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.