Version May 2024
INTRODUCTION — As the ureters pass in close proximity to gynecologic structures, 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, mortality, and costs. 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.
This topic will discuss the decision to perform cystoscopy at the time of gynecologic surgery as well as the evaluation and management of urinary tract injury resulting from gynecologic surgery. 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 "Assisted (operative) vaginal birth", section on 'Maternal complications'.)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-diverse individuals.
INTRAOPERATIVE DETECTION — Techniques for evaluation include direct visual inspection at the time of surgery, cystoscopy, and imaging studies. Evaluation is warranted any time there is a concerning finding or symptom suggesting urinary tract injury related to surgery.
Visual inspection of operative field — Visual inspection involves looking at the anatomic structures in the operative field to visually exclude or identify injury.
●Overview – If urinary tract injury is suspected at the time of surgery, the first step is visual inspection of the operative field to assess the integrity of the bladder and ureters as well as the nature and severity of any identified injury [1]. If an injury is identified, evaluation of the entire urinary tract is performed as the contralateral ureter or bladder may also have been injured. While it is not possible to visually evaluate the bladder or ureters during vaginal surgery, all surgical vascular pedicles and the anterior vaginal wall are inspected for possible areas of impingement upon urinary tract structures.
Bladder injury is more likely than ureteral injury to be diagnosed using visual inspection [2-5]. In a prospective study over 800 women who underwent hysterectomy, visual inspection detected 38 percent bladder injuries versus 7 percent of ureteral injuries [3].
●Diagnostic findings – Visual findings that confirm surgical urinary tract injury include:
•Urine in the operative field
•Visible defect of the ureter or bladder (eg, transection, laceration, or perforation)
•Bladder catheter and/or bladder or urethral mucosa in the operative field
●Suggestive findings – Findings suggestive of urinary tract injury include:
•Hematuria – Persistent gross hematuria, seen as blood-tinged urine in the bladder catheter, 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 should be performed.
•Location of surgical instruments – Surgical clamps, sutures, or staples in close proximity to the ureters, bladder, and/or urethra raise concern for possibly injury to the adjacent structure.
•Gas bubbles – Visible gas in the urine, bladder catheter, or urinary collection bag is concerning for injury at laparoscopic surgery.
Evaluation of ureters — If the ureter could reasonably be in the operative field; it should be clearly identified and protected from injury. The approach varies by type of surgery as this determines the anatomic length of ureter that requires evaluation.
●Limits of observing ureteral peristalsis – Observing ureteral peristalsis in the retroperitoneum can help identify the ureter and its anatomic course, as well as exclude a mistakenly identified vessel, but is not a valid test to assess ureteral integrity. In a retrospective study in which patients undergoing total abdominal hysterectomy were evaluated with intraoperative cystoscopy, peristalsis was present in five of six with ureteral injury [5].
●Ureteral dissection – Full evaluation of a ureter may require additional dissection of the ureter. Whether to perform 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'.)
●Role of ureteral catheterization – We prefer this approach if anatomy is distorted by pathology and/or prior surgery. Ureteral catheters can facilitate tissue dissection, aid detection of injury, and/or prevent a ureteric injury; use will depend on a surgeon's preference and skills. It will also depend on whether the patient is in low lithotomy position with boot-type stirrups. (See 'Procedure and findings' below.)
Cystoscopy
Preference for routine use — In our practice, we routinely perform cystoscopy (in addition to visual inspection) in all patients during major gynecologic surgery (eg, hysterectomy, continence procedures, prolapse repair) [2,6]. However, decision to perform cystoscopy is surgeon dependent and other experts may perform cystoscopy selectively rather than universally [7-9]. The debate and supporting data are discussed below. (See 'Debate of universal versus selective cystoscopy' below.)
In our practice, we find cystoscopy particularly useful with the following procedures:
●Urinary incontinence and/or pelvic organ prolapse [6,7,10]
●Hysterectomy (any route)
●Oophorectomy if there are additional risk factors for ureteral injury (eg, endometriosis, history of pelvic irradiation, or laparoscopic hysterectomy)
●Complex gynecologic procedures (eg, ureteral dissection, dense adhesions, pelvic side-wall dissection)
●Any time we have clinical concern for injury
We encourage surgeons to have a low threshold for performing cystoscopy. Additional benefits of universal cystoscopy include increased trainee experience and comfort with cystoscopy skills and interpretation and, on rare occasions, detection of an unsuspected urinary tract injury. Intraoperative detection of an injury allows repair during the same surgery and avoids sequelae.
Procedure and findings — Intraoperative cystoscopy evaluates for bladder injury (eg, perforation, bleeding, suture, and/or staple) and confirms urine efflux from both ureteral orifices. However, as cystoscopy does not visualize the ureters directly, injuries such as partial ureteral obstruction, partial transection, and thermal injury may be missed [11]. A detailed description of diagnostic cystoscopy is presented in related content. (See "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions", section on 'Procedure'.)
●Patient positioning – 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 easy access for cystoscopy when needed.
•(See "Urogynecologic surgery: Perioperative care issues", section on 'Positioning'.)
Patients who are in dorsal supine position and need cystoscopy can either be repositioned to lithotomy position for transurethral cystoscopy or undergo transvesical cystoscopy (ie, through an incision in the bladder). For transvesical cystoscopy, a 70- or 30-degree cystoscope is inserted through an incision in the dome of the bladder that has been secured with a purse-string suture. Alternately, a simple incision can be made into the dome of the bladder and direct visual inspection performed.
●Use of urine contrast – To visualize urine efflux (ie, jets) from the ureteral orifices, we give IV sodium fluorescein to color the urine fluorescent yellow [12]. 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 [13].
Absence of contrast in the operative field does not fully exclude injury since urine may be sequestered (eg, in the retroperitoneum) or an injury other than a laceration may have occurred (eg, thermal injury). Additional discussion of urine contrast or distending media is presented in detail in related content. (See "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions".)
●Findings suggestive of obstruction – Absent or abnormal (delayed or sluggish) flow from one or both ureters is concerning for ureteral transection or obstruction. Marked delay between drainage from one ureter or obvious differences in the amount of yellow urine seen coming from each ureter suggests partial obstruction. Blood coming from a ureteral orifice is also concerning for ureteral injury.
If we do not see one or both ureteric jets after approximately 5 to 10 minutes after administration of dilute IV sodium fluorescein, or if there is concern for partial ureteral obstruction, we perform ureteric catheterization as below.
●Ureteric catheterization – For ureteric catheterization, we assemble a 21-French cystoscope, deflector bridge, and 5-French flexi-tip ureteric catheter. We then introduce the 5-French flexi-tip ureteric catheter into the ureteric orifices that are not effluxing urine and advance the catheter into the ureter at least 15 to 17 cm. The catheter should glide easily; if so, we then remove the catheter and complete the surgical case. 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.
Debate of universal versus selective cystoscopy — Performing universal or selective cystoscopy for intraoperative detection of urinary tract injury at the time of gynecologic surgery is a topic of debate [2,7,8,14-16].
●Benefits of universal approach – 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 presently not standard clinical practice, 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 and/or 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 diagnostic or selective cystoscopy may be adopted.
●Concerns for universal approach – The most compelling argument against universal intraoperative cystoscopy is that a statistically significant decrease in postoperatively detected injuries has not been consistently demonstrated when intraoperative cystoscopy is routinely used [16]. 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]. General concerns about universal cystoscopy include increased cost, detection of clinically insignificant injuries (eg, absorbable suture in bladder) [17], false-positive findings, complications, and lack of clinician training with both equipment and interpretation of findings [14,18,19].
Counterarguments to these concerns include:
•The risk of false-positive findings appears to be low [3].
•The concern for over-detection of minor injuries does not appear warranted [3,19].
•Although many gynecologists are not trained to perform cystoscopy, it is easily learned. (See "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions", section on 'Procedure'.)
•The cystoscopy complication rate is low [20,21]. (See "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions", section on 'Complications'.)
●Cost-effectiveness analysis – Studies that have assessed the cost-effectiveness of cystoscopy at the time of hysterectomy report conflicting conclusions. A 2019 study favored diagnostic or "selective" cystoscopy when the surgeon had a high suspicion of injury and a 2021 study favored screening or "universal" cystoscopy after all surgical cases [22,23]. Limitations of cost-effectiveness assessment include 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.
Procedure efficacy and safety — Despite the restrictions of the available data, all of the intraoperative cystoscopy techniques for detecting surgical urinary tract injury appear to be safe and effective with high specificity (>99 percent) and low rates of complications [24]. Study limitations include variations in the cystoscopy techniques, surgeon skill, and intraoperative interpretation. Most studies are of low quality with high risks of bias [24]. Bias likely accounts for prospective studies overestimating underlying urinary tract injury rates and database/retrospective studies underestimating injury rates [2,3,20,25-27].
Imaging — While intravenous pyelogram (IVP), ultrasound, and non-contrast computed tomography (CT) have been tried for intraoperative detection of urinary tract injury, they are generally no longer in use because the results are non-specific and the logistics challenging. Rather than imaging, we advise cystoscopy (with or without dilute sodium fluorescein) and/or ureteral catheterization.
POSTOPERATIVE EVALUATION AND DIAGNOSIS — Urinary tract injuries are distressing for patients. The attending gynecologic surgeon should stay involved with the patient's care, assisting with explaining upcoming procedures and 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.
Timing of injury detection — While many urinary tract injuries are recognized intraoperatively (up to 75 percent in one small series [28]), those that are not detected typically present within the first two weeks after surgery. A review of 136 ureteral injury claims submitted to the Dutch Patient Insurance Association reported urinary tract injuries were detected in the following time frames: 17 intraoperatively, 50 within a week of surgery, 47 within one month, and 17 greater than one month after surgery [29]. In five patients, damage was not noted until two years after the surgery.
Clinical manifestations — The signs and symptoms of operative urinary tract injury vary by the anatomic location and nature of the injury, are often nonspecific, and can overlap with symptoms of other postoperative complications. Any postoperative patient with complaints suspicious for urinary tract injury should be promptly assessed. Patients who have been discharged will most likely need to return to a medical setting for evaluation. Early diagnosis facilitates management of the injury and improves outcomes [25].
Clinical presentation is impacted by both mechanism of injury and time elapsed since surgery. In addition, more than one area may be injured and result in a combination of symptoms. Common signs and symptoms include:
●Fever – Fever may be a direct consequence of the injury or reflect infection (cystitis, pyelonephritis) complicating the injury.
●Ileus – Intraperitoneal urine may cause inflammation of the peritoneum and/or bowel and result in ileus.
●Persistent abdominal pain or distension – While abdominal pain and distention are common after gynecologic surgery, symptoms that persist or appear out of proportion to the clinical scenario should prompt concern for urinary tract injury.
●Persistent nausea with or without vomiting – Similar to persistent abdominal pain, persistent nausea may indicate underlying urinary tract injury.
●Hematuria – Hematuria may be visible immediately after removal of the bladder catheter but should clear quickly. Urinary tract injury should be suspected if bleeding persists or occurs significantly after the removal of the catheter.
●Oliguria or anuria – 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). Anuria signifies bilateral ureteral obstruction or transection or other structural or intrinsic renal process (eg, renal failure) and requires immediate evaluation.
●Unilateral or bilateral flank pain – While ipsilateral flank pain within 24 hours after surgery is highly concerning for ureteral obstruction (complete or partial), patients may present with pain in other locations or may be asymptomatic. Use of postoperative analgesics may make pain assessment challenging. In addition, stasis of urine resulting from obstruction can predispose to pyelonephritis. Patients with partial obstruction who are asymptomatic may progress over time to complete obstruction that results in loss of kidney function that is ultimately diagnosed during evaluation for another health condition. (See "Clinical manifestations and diagnosis of urinary tract obstruction (UTO) and hydronephrosis", section on 'Clinical features'.)
Flank pain may also be caused by a retroperitoneal urinoma. Additionally, patients with a urinoma may become febrile from resulting local inflammation or associated infection. Retroperitoneal urinomas typically result from ureteral rather than bladder injury.
●Leakage of urine from the vagina or abdominal incision – New postoperative leakage of urine warrants immediate evaluation for urinary tract injury. Possible sources include both ureters and/or bladder.
•Incision – Peritoneal urine collections typically drain through the vagina because it is the most dependent area, but can also drain through an abdominal incision in the immediate postoperative period.
•Fistula – Vesicovaginal or ureterovaginal fistula formation typically takes days to weeks.
Evaluation — Patients with postoperative signs or symptoms suggestive of surgical urinary tract injury should undergo an initial physical examination and laboratory evaluation. Next steps include cystoscopy and/or imaging studies; the choice is based on the patient's symptoms and the results from the initial evaluation.
Physical examination — In addition to a general physical examination, we pay particular attention to the following:
●Vital signs – The patient's temperature, pulse, blood pressure, and oxygen saturation are assessed to evaluate for hemodynamic (in)stability and fever, if there are concerns for sepsis and/or hemorrhage.
●Urine output – Urine output should be accurately tracked. Patients who are unable to void into a urimeter may benefit from a bladder catheter collection system for accurate measurement. The urine output is calculated for 24-hour periods and the urine inspected for hematuria.
●Examination – In addition to performing a general physical examination, we pay particular attention to the following:
•Abdomen – The abdomen is evaluated for tenderness, peritonitis, ascites, and the presence of bowel sounds.
•Incisions – Incision sites are evaluated for integrity, drainage, and evidence of infection.
•Pelvic examination – A pelvic examination is performed to identify pelvic mass, tenderness, and/or leakage of urine from the vaginal incision(s).
•Back and flanks – The back and flanks are examined for focal and costovertebral tenderness.
Laboratory evaluation — We perform serum studies on all patients with suspected urinary tract injury. We do not find urinalysis results helpful as patients who have had a bladder catheter and/or intraoperative bladder manipulation will typically have hematuria. If a patient with suspected uroperitoneum has an intra-abdominal drain, peritoneal fluid may be tested.
●Blood studies – We order serum electrolytes, blood urea nitrogen (BUN), and creatinine. A notable rise in BUN and creatinine diagnostic of acute kidney injury is suggestive of urinary tract obstruction (table 1). (See "Evaluation of acute kidney injury among hospitalized adult patients", section on 'Clinical manifestations'.)
•Bilateral obstruction – Bilateral ureteral obstruction causes acute kidney injury. Patients will have significantly elevated serum creatinine (often ≥50 percent) and/or reduced urine output (>0.5 mL/kg/hour for >6 hours) (table 1).
•Unilateral obstruction – Complete unilateral obstruction causes a temporary rise in creatinine as the non-obstructed kidney compensates for the obstructed kidney. A case control study of 15 women with unilateral ureteral obstruction after gynecologic surgery reported a mean creatinine increase of 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) at 36 to 48 hours after surgery [30].
●Urine and blood cultures –Patients with signs or symptoms suggestive of infection and/or sepsis should have urine and blood cultures.
●Tests of peritoneal fluid for uroperitoneum – An indirect test for uroperitoneum and, presumably, urinary tract injury, is performed by comparing BUN and creatinine levels from peritoneal fluid with those of blood and urine samples [31]. While we prefer direct diagnostic tests (ie, cystoscopy and/or imaging), such tests may not be rapidly available in all settings. Limitations of peritoneal fluid assessment include that the specificity and sensitivity of this approach are unknown (ie, a normal test result does not definitively exclude injury), test results suggesting uroperitoneum require confirmation, injury that does not result in uroperitoneum cannot be identified, and liver cirrhosis interferes with result interpretation. Peritoneal fluid can be obtained from intraoperative drains, if present, or by paracentesis.
If peritoneal fluid evaluation is performed, the results are interpreted as follows:
•Similar normal values for blood and ascites – Similar BUN and creatinine values in blood and ascitic fluid (or lower levels in ascitic fluid) are reassuring for the absence of uroperitoneum but cannot definitively exclude injury. Patients with persistent symptoms require further evaluation. (See 'Evaluation' above.)
•Similar values for urine and ascites – If the BUN and creatinine levels are similar for urine and ascites samples but normal in serum, urinary tract injury is likely (ie, uroperitoneum) [31-33]. However, the finding is not definitive as other conditions can cause similar BUN and creatinine concentrations in urine and ascites (eg, liver cirrhosis) [34]. Further evaluation is required. (See 'Evaluation' above.)
•Elevated values for blood and ascites – If both BUN and creatinine values are elevated above normal in blood and ascites, the patient may have both acute renal failure and uroperitoneum, possibly from urinary tract injury. The patient should under further testing of their renal function and urinary tract (ie, cystoscopy and/or imaging). (See "Assessment of kidney function".)
Postoperative cystoscopy — Cystoscopy can be performed postoperatively to assess for bladder injury and evaluate ureteral efflux. (See 'Cystoscopy' above.)
Imaging studies
CT with contrast and delayed images — CT (computed tomography) with intravenous contrast and delayed images is the preferred study for imaging the urinary tract from kidneys to urethra. Ureteric obstruction and/or extravasation of contrast confirm a ureteric injury. CT is also able to see findings unrelated to surgery such as evidence of chronic renal injury and/or absent kidney and/or collecting system. (See "Overview of traumatic and iatrogenic ureteral injury", section on 'CT urography'.)
Retrograde pyelography — Retrograde pyelogram provides information on the precise location of the injury. This test is usually done in a fluoroscopy suite. One advantage of this test is that ureteral double-J stents can be placed during the study, which may manage the injury and avoid the need for more invasive surgery, especially in cases of partial ureteric obstruction in the postoperative period without large lacerations [35].
Cystography — If intraoperative cystoscopy is not available, postoperative retrograde cystography can evaluate both the integrity of the urethra and bladder. Leakage of contrast indicates a laceration or perforation. A filling defect can represent a foreign body (or under distention). However, limitations of cystography include missing subtle findings such as a transmural suture, attenuation of the bladder mucosa, or a concurrent ureteral injury. (See "Traumatic and iatrogenic bladder injury", section on 'Cystography'.)
Separate from injury detection, cystography can be helpful in settings of complex bladder repair to confirm bladder integrity prior to urinary catheter removal [36].
Tests no longer in use — CT with intravenous contrast has replaced intravenous pyelogram (IVP) in most practices, although exceptions remain. Ultrasound imaging cannot reliably detect injury. In an observational study of routine postoperative renal ultrasound, none of the six injuries diagnosed postoperatively were identified with ultrasound imaging [28].
Diagnosis — Urinary tract injury is diagnosed by directly seeing the injury with cystoscopy or by visualizing the sequelae of injury (eg, hydroureter, urinoma) with imaging studies. Patients with a diagnosed injury are also evaluated for possible complications resulting from the injury (eg, renal insufficiency, urinary tract infection). (See 'Laboratory evaluation' above.)
MANAGEMENT — Urinary tract injury is treated as soon as recognized. Approach is based on the site(s) of injury; bladder injury is approximately three times more common than ureteral injury [2,3,37]. A general approach to management of lower urinary tract injury is presented in the algorithm (algorithm 1).
Full discussion of the epidemiology and prevention of urinary tract injury is presented in related content. (See "Urinary tract injury in gynecologic surgery: Epidemiology and prevention".)
General considerations — When urinary tract injuries are diagnosed after surgery, initial priorities include relieving renal obstruction, treating infection, and stopping urine leakage (internal or external). In some cases of isolated ureteral injury, obstruction or leakage can be managed with ureteral stents placed retrograde via cystoscopy or anterograde by interventional radiology. Otherwise, surgical exploration is required for repair of the injury; repair techniques are described below.
If surgical repair must be delayed, temporary measures such as nephrostomy may be necessary. Consultation with clinicians experienced in caring for these patients is advised. (See 'Ureteral injury' below.)
Repair of genitourinary fistula is discussed separately. (See "Urogenital tract fistulas in females", section on 'Management'.)
Ureteral injury — Ureteral injury is typically treated with ureteral stents or direct surgical repair. One exception is a ureter that has been ligated or kinked with a suture; these patients undergo suture removal and repeat cystoscopy to re-evaluate ureteral function. If concern remains for ureteral integrity, a ureteral stent may be necessary [38]. (See "Placement and management of indwelling ureteral stents".)
●Ureteral stents – Incomplete ureteral injury, such as obstruction, can be relieved by placement of indwelling stents. However, if there is concern for inadequate tissue viability, surgical repair is preferred. (See "Placement and management of indwelling ureteral stents".)
●Surgical repair – Ureters that have been cut or extensively damaged (eg, crush injury, thermal damage) may require reanastomosis or ureteroneocystostomy [38]. Repair of such injures, which are generally performed by a urologist or other surgical specialist, are reviewed in detail in related content. (See "Surgical repair of an iatrogenic ureteral injury".)
●Role of nephrostomy tube – If acute injury cannot be repaired during the initial surgery or within a few days postoperatively, a percutaneous nephrostomy tube can be inserted by a urologist or interventional radiology to temporarily drain the kidney of urine until definitive repair can be performed. (See "Overview of traumatic and iatrogenic ureteral injury", section on 'General principles'.)
Bladder injury — Surgical repair of bladder injuries is influenced by anatomic site (dome, supratrigonal area, trigone, and below the trigone) (table 2), type of injury (eg, perforation, laceration, thermal injury), and injury severity (algorithm 1). If there is any concern about the extent of injury or optimal approach for repair, intraoperative consult with a surgical specialist is typically performed.
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.
●Surgical foreign body – Inappropriately placed suture, staples, synthetic mesh, or trocars are removed. The bladder is then re-inspected after foreign body removal to confirm no tear has occurred. If laceration is identified, it is repaired as discussed immediately below.
●Cystotomy – Repair of bladder dome injury is a straightforward procedure in most patients. However, patients with a complicated injury likely benefit from intraoperative consultation with an advanced gynecologic or urologic surgeon. Complicated injuries include large lacerations, lacerations that extend towards the trigone or ureters, and thermal injuries as well as injuries in patients who have undergone prior pelvic surgery or pelvic radiation (table 2).
Management of a bladder dome cystotomy varies with the size of the defect.
•Minimal defects – Minimal defects in the bladder dome (eg, a <2 mm injury from pneumoperitoneum needle during laparoscopic surgery) can be managed expectantly.
•Defects up to 1 cm – Very small injuries (eg, <1 cm) may either be repaired or managed with bladder drainage [39]. If drainage is chosen, we leave an indwelling bladder catheter in place for five to seven days, followed by a voiding cystogram to confirm closure prior to removing the bladder catheter. (See "Traumatic and iatrogenic bladder injury", section on 'Follow-up'.)
•All other injuries – All other cystotomies should be repaired [9,39,40]; repair is delayed until all surgical dissection has been completed as other injuries may occur.
-Suture – We repair defects using absorbable synthetic suture (eg, polyglactin or poliglecaprone) placed in a nonlocked running fashion.
-Layers – We use one layer for a small cystotomy (eg, <2 cm) or two layers for larger cystotomies.
-Multiple defects – When there are multiple cystotomies near each other but 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.
-Option for test of closure – We do not test the integrity of the bladder repair (ie, water tightness) intraoperatively and instead prefer bladder catheter drainage followed by voiding cystogram. However, there is variation in this approach; other surgeons may reasonably test the closure by instilling contrast into the bladder catheter and assessing for spill into the peritoneal cavity.
●Postoperative care
•Bladder catheter – We usually leave the bladder catheter in for 5 to 14 days. Longer duration is used for larger defects, complex closures, or if there are multiple unconnected repairs. The bladder will re-epithelialize within three to four days and will regain its normal strength after 21 days [41-43].
•Voiding cystogram – Most clinicians obtain a voiding cystogram, formally called voiding cystourethrogram (VCUG), to confirm the injury has healed before removing the catheter, especially for larger or challenging cystotomies. In a study of 245 VCUG performed after surgical lower urinary tract injury, 125 (51 percent) were performed following cystotomy repair at a median of nine days from surgery. Of the three abnormal studies (2.4 percent) reported, the initial cystotomies ranged in size from 2 to 6 cm [44].
In our practice, we perform cystogram selectively, 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 this study. (See 'Role of antibiotics' below.)
•Post-void residual – Prior to removing the bladder catheter, we measure a post-void residual for patients who had a concomitant incontinence surgery or if the patient has any risk factors for voiding dysfunction, such as prior incontinence surgery and/or hypotonic detrusor. To measure the post-void residual, we backfill approximately 300 mL of sterile water into the bladder, withdraw the bladder catheter, and ask the patient to void. While consensus is lacking regarding an elevated PVR, patients who void at least 200 mL are considered to be emptying adequately. (See "Urogynecologic surgery: Perioperative care issues", section on 'Catheter removal and voiding trial'.)
Bladder trigone — As a result of the anatomic complexity of the trigone, repair of trigone defects or other injuries are generally performed by advanced gynecologic or urologic surgeons. The trigone is in the inferior and posterior aspect of the bladder and includes the ostia for the ureters and urethra (figure 2). Injuries to or just below the trigone may involve the ureters or urethra, are more difficult to access for repair compared with dome or supratrigonal injuries, and may require ureteral stent placement to prevent ureteral obstruction. Following trigone repair, the integrity of the ureters and urethra must be assessed.
Urethral injury — Management of urethral injury generally involves bladder catheter placement followed by delayed repair as indicated. Consultation with a urologist is advised. Urethral injury most commonly occurs during surgery for pelvic organ prolapse or urinary incontinence. Less commonly, urethrovaginal fistula can result from anterior colporrhaphy or obstetric forceps rotations. These injuries and repairs are discussed separately in related content.
●(See "Overview of traumatic lower genitourinary tract injury", section on 'Urethral injury'.)
●(See "Urogenital tract fistulas in females", section on 'Urethrovaginal fistulas'.)
ROLE OF ANTIBIOTICS — Antibiotics are used to treat clinical infection but are not helpful for preventing infection at the time of urinary tract injury or after placement of an indwelling bladder catheter. Most patients who experience urinary tract injury at the time of gynecologic surgery have already received prophylactic antibiotics to reduce the risk of surgical site infection (table 3A-B). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
Additional prophylactic antibiotics at the time of indwelling catheter placement (ie, as part of injury management) have not been shown to be helpful. As patients with indwelling bladder catheters or urinary stents are at increased risk of UTI, clinicians should remain vigilant to promptly recognize signs of infection in these patients and treat documented infection accordingly. (See "Placement and management of urinary bladder catheters in adults", section on 'Prophylactic antibiotics'.)
POSTOPERATIVE URINARY RETENTION — Gynecologic surgery can cause tissue edema, hematoma formation, and/or obstruction that impairs normal micturition and results in urinary retention. A prospective series of 284 patients undergoing gynecologic surgery reported a nine percent incidence of new-onset postoperative urinary retention [45]. Acute urinary retention related to edema or hematoma is typically self-limited and managed with a short course of catheterization. (See "Postoperative urinary retention in females".)
Chronic postoperative urinary retention can result from extensive tissue dissection around the bladder that disrupts parasympathetic and sympathetic innervation, such as with radical hysterectomy. Management of neurogenic bladder dysfunction is discussed separately. (See "Postoperative urinary retention in females", section on 'Persistent postoperative voiding dysfunction'.)
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
●Goals of injury detection – Intraoperative identification of urinary tract injury during gynecologic surgery permits prompt repair. Delayed diagnosis of urinary tract injuries may result in severe renal complications, genitourinary fistula formation, sepsis, and death. (See 'Introduction' above.)
●Intraoperative detection of injury – Urinary tract injuries are optimally recognized during the primary surgery. Techniques include visual inspection, ureteral evaluation, and cystoscopy. (See 'Intraoperative detection' above.)
●Intraoperative cystoscopy – Intraoperative cystoscopy can directly visualize injuries of the urethra and bladder injury (eg, perforation, bleeding, suture, and/or staple) and evaluate for bilateral urine efflux from the ureteral orifices. (See 'Procedure and findings' above.)
•Our preferred approach – In our practice, we routinely perform cystoscopy (in addition to visual inspection) in all patients during major gynecologic surgery (eg, hysterectomy, continence procedures, prolapse repair). However, decision to perform cystoscopy is surgeon dependent. Other experts may perform cystoscopy selectively rather than universally. (See 'Preference for routine use' above and 'Debate of universal versus selective cystoscopy' above.)
•Technique – After visual inspection of the bladder, we use cystoscopy to evaluate the bilateral ureteral orifices for evidence of normal urine efflux (ie, ureteral jets). To aid visualization of the jets, we give sodium fluorescein 1 mL (10 mg) intravenously (dilute 1 mL of 10 percent sodium fluorescein in 9 mL of normal saline). In cases with delayed or absent ureteral efflux, we perform ureteric catheterization. (See 'Procedure and findings' above.)
●Postoperative detection of injury
•Clinical suspicion – Surgeons should have a high level of suspicion for urinary tract injury in patients who have undergone gynecologic surgery. Presenting signs and symptoms may be vague and can include flank and/or abdominal pain, abnormal urine (eg, anuria, oliguria, hematuria), fever, and/or leakage of urine from vaginal and/or abdominal incisions. Multiple sites of injury may result in a combination of symptoms. (See 'Clinical manifestations' above.)
•Evaluation – Initial evaluation for possible urinary tract injury includes physical examination and laboratory tests for evidence of acute kidney injury or urinary tract infection. Additional evaluation includes postoperative cystoscopy to exclude urethra and bladder injuries and/or imaging with CT with intravenous contrast and delayed images. (See 'Evaluation' above.)
•Diagnosis – Urinary tract injury is diagnosed by directly seeing the injury with cystoscopy or by visualizing the sequelae of injury (eg, hydroureter, urinoma) with imaging studies. Patients with a diagnosed injury are also evaluated for possible complications resulting from the injury (eg, renal insufficiency, urinary tract infection). (See 'Diagnosis' above.)
●Management – Initial management priorities include relieving renal obstruction, treating infection, and stopping urine leakage (internal or external). (See 'General considerations' above.)
•Ureteral injury – Repair of ureteral injuries often involves ureteral stenting or advanced surgical repair, including ureteral reanastomosis or ureteroneocystostomy. Nephrostomy tube placement for urine drainage can be a temporary step if surgical repair is delayed. (See 'Ureteral injury' above.)
•Bladder injury– The approach to repair of a bladder injury depends upon the site (dome or trigone), type, and severity of injury. Injuries to the trigone are the most difficult to repair. (See 'Bladder injury' above.)
•Urethral injury – Management of urethral injury generally involves bladder catheter placement followed by delayed repair as indicated. Consultation with a urologic specialist is advised. (See "Overview of traumatic lower genitourinary tract injury", section on 'Urethral injury'.)
●Role of antibiotics – After the initial perioperative dose of antibiotics for prevention of surgical site infection, further antibiotic therapy generally is not necessary for patients with urinary tract injuries unless the patient develops a UTI. Prophylaxis for surgical site infection and treatment of UTI are discussed separately. Antibiotics are used to treat clinical infection but are not helpful for preventing infection at the time of urinary tract injury or after placement of an indwelling bladder catheter, although clinicians should remain vigilant to promptly recognize signs of infection in these patients.
•(See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
•(See "Catheter-associated urinary tract infection in adults".)
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