膀胱损伤诊治分析

目的 探讨医原性输尿管膀胱损伤发生原因及防治方法.方法 医原性输尿管膀胱损伤患者47例,男7例,女40例.其中妇产科手术损伤38例、泌尿外科5例、普外科4例. 结果 术中发现输尿管损伤16例,其中断裂14例,输尿管壁部分撕裂伤2例;行输尿管断端吻合术13例,肾盂输尿管吻合术1例,1例输尿管镜手术引起输尿管穿孔者予终止手术并留置双J管,1例被迫切除肾脏;术后3～7 d发现输尿管损伤7例,其中输尿管下段被结扎4例.输尿管阴道瘘3例,均于术后2周内行输尿管下段膀胱再植术.术中发现膀胱损伤19例,膀胱壁不规则撕裂长约1～3 cm;行膀胱修补术17例,由腔镜和TVT手术引起膀胱穿孔2例予留置导尿1周;术后1周～1个月发现膀胱阴道瘘5例,均于3个月后行瘘管切除修补术.术后47例随访5个月～11年,平均47个月,患者均治愈,无并发症. 结论 医原性损伤重在预防,术中及时发现、正确处理可避免二次手术;术后出现尿瘘者选择合理治疗方案可提高治愈率.     

医源性输尿管损伤的诊断和治疗

目的 探讨医源性输尿管损伤的原因、处理和预防。方法 对1989年10月至2002年6月收治的38例(40侧)医源性输尿管损伤病例进行回顾性分析。结果 4例行双J管保守治疗．7例(9侧)行输尿管端端吻合术，22例行输尿管膀胱再植术，2例行膀胱壁瓣输尿管吻合术，2例行阑尾代右侧部分输尿管术，1例行肾切除术。除1例行肾切除术外．其余37例(39侧．97．5％)均获得痊愈。结论 术前、术中了解与熟知输尿管的解剖位置，细致、规范的手术操作是预防医源性输尿管损伤的关键；一旦确诊为医源性输尿管损伤．应及早处理。     

Our experience with salvage genitourinary fistulae repair: technique and outcomes

Objectives The objectives are to present the long-term results of vaginal reconstructive operations using the labial fat pad flap (Martius flap) interposition. Patients and methods Eight women, 27–65 years old (mean 40), suffering from urinary fistulae (five urethrovaginal and three vesicovaginal) who failed primary repair underwent salvage vaginal reconstruction for damaged urethra or bladder. Urethral or bladder and vaginal defect was closed and a Martius fat flap was interposed between urethra or bladder and vaginal wall flap to secure a watertight separation of the structures. A Martius flap was also used successfully for salvage vaginal reconstruction in three more women, two with extensive injury of their urethra and bladder neck and one with vaginal leakage, after a rectosigmoid neobladder diversion following cystectomy. Results The repair was successful in all eight patients with urinary fistulae and in the one with rectovaginal leakage. The patient with the traumatically injured urethra and bladder neck developed an anastomotic stricture treated with urethral dilatations and internal urethrotomy. The older one developed a vesicovaginal fistula due to bladder neck closure, and this was repaired with a second transvaginal closure. Conclusion Martius labial fat flap is an easy to prepare, well-vascularized tissue that can be most helpful in achieving a long-lasting favorable outcome in vaginal reconstructive surgery.     

Post-traumatic female urethral reconstruction

Post-traumatic urethral damage resulting in urethrovaginal fistulas or strictures, though rare, should be suspected in patients who have unexpected urinary incontinence or lower urinary tract symptoms after pelvic surgery, pelvic fracture, a long-term indwelling urethral catheter, or pelvic radiation. Careful physical examination and cystourethroscopy are critical to diagnose and assess the extent of the fistula. A concomitant vesicovaginal or ureterovaginal fistula should also be ruled out. The two main indications for reconstruction are sphincteric incontinence and urethral obstruction. Surgical correction intends to create a continent urethra that permits volitional, painless, and unobstructed passage of urine. An autologous pubovaginal sling, with or without a Martius flap at time of reconstruction, should be considered. The three approaches to urethral reconstruction are anterior bladder flaps, posterior bladder flaps, and vaginal wall flaps. We believe vaginal flaps are usually the best option. Options for vaginal repair of fistula include primary closure, peninsula flaps, bilateral labial pedicle flaps, and labial island flaps. Outcomes are optimized by using exacting surgical principles during repair and careful postoperative management by an experienced reconstructive surgeon.     

Role of the martius procedure in the management of urinary-vaginal fistulas

BACKGROUND: Urinary-vaginal fistula is one of the most common and dreaded complications of obstetric trauma in developing countries. Management of these fistulas is complicated by the presence of substantial urethral loss and the tendency of the repair to break down. STUDY DESIGN: We retrospectively studied 46 patients with urinary-vaginal fistulas operated on in our institution over 5 years. Most of the patients had obstetric trauma as the causative factor. Twelve patients had urethrovaginal and 34 had vesicovaginal fistulas. Of the 12 patients with urethrovaginal fistulas, 8 underwent a Martius procedure and 4 were treated with simple anatomic repair. Of the 34 patients with vesicovaginal fistulas, 13 underwent a Martius procedure and 21 were treated with anatomic repair. Nineteen patients had recurrent fistulas and 17 had multiple fistulas. RESULTS: Only one patient with a urethrovaginal fistula treated with a Martius procedure had recurrence, compared with three of four of the patients having anatomic repair. None of the patients with vesicovaginal fistulas treated with a Martius flap had recurrence, compared with 4 of 21 in the anatomic-repair group (19.05%). Thirteen patients with single fistulas (7 urethrovaginal and 6 vesicovaginal) treated with a Martius procedure healed well without failure, compared with 1 failure among 16 fistulas (1 urethrovaginal and 15 vesicovaginal) in the anatomic-repair group. In the group of patients with multiple fistulas, the Martius flap also showed a definite advantage. Eight patients with multiple fistulas were offered the Martius flap. The procedures were successful in all but one, compared with six failures out of nine treated with anatomic repair. None of the patients having primary treatment with the Martius flap had postoperative recurrence, compared with 3 of 18 having anatomic repair (16.67%). Only 1 of 12 patients with recurrent fistulas undergoing Martius flap repair had failure (8.33%), compared with 4 of 7 undergoing anatomic repair (57.14%). None of the patients treated with the Martius procedure experienced dyspareunia postoperatively, compared with 33.33% of the patients treated with anatomic repair. CONCLUSIONS: The overall success rate was far better and the complication rate (especially incontinence and dyspareunia) was considerably less with the Martius procedure. We recommend the Martius procedure for urethrovaginal and vesicovaginal fistulas, especially those that are recurrent or multiple.     

Early repair of injury to the ureter or bladder after hysterectomy

In the present study we investigated the effectiveness of early diagnosis, repair of injuries to the ureter and urinary bladder sustained during hysterectomy, as compared to the results of delayed intervention. There were 46 ureteral injuries and 20 vesicovaginal fistulas in 55 patients. In 14 cases of ureteral injury an endoscopic approach management was employed. There was complete healing in 18 vesicovaginal fistulas while there was a single case of a ureteral injury that required nephrectomy because of stenosis. This study shows that early repair of urological injuries after hysterectomy has considerable advantages and the results are equally comparable with those of delayed intervention. In most cases of ureteral injury an attempt of an endoscopic repair is warranted before proceeding to open surgery.     

Pelvic fracture urethral injuries in girls

PURPOSE: Injuries to the female urethra associated with pelvic fracture are uncommon. They may vary from urethral contusion to partial or circumferential rupture. When disruption has occurred at the level of the proximal urethra, it is usually complete and often associated with vaginal laceration. We retrospectively reviewed the records of a series of girls with pelvic fracture urethral stricture and present surgical treatment to restore urethral continuity and the outcome. MATERIALS AND METHODS: Between 1984 and 1997, 8 girls 4 to 16 years old (median age 9.6) with urethral injuries associated with pelvic fracture were treated at our institutions. Immediate therapy involved suprapubic cystostomy in 4 cases, urethral catheter alignment and simultaneous suprapubic cystostomy in 3, and primary suturing of the urethra, bladder neck and vagina in 1. Delayed 1-stage anastomotic repair was performed in 1 patient with urethral avulsion at the level of the bladder neck and in 5 with a proximal urethral distraction defect, while a neourethra was constructed from the anterior vaginal wall in a 2-stage procedure in 1 with mid urethral avulsion. Concomitant vaginal rupture in 7 cases was treated at delayed urethral reconstruction in 5 and by primary repair in 2. The surgical approach was retropubic in 3 cases, vaginal-retropubic in 1 and vaginal-transpubic in 4. Associated injuries included rectal injury in 3 girls and bladder neck laceration in 4. Overall postoperative followup was 6 months to 6.3 years (median 3 years). RESULTS: Urethral obliteration developed in all patients treated with suprapubic cystostomy and simultaneous urethral realignment. The stricture-free rate for 1-stage anastomotic repair and substitution urethroplasty was 100%. In 1 girl complete urinary incontinence developed, while another has mild stress incontinence. Retrospectively the 2 incontinent girls had had an associated bladder neck injury at the initial trauma. Two recurrent vaginal strictures were treated successfully with additional transpositions of lateral labial flaps. CONCLUSIONS: This study emphasizes that combined vaginal-partial transpubic access is a reliable approach for resolving complex obliterative urethral strictures and associated urethrovaginal fistulas or severe bladder neck damage after traumatic pelvic fracture injury in female pediatric patients. Although our experience with the initial management of these injuries is limited, we advocate early cystostomy drainage and deferred surgical reconstruction when life threatening clinical conditions are present or extensive traumatized tissue in the affected area precludes immediate ideal surgical repair.     

External and iatrogenic trauma of the urinary bladder: a survey in Poland

OBJECTIVE: To assess incidence of urinary bladder injuries (frequently associated with pelvic trauma and often iatrogenic) in Poland. MATERIALS AND METHODS: The records and details of urinary bladder injuries treated between 1995 and 1999 were analysed for 61 urological departments in Poland. RESULTS: During the 5-year period 512 patients had urinary bladder injuries; in 210 (41%) the injury was caused by a road traffic accident, in eight (2%) by compression (crushing injury) within the limits of the pelvic bones, in 40 (8%) by a fall from a height, in three by a gunshot wound and in the remaining 251 (49%) the injury was iatrogenic. Among the 261 bladder injuries that were not iatrogenic, 41 (16%) were associated with pelvic bone trauma. In 36 patients there was simultaneous injury of the urinary bladder and posterior urethra, constituting 14% of such injuries and 7% of all trauma cases. The iatrogenic injuries were in 98 patients (39%) in urological departments, in 130 (52%) women in gynaecological departments and in 23 (9%) on surgical wards. The injury was open in 102 patients (20%) and closed in 372 (73%); there was bladder contusion in 38 patients (7%). The injuries were intraperitoneal in 225 patients (44%) and extraperitoneal in 287 (56%). For diagnosis, abdominal ultrasonography was used in 455 (89%) patients, intravenous pyelography in 266 (52%), cystography in 388 (76%) and computed tomography in 15 (3%). The delay between trauma and diagnosis was 0.5-124 h. Surgical treatment of the injury comprised a monolayer suture of the bladder wall in 51 patients (10%), a two-layered suture in 461 (90%), perivesical drainage in 468 (91%) and inspection of the peritoneal cavity in 232 (45%). The mean (range) interval between diagnosis and treatment was 14 (7-70) days. Seven patients died after the treatment failed. CONCLUSIONS: Almost half the patients had iatrogenic injuries, of which over half occurred in gynaecological and maternity wards. Thus it is important teach the basic range of urological operations to trainee doctors. The commonest diagnostic method was not ascending cystography but ultrasonography; we recommend ascending cystography be used with at least two views after filling the urinary bladder with approximately 300 mL of contrast medium, with an additional film after emptying the contrast medium. In patients with pelvic bone trauma it is reasonable to use spiral computed tomography with virtual analysis before surgery. A two-layered suture of the bladder wall with perivesical drainage should be used.     

Vesicovaginal and Ureterovaginal Fistulas: A Review of 39 Cases

The aim of this retrospective study was to present our experience in the treatment modalities of patients with vesicovaginal and ureterovaginal fistula. Between 1987 and 1997, 39 patients were diagnosed and operated on for vesicovaginal and ureterovaginal fistula. Of these patients, 31 had vesicovaginal, 7 had ureterovaginal and 1 had both vesicovaginal and ureterovaginal fistula. The ureterovaginal fistulas were repaired by simple ureteroneocystostomy with 100% success. Vesicovaginal and urethrovaginal fistulas were repaired transvaginally in 7 cases, transabdominally in 23 cases and endoscopically in two cases with 77% success at first attempt and 92% success with several attempts. The successful repair of urinary tract fistulas can be achieved in the majority of cases by adhering to the basic surgical principles. The optimum approach is that which works best in the surgeon's hands.     

Management of giant vesicovaginal and vesicourethrovaginal fistulas

We herein report on 15 patients with giant vesicovaginal (7) and vesicourethrovaginal (8) fistulas repaired since July 1979. All fistulas were repaired by a suprapubic approach with or without a concomitant vaginal approach. All 7 patients with giant vesicovaginal fistulas underwent a standard racket incision of the bladder with excision of the fistula, closure of the vagina and bladder, and an omental interposition, and were cured. Four patients with giant vesicourethrovaginal fistulas had a similar successful closure but only 2 were cured of the incontinence, while 2 remained totally incontinent owing to failure of the bladder outlet sphincteric mechanism. The latter 2 patients were managed by a Tanagho bladder flap urethral reconstruction: 1 remained totally incontinent and finally underwent diversion, while 1 was improved but not cured totally. Four patients were managed by repair of the fistula simultaneously with a Tanagho bladder flap: 2 had no previous abdominal repairs and both achieved continence postoperatively, while 2 had numerous attempts at repair (including abdominal approaches) before referral and only 1 was cured. Giant vesicovaginal fistulas can be repaired successfully in almost all patients. Although vesicourethrovaginal fistulas can be closed as readily there is a high likelihood of sphincteric inadequacy in patients with extensive urethral involvement. A bladder flap urethral reconstruction is valuable in these patients, particularly in the absence of prior suprapubic procedures.     

Do unplanned cystotomies during vaginal operative procedures lead to vesicovaginal fistulae or other complications?

Urology has recently experienced a renewed interest in vaginal operative procedures such as bladderneck suspension, vesicovaginal fistula closure, fascial slings and artificial urinary sphincters. Because many vaginal operations are done on patients who have had previous bladder neck or urethral surgeries, considerable scar tissue may be encountered. With the absence of normal tissue planes unplanned cystotomy may occur. These patients seem likely to develop vesicovaginal fistula due to the dependent vesicotomy. The authors studied a group of 12 patients who had had unplanned cystotomies while undergoing a vaginal procedure. In 11 cases the cystotomy was repaired transvaginally using two layers of 4/0 polyglycolic acid suture, and the originally planned operation was carried out. All patients had a negative cystogram 10 days postoperatively. No patient developed a vesicovaginal fistula or a perivesical infection, even if an artificial urinary sphincter or silastic pledgets were placed. Unplanned cystotomy at the time of vaginal operation should be closed and the scheduled procedure completed. A simple two-layer watertight closure and adequate urethral drainage for at least 1 week is unlikely to develop into a perivesical infection or a vesicovaginal fistula.     

Urological trauma after gynecological and obstetric surgeries

OBJECTIVE: Gynecological and obstetric surgeries are not uncommon causes of iatrogenic injury of the urinary tract. Herein, we retrospectively report our experience with these injuries over the last 18 years. MATERIAL AND METHODS: Between 1985 and 2003, 120 females (mean age 34.2+/-13.7 years) were included in this study. The types of injury were as follows: vesicovaginal fistula, n=90; ureterovaginal fistula, n=14, ureteric ligation, n=13, vesicouterine fistula, n=2; and ureterouterine fistula, n=1. Definitive repair of such injuries was performed in all cases, including 10 cases of recurrent vesicovaginal fistulae which were treated by means of augmentation cystoplasty or urinary diversion. All patients were evaluated regarding the time and type of surgical intervention and early and late postoperative complications, including failure of primary repair. RESULTS: Of the 80 cases of vesicovaginal fistulae treated with definitive repair, 12 (13.3%) showed recurrence of the fistula. Early ureteric deligation and early or delayed ureteroneocystostomy or ureteric replacement were successful in all cases with ureteric injury. There was no loss of kidney function following the trauma or its repair. CONCLUSIONS: It is mandatory for gynecologists and obstetricians to pay careful attention to the anatomy of the urinary tract in order to avoid its iatrogenic injury. Endourologic means were successful in enabling first aid management of some of these injuries. Early exploration is indicated in cases of ureteric obstruction that present early after trauma. Augmentation cystoplasty, urinary diversion or ileal replacement are indicated in only a few cases.     

Late sequelae after urogenital trauma. Results of follow-up studies

In the course of the Multicenter Study on Urological Traumatology ("UMCEST"), 61 patients who had been treated at the Departments of Urology of the Ludwig Maximilian University in Munich and the Heinrich Heine University in Düsseldorf were followed up. These included 39 patients with multiple trauma and 22 patients who had suffered isolated urological injuries. There were 45 patients with renal injuries, 7 with injuries to the bladder, and 11 who had presented with urethral injuries. Late complications were detected in 38% of the 45 patients with renal injuries. Of the 11 patients with urethral injuries, 6 suffered from urethral strictures, 9 from sexual dysfunction and 3 from incontinence. The 7 patients with bladder injuries had no late complications related to the bladder trauma.     

A study of 114 cases of urinary tract injury

In 11 years between January, 1974 and December, 1984 114 patients (92 males and 22 females) were admitted to our departments for urologic injuries. As there were four patients with multiple injuries (both kidneys 1, kidney and ureter 1, kidney and urethra 1, and bladder and urethra 1), the number of cases with kidney, ureter, bladder and urethral injuries were 76 (64%), 33 (28%), 6 (5%) and 3 (3%), respectively. The most frequent incidence was in the second decade. Out of the 75 cases of renal injuries there were 42 cases (56%) of contusions, 21 (28%) of lacerations, 7 (9.3%) of ruptures and 5 (6.7%) of pedicle injuries. Only 14 cases (18.7%) were treated surgically, namely six by nephrectomy and eight by a conservative approach (suture 1, drainage 3, partial nephrectomy 3 and pyeloplasty 1). Of the 3 cases of ureteral injuries all cases were treated surgically. Of the 6 cases of bladder injuries four cases were treated surgically. Of the 33 cases of urethral injuries 10 cases were complicated by fractures of the pelvis. Twenty three cases (74%) were treated surgically.     

Rupture of the urinary bladder, a potentially serious condition

During the years 1969 to 1983, 61 patients with rupture of the urinary bladder were treated at the Department of Surgery, University of Turku, Finland. The etiology of the injury was accident trauma in 48%, iatrogenic trauma in 28%, minor trauma in association with misuse of alcohol in 21% and other causes in 3% of the cases. In the first three groups the most reliable signs for diagnosing rupture were abdominal pain and tenderness, together with macroscopic or microscopic haematuria. In some cases cystography was of decisive importance in making the diagnosis. The prognosis for this condition, especially when it was associated with other injuries, was serious. Nine patients (14.8%) died and 35 patients (57.3%) had postoperative complications, for the most part infection-related. Fifty-nine patients underwent operative exploration and repair of the bladder, followed by urethral catheter drainage. Two patients were treated conservatively, with an indwelling urinary catheter only.     

Early repair of iatrogenic injury to the ureter or bladder after gynecological surgery

Contrary to the traditional doctrine of delayed intervention in post-hysterectomy injuries of the ureter or bladder, the policy at our department has been to operate as soon as possible after the diagnosis is made. Of 68 patients (25 with vesicovaginal fistulas and 43 with ureteral injuries) early intervention was possible in 40 (59%). Primary healing was obtained in all patients. These results suggest that there is no disadvantage in early repair.     

Complications associated with surgical repair of urethrovaginal fistula

We present 4 patients seen in the last five years with urethrovaginal fistulas involving the mid or proximal urethra. Our experience in the transvaginal repair of these fistulas has been disappointing. The best chance for the development of a functioning continent urethra is by suprapubic bladder flap technique or bladder tube replacement with suprapubic urinary diversion. We suggest that no urethral catheter be placed. Complications following surgical repair have been fistula recurrence, urethral shortening and retraction, persistent reflux, bladder calculi, and bladder cancer.