Urogynaecological problems in pregnancy

The majority of urogynaecological problems can manifest during pregnancy or as a direct result of pregnancy and delivery. Those most commonly occurring during pregnancy are urinary tract infection, filling and voiding disorders, urinary incontinence, pelvic organ prolapse and faecal incontinence. The development of these may be as a result of physiological changes that occur in pregnancy or as a result of previous pregnancies. There may also be urogynaecological sequelae that occur as a result of trauma sustained during delivery. These include perineal and anal sphincter trauma, bladder or ureteric injuries during caesarean section or operative deliveries, and the development of vesico-vaginal or recto-vaginal fistulae.     

Ureteric obstruction in pregnancy--diagnosis and management.

OBJECTIVE--To discuss the aetiology, diagnosis and management of ureteric obstruction in pregnancy and to describe the use of double-pigtail ureteric stents in a series of 10 patients. DESIGN--Retrospective study of women presenting to a maternity unit in whom the diagnosis of ureteric obstruction is reached. SETTING--Southmead Hospital in Bristol; a large district general hospital with a throughput of around 6000 maternity patients per year. SUBJECTS--10 women (8 in their first pregnancy, 1 in her second and 1 in her third; mean age 29.2 years (range 18-31 years). INTERVENTIONS--Double-pigtail ureteric stents were electively passed after a diagnosis of ureteric obstruction. Stents remained in situ for a mean 15.5 weeks (range 8-25 weeks) and were electively removed 4-6 weeks post partum. RESULTS--Nine women progressed uneventfully through the remainder of their pregnancy. One developed strangury, haematuria and discomfort after stent insertion. Seven women had normal vaginal deliveries, two assisted vaginal deliveries and one was delivered by caesarean section. None required to have external urinary drainage. CONCLUSIONS--Double-pigtail ureteric stents are easy to place and remove and are well tolerated. They provide a simple, safe and effective method of internal upper urinary tract drainage in ureteric obstruction in pregnancy.     

Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy

OBJECTIVE: To estimate the rates of urinary tract injury after benign gynecologic surgery. To explore the role of routine intraoperative cystoscopy at benign gynecologic surgery. DATA SOURCES: We conducted a systematic MEDLINE search for urinary tract injuries at gynecologic surgery for the period from November 1998 to May 2004 and combined this with a previous systematic review performed in the same fashion for the period from January 1966 to October 1998. METHODS OF STUDY SELECTION: There were 47 studies that fit our inclusion criteria: 29 that did not use routine intraoperative cystoscopy, 17 that used routine intraoperative cystoscopy, and 1 that reported the frequency of urinary tract injury separately, with and without routine intraoperative cystoscopy. We determined the crude and fitted ureteric and bladder injury rates for each surgery type from the studies where routine intraoperative cystoscopy was not performed and then from the studies where routine intraoperative cystoscopy was performed. TABULATION, INTEGRATION, AND RESULTS: From studies without routine cystoscopy, combined ureter and bladder injury rates varied according to the complexity of the surgery, ranging from less than 1 injury per 1000 for subtotal hysterectomy with or without bilateral salpingo-oophorectomy to as many as 13 injuries per 1000 surgeries for laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy and for other gynecologic and urogynecologic surgeries. Injury rates were higher when routine intraoperative cystoscopy was used, but the confidence intervals were wider. CONCLUSION: The reasons for higher injury detection rates when routine cystoscopy was performed are unclear. Further study is needed to identify the scenarios where routine cystoscopy is warranted after major gynecologic surgery.     

The techniques of trocar insertion and intraoperative urethrocystoscopy in tension-free vaginal taping: an experience of 600 cases

BACKGROUND: To determine the frequency of lower urinary tract (LUT) injury for stress incontinent women undergoing the tension-free vaginal tape (TVT) procedure with or without concomitant procedures. METHODS: Over a period of 5 years, 600 women who had stress urinary incontinence (SUI), with or without pelvic prolapse, consecutively underwent the TVT procedure either with or without concomitant surgery. All study subjects underwent intraoperative transurethral urethrocystoscopy. During the examination 34 (6%) women at high risk of ureteral injury also received intravenous injection of 6 mL of diluted methylene blue to observe the patency and function of the ureter as well as the integrity of the bladder. RESULTS: The mean patient age was 52.75 years (range 32-76) and mean parity was 2.54 (range 0-6). Of the 600 women, 188 (31.4%) had had previous surgery, 169 (28.2%) had concomitant surgery, and 9 (1.5%) had abnormal urethrocystoscopic findings. These findings included one case each of previously placed suspension sutures, granuloma-like tissue in the bladder, a delayed dye emission from the ureteric orifice, an adhesive band in the urethra, three cases of perforation of the bladder by the trocar and two cases of an area of thin bladder mucosa. The bladder perforation rate related to the TVT device was 0.8% (5/600). CONCLUSIONS: Based on the data of this 5-year review, and a high rate of bladder injury (0-25%) reported in the literature, intraoperative urethrocystoscopy is imperative in the TVT procedure, although the rate of bladder injury was only 0.8% in the present study.     

Urinary tract injury in laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE: To evaluate the incidence and characteristics of urinary tract injury after laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: A retrospective study that evaluated all cases of urinary tract injury at the time of LAVH in an 11-year period. Parameters including surgical indication, site of injury, time of diagnosis, method of treatment, and long-term follow-up were analyzed. (Canadian Task Force classification II-2). SETTING: Tertiary care university hospital. PATIENTS: A total of 38 urinary tract injuries were found in 7725 LAVH. INTERVENTION: LAVH and repair of urinary tract injuries with transvaginal or transabdominal approach. MEASUREMENTS AND MAIN RESULTS: The incidence of urinary tract injury after LAVH was 4.9/1000 procedures: 3.9/1000 for urinary bladder injury and 1.0/1000 for ureteral injury. Prior cesarean section was the most common risk factor for bladder injuries. Ninety-six percent (29/30) of urinary bladder injuries were detected and treated during surgery. Half (4/8, 50%) of the ureteral injuries were identified during surgery. Of the 38 complications, 28 (75.7%) occurred in surgery. CONCLUSION: Most urinary tract injuries in LAVH were identified during surgery and are associated with the surgeon's experience. Bladder injury can be repaired either transvaginally or abdominally; ureteral injury can be repaired abdominally.     

Hysterectomy within the scope of cesarean section

In this paper 19 cases of caesarean hysterectomy were analysed with regard to indications, choosing the method of operation, post-surgery procedure and management in cases of surgical complications. In period 1975-1985 in Ist Clinic of Obstetrics and Gynecology in Bytom we had 2,961 sections. Caesarean hysterectomy occurred in 0.07% of normal deliveries and in 0.64% of caesarean sections. The most frequent indication for caesarean section followed hysterectomy was placenta praevia (28%) and the most frequent indication for hysterectomy was atony and coagulopathy (32%). In all cases a total abdominal hysterectomy has been made. Mortality rate was 10.5% and the most frequent complications were lesions of urinary bladder (10.5%). The results obtained have been compared with the data from world literature.     

Maternal morbidity after elective repeat caesarean section after two or more previous procedures

OBJECTIVES: To determine the incidence of maternal morbidity following elective caesarean section in women with a history of at least two previous caesarean sections, and to determine if the incidence of morbidity correlates with the number of previous sections. STUDY DESIGN: We conducted an individual chart review of all women who had an elective caesarean section because of a history of two previous sections from 1990 to 1999. RESULTS: There were 67,097 deliveries of babies weighing 500 g or more. The total number of cases eligible for the study was 250. There were 12 cases (4.8%) of placenta praevia of which four required a transfusion and two a hysterectomy. The incidence of wound infection was 6.3% and urinary tract infection was 11.2%. There were no cases of thromboembolism recorded. CONCLUSIONS: Maternal morbidity with elective repeat caesarean section is low. The major morbidity is associated with placenta praevia. We found no correlation between the incidence of maternal morbidity and the number of previous sections.     

Confirmation of Ureteric Patency During Cystoscopy Using Phenazopyridine HCl: A Low-cost Approach

ObjectiveTo describe the use of oral phenazopyridine (Pyridium) prior to pelvic surgery to facilitate intraoperative confirmation of ureteric patency.Materials and MethodsWe performed a chart review of women given phenazopyridine preoperatively prior to pelvic surgery in a tertiary care centre between July 2004 and June 2005. The primary outcome was the cystoscopic observation of bilateral ureteric urine efflux. Secondary outcomes included the visualization of bladder mucosa during cystoscopy, postoperative complications, and urinary tract injury diagnosed postoperatively (i.e., missed intraoperatively).ResultsPelvic reconstructive surgery requiring intraoperative cystoscopy was performed in 124 women. Bilateral ureteric patency and bladder mucosal integrity was confirmed in all cases. Phenazopyridine was well tolerated by all patients, and its use was unequivocally documented in 32 subjects whose chart was reviewed to determine postoperative course. Bladder mucosal appearance was unaltered. Dye continued to be excreted during prolonged procedures. Postoperatively, no ureteric injuries were subsequently diagnosed in any patients. The cost per patient of phenazopyridine ($0.29) is substantially lower than indigo carmine ($34.50).ConclusionPreoperative oral phenazopyridine is an inexpensive and safe dye that assists effectively in the confirmation of ureteric patency when cystoscopy is planned during pelvic surgery.     

Higher order repeat caesarean sections: how safe are five or more?

OBJECTIVE: To determine the maternal morbidity and mortality associated with multiple repeat caesarean sections. DESIGN: Retrospective study. SETTING: Security Forces Hospital serving Ministry of Interior and Security Forces personnel in Riyadh, Kingdom of Saudi Arabia. POPULATION: Three hundred and eight case records undergoing between fifth and ninth caesarean section (mean 7) were studied and compared with a control group of 306 patients undergoing third or fourth caesarean section during the period January 1994-December 2002. MAIN OUTCOME MEASURE: Operative and post-operative complications and difficulties. RESULTS: Five or more caesarean sections were associated with a longer operating time as well as an increased rate of severe adhesions. Blood transfusion rate was similar in the two groups but a drop of pre-operative to post-operative haemoglobin was significantly higher in the study group compared with the controls. There was no significant difference in the Apgar score of the baby, neonatal admission rate, incidence of caesarean hysterectomy, uterine scar rupture, placenta praevia, placenta accreta, bladder injury, incidence of postpartum pyrexia, wound infection and urinary tract infection between the two groups. There was no maternal death in the study group but one mother died in the control group. CONCLUSION: The higher order (5-9) repeat caesarean sections carry no specific additional risk for the mother or the baby when compared with the lower order (3 or 4) repeat caesarean sections.     

The role of intraoperative cystoscopy in prolapse and incontinence surgery

OBJECTIVE: Unrecognized ureteral and bladder injury are a known source of morbidity and mortality in gynecologic surgery. The objective of this study was to determine the frequency that intraoperative cystoscopy during prolapse and incontinence procedures produced a change in intraoperative management to prevent ureteric and bladder injury. STUDY DESIGN: This study reviewed the charts and operative reports of 235 cases of routine intraoperative cystoscopy during prolapse and incontinence surgery during a 2-year period in a tertiary care urogynecology unit. Demographic data and potential risk factors for intraoperative urinary tract injury were recorded. Cases that involved a change in management brought about by intraoperative cystoscopy with intravenous indigo carmine were compared with cases in which intraoperative cystoscopy was normal. Variables were compared with use of the Student t test and the chi(2) test. RESULTS: Of 235 cases, 11 were excluded. Of the 224 remaining cases, 12 (5.3%) underwent changes in intraoperative management as a result of cystoscopic findings. Eight cases involved ureteric blockage. Patients with abnormal cystoscopies did not differ from patients with normal intraoperative findings with regard to age, weight, parity, maximum grade of prolapse, estimated blood loss, or previous surgery. In 58% of patients with abnormal cystoscopies, there was no suspicion of technical difficulty on the basis of previous surgical history. Preoperative renal imaging did not predict cases with abnormal cystoscopy. There were no cases of complications caused by the intraoperative cystoscopy. CONCLUSION: Intraoperative cystoscopy with intravenous injection of indigo carmine is a safe technique that can detect otherwise undetected intraoperative compromise of the urinary tract during prolapse and incontinence surgery. It is recommended that cystoscopy be used liberally to reduced the frequency of serious sequelae from urinary tract injury.     

Case series of multiple repeat caesarean sections: operative,maternal, and neonatal outcome

Objective: The objective of this study is to review the maternal and neonatal morbidity and mortality associated with six or more caesarean section (CS).

Methods: We conducted a retrospective chart review, at King Abdulaziz University Hospital (KAUH) in Jeddah, for all patients admitted between 2000 through 2010 and identified five patients having more than six CS deliveries.

Results: Deliveries occurred in the ranges of 31–38 weeks, from which four cases required emergency CS. There were two cases in the series with a placenta previa. There was a single case of uterine dehiscence. Only one case required a blood transfusion and was complicated with a placenta accreta, bladder injury, urinary tract infection, and prolonged maternal hospital stay with neonatal intensive care unit (NICU) admission. All cases had moderate to severe adhesion intra-operatively. Operative time was long in all cases with a range 55–106?min. One of the five cases had a postoperative wound infection. Finally, none of the current series showed fetal or maternal mortalities.

Conclusions: The long-term complications associated with CS should be discussed with patients in the first and subsequent pregnancies. This case series highlighted the outcomes in these unique cases of higher order caesareans.     

Urological complications following gynaecological surgery

Iatrogenic urological injuries during gynaecological surgery can have devastating consequences and significant long-term sequelae. Timely recognition of injury and appropriate investigation and treatment, whether in the acute or delayed setting, are vital in reducing the potential impact of subsequent complications to both patient and doctor. In this review, we will describe the aetiology, diagnosis and management of ureteric, bladder and urethral injuries in both the acute and delayed setting, with a special focus on urogenital fistulas in women in order to facilitate a better understanding of what can be done to minimize iatrogenic injury to the urinary tract and the optimal management of these complications when they do occur.     

Urinary tract injuries during cesarean section in patients with morbid placental adherence: retrospective cohort study

Background/objective: The purpose of this study is to evaluate the cases of lower urinary tract injuries during cesarean section with or without hysterectomy in cases with morbid placental adherence.

Methods: This record based retrospective study was conducted at Ain Shams University Maternity Hospital in Cairo, Egypt during the period between January 2014 and December 2016. It included all patients who had urinary tract injuries during cesarean section with or without hysterectomy in the cases with morbid placental adherence and they were collected from files of pregnant women who were admitted at hospital planned for termination of pregnancy. Patients were enrolled in four groups, Group 1: cases without urinary tract injuries. Group 2: cases with injuries to the bladder. Group 3: cases with injuries of the ureter. Group 4: cases with injuries to the bladder and ureter.

Results: This study gave us new information about the incidence of urinary tract injuries during cesarean section with morbid adherence placenta was 21.7% (Bladder 11.7%, Ureter 4.7%, and bladder with ureter 5.3%). There were various types of repair of urinary tract injury, as the following, bladder repair 10.8%, ureteric catheterization 0.9%, ureterovesical repair or reimplantation 1.5%, bladder repair and ureterovesical 1.2%, bladder repair and ureteric catheterization 2.3%, ureteric catheterization and ureterovesical 1.5 and 6.4% of cases needed urologic consultations. There is a real relation between urinary tract injury and obesity (55.3%). Bladder invasion was found in only 26.9% of all cases according to sonography findings. Most of the cases were delivered by cesarean section in 67.5%, and the remainders were delivered by cesarean hysterectomy 32.5%. About 96.5% of cases needed a blood transfusion.

Conclusions: The morbid adherent placenta is still a challenge, which faces us as obstetricians, due to high morbidity and mortality. A multidisciplinary team is mandatory to avoid complications.     

Harnverhalt und postrenales Nierenversagen

Acute urinary retention and postrenal azotemia as urological emergencies are comparatively rare events in gynecological practice. Acute urinary retention in women is most commonly caused by a neurogenic bladder dysfunction following radical pelvic surgery. The most common cause of postrenal azotemia in women is extrinsic pelvic ureteric obstruction. Careful sonographic examination can usually confirm the diagnosis. Further evaluation necessitates the use of computerized tomography, magnetic resonance imaging and minimally invasive retrograde ureterography. Acute urinary retention can adequately be treated by suprapubic or transurethral catheter insertion. In cases with neurogenic bladder dysfunction further extensive urological investigations are required. Treatment of choice for postrenal renal failure is immediate urinary diversion by the insertion of a percutaneous nephrostomy tube or internal ureteric stenting. Chronic hydronephrosis or dilatation of the upper urinary tract should be detected early and should receive urological evaluation and treatment.     

What are the maternal implications of a classical caesarean section?

Sixty-two caesarean sections involving a vertical upper uterine segment incision were performed at the Coombe Women's Hospital between January 1983 and December 1995. A detailed chart review was performed. There were no maternal deaths. The maternal outcome was complicated by infection in 49% of cases, and haemorrhage in 19% requiring hysterectomy in two cases. In 15 subsequent pregnancies scar rupture occurred in one case and scar separation in two cases. The perinatal mortality was 200/ 1000; no perinatal death was directly related to the surgery. The operation is associated with a high incidence of maternal morbidity. It also has implications for subsequent deliveries. We recommend that every effort should be made to evaluate critically the need for a caesarean section in the first place and where possible to use a lower uterine segment transverse incision. The patient should be informed of the additional morbidity and long-term risks associated with a vertical incision.     

Total Laparoscopic Hysterectomy in Women with Previous Cesarean Sections

ObjectiveTo analyze the feasibility and technique of dissecting the urinary bladder from the lower uterine segment during total laparoscopic hysterectomy in women who have previously delivered by cesarean section.DesignRetrospective review (Canadian Task Force classification II-1).SettingDedicated high-volume gynecologic laparoscopy center.PatientsTwo hundred sixty-one women who underwent total laparoscopic hysterectomy at our center. There were no exclusion criteria based on the size of the uterus or the number of previous cesarean section deliveries.InterventionAll patients underwent total laparoscopic hysterectomy and lateral dissection of the bladder.Measurements and Main ResultsOf the study cohort, 52% had undergone 1 cesarean section, 42% had undergone 2 cesarean sections, and 6% had undergone 3 caesarean sections. Median (range) clinical size of the uterus was 12 (6–30) weeks; weight of the specimen was 200 (40–2200) g; total duration of surgery was 80 (30–240) min; and total blood loss was 50 (10–2000) mL.ConclusionTotal laparoscopic hysterectomy in patients with previous cesarean section deliveries is technically feasible. It can be performed by experienced surgeons irrespective of the size of the uterus or the number of previous cesarean sections.     

Urogynaecological complications in pregnancy

Obstetricians should remain aware of physiological adaptations that the urinary tract undergoes in pregnancy. This altered physiology makes pregnant women susceptible to increased risk of urological complications such as acute infection and urinary retention. Close anatomical proximity between gynaecological and urinary system makes the urinary bladder and ureters prone to iatrogenic injury during caesarean section, and this may result in long term sequalae. This review article provides an overview of presentation and management of common Urogynaecological conditions that may be encountered in pregnancy.     

An Unusual Cause of Vaginal Bleeding and Abdominal Pain -Prolapsed Ureterocele

EDITORIAL COMMENT: The editor has never seen a urinary tract vulval mass like this. However, in 1963 at the Austin Hospital, Melbourne, he saw and unfortunately failed to photograph, a pink vulval mass in a woman with paraplegia who had turned her bladder inside out and passed it per urethra like an intussusception. The nature of the mass became apparent when urine spurted from the ureteric orifices. This woman was managed by a urologist by ureteric transplantation into an ileal loop.     

Ganglioneurofibroma partim plexiforme of the urinary bladder in a pregnant woman--a case report

This study describes the case of 29 year old pregnant woman. During the caesarean section the tumor of the bladder was detected. The reason for the caesarean section was the lack of delivery progress and impending asphyxia. After the opening of the abdominal a hard and solid conglomerate of tumors coming out of the bladder was certified. The tumor of the urinary bladder was the reason for the caesarean section and removing 2/3 of the urinary bladder. The histopatological examination showed that it was ganglioneurofibroma partim plexiforme. The medical literature knows only very few cases concerning this type of cancer of the bladder.     

Once cesarean section--always cesarean section?

Between 1975 and 1985 from 522 patients, who had undergone caesarean section during their previous delivery or deliveries, per cent 63 have been delivered vaginally and 37 per cent with a caesarean section (52.8% primary, 47.2% secondary). The rate of spontaneous labour was higher, if patient had a spontaneous delivery before caesarean section or the first caesarean section has been performed because of a placenta praevia, a breech presentation or a fetal distress syndrome. Cephalopelvic disproportion went on in 67.2 per cent with a caesarean section. Rupture of the scare occurred in 2.9 per cent. Expectative management of delivery is justified following previous caesarean section. Oxytocin infusions are possible in cases if internal tocography will be done.