ORIGINAL ARTICLE

Assessment of Urological Complications Following Obstetric

and Gynaecological Surgery- AFive Years Review
SAJID MAHMOOD, NAVEED IQBAL, SHUMAILA ASLAM

ABSTRACT
Aim: To assess the features of urological complications following obstetric and gynaecological
surgery, their management, outcome and identification of risk factors for such injuries.
Method:The study was conducted in Jinnah Hospital Lahore from June-2012to June-2017. The study
was prospective interventional. We included 220 patients who had urological injuries following
obstetric and gynaecological surgery.The nature of urological injury, timing of diagnosis, and methods
of repair were taken into account. Risk factors for such injuries were also identified. Mean age was
36.2 years (range 26-62 years). Bladder injuries were repaired in two layers with 2/0 vicryl and bladder
was drained by Foleys catheter which was retained 4 to 6 weeks. In ureteric injuries, DJ stenting
alone, end to end ureteral anastomosis over a DJ stent and re-implantation of ureter into the bladder
were the procedures applied.
Results:Out of 220 patients, 161(73.1%) had urinary bladder injury. Most common site of injury was
dome and posterior wall of the urinary bladder. The rent was repaired in two layer with 2/0 vicryl. Out
of 161 cases with urinary bladder injury 145(90%) were detected during the surgery and underwent
primary repair with successful outcome. In 8(3.6%) cases of urinary bladder injury, the rent was
missed during the surgery. 5 cases out of these 8 were managed conservatively with bladder drainage
with wide bore catheter. Re-exploration needed in remaining 3 cases. The rent identified, margin
freshed and 2 layer closure done with 2/0 vicryl. Outcome was uneventful. 48 patients (21%) had
Ureteric injuries. Out of 48 patients 18(37.5%) were detected during the surgery. In 30 patients injury
was detected in 3 to 33 days post operatively. 8 (16.6%) cases were managed by DJ Stenting only.
Conclusion:Urinary bladder injury was most common urological injury during obstetric
andgynecologic surgery followed by ureteral injury. Presence of adhesions, previous pelvic surgery
and nature of disease were significant risk factors for urological injuries. Precise knowledge of normal
and morbid pelvic anatomy, early diagnosis and early urological intervention arekey to success
Keywords:Obstetric gynecologic surgery, bladder injury, Ureteral injuries, ureteroureterostomies

INTRODUCTION stricture which can occur later on. Incidence of

bladder injury increases width previous cesearian
Anatomically urinary tract and female genitaltractare 4
deliveries . Laparoscopic hysterectomy in many
closely related, sopotential for injury to urinary tract centers has resulted in an increased incidence of
must always be considered while operating on genital 5
urological injuriesespecially Ureteric injury . Urinary
1
system . Injury to urinary system is known bladder injuries are easy to diagnose and manage as
complications following obstetric and gynecologic compared to Ureteric injuries which are diagnosed
2
procedures .Urological complicationsare defined late. This diagnostic delay and management failure
aslacerations, rent in urinary bladder, ligation, may end up in increased morbidity and mortality. To
transection of ureter and leakage of urine or contrast avoid injury to urinary tract,the gynecologist must
media fromurinary tract after surgery. Urinary tract have precise knowledge of normal and morbid pelvic
complication rate is 0.2 to 1% of all gynecological and anatomy,meticulous surgical techniques,adequate
3
pelvic procedures . However true incidence is difficult exposure and to have a constant high level of
to ascertain from literature as most of studies or vigilance. Ureteric injuries need early detection and
review cases take only those patients who become early intervention to prevent deterioration of renal
symptomatic.Urinary tract injuries following obstetric function and bring satisfactory outcome.
and gynecologic surgery can normally be divided into
acute complications such as bladder laceration/ rent
MATERIAL AND METHODS
or ureter laceration, transaction or ligation that can be
recognized immediately during surgery and chronic The study was conducted in Jinnah Hospital Lahore
complications such as VVF, UVF and ureteral from June 2012 to June 2017, a five years review.
----------------------------------------------------------------------- This was a prospective interventional study. We
Department of Urology, Jinnah Hospital, Lahore included 220 patients who had urological
Correspondence: Dr. SajidMahmood, Assistant Professor, Email:
dhmsk71@gmail.com complications following obstetric and gynecologic

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Assessment of Urological Complications Following Obstetric and Gynaecological Surgery

surgery. The patients were operated by senior patients injury was diagnosed within 7 days of
surgeons. Mean age was 36.2 years (range 26-62 operation. In 3(1.8%) patients the injury was
years). The nature of urological injury, timing of diagnosed with in 4 weeks of operation. In 5(3.1%)
diagnosis, methods of repair and outcome was taken patients injury was diagnosed after 4 weeks of
into account. Risk factors for such injuries were also operation.
identified. In case of bladder injury repair was done Out of 220 patients, 48(21%) had ureteric
with 2/0 vicryl in two layers and bladder drained for 3 injuries. 8(16.6%) cases were managed by insertion
to 6 weeks. In Ureteric injury, DJ Stenting alone, of DJ Stent only. 18(37.5%) cases were managed by
ureteroureterostomies and re-implantation of the end to end ureteral anastomosis. 22(45.8%) cases
ureter into the urinary bladder were the procedures required re-implantation of ureter into the urinary
applied. We utilized modified leich technique for bladder. Out of 48 patients, 5(10.4%) had bilateral
ureter re-implantation. The anastomosis were carried ureteric injury. 19 (39.5%) cases had right ureteric
with 4/0 vicryl over a 6 Fr DJ Stent. The DJ Stent was injury and 24(50%) cases had left ureteric injury.
removed after 6 to 8 weeks. Patients with primary Time of diagnosis of ureteric injuries is shown in table
repair were followed on daily basis till the time they 2 below,
got discharged. Apart from routine exanimation
leakage of urine/ contrast from vagina, from wound, Table 2:Time of diagnosis of ureteric Injury
flank distention, unexplained fever, prolonged ileus Time Frequency % age
and signs of sepsis were noted during the follow up Intra-operative 16 33.3
of cases with primary repair. After discharge, the 1-7 days 11 22.9
1-4 weeks 14 29.1
patients were followed on weekly basis in OPD if they
> 4 weeks 07 14.5
were from Lahore. Patients outside Lahore were
followed on monthly basis depending upon their Table 3:Type of Obstetric & Gynecological Surgery resulting in
convenience. Telephonic liaison maintained with the Urinary Tract Injury
patients who were from far flung areas. The study Surgery Frequency % age
was in accordance with the ethical regulations of our Total Abdominal Hysterectomy 104 47.2
Hospital ethical committee. Sub-totalHysterectomy 20 09
Caesarian Section 60 27.2
Caesarian Hysterectomy 28 12.7
RESULTS VaginalHysterectomy 8 3.6

Two hundred and twenty two patients who sustained

Out of 48 cases with ureteric injury, 16(33.3%)
urinary tract injury following obstetric and gynecologic
were diagnosed intra-operatively. 11 cases (22.9%)
surgerywere included in the study. Out of 220
patients, 161(73.1%) had urinary bladder were diagnosed within a week after operation.
injury.Common sites of injury were dome and 14(29.1%) cases were diagnosed within week 1-4
after operation. 7(14.5%) cases were diagnosed late
posterior wall of the urinary bladder. Out of 161 cases th
after 4 week of operation. So ureteric injuries were
with urinary bladder injury 145(90%) were detected
difficult to diagnose early as compared to bladder
during the surgery and underwent primary repair with
injuries which were easy to diagnose earlier.Now we
successful outcome.In 8(3.6%) cases of urinary
bladder injury the rent was missed during the take into account the type of obstetric and
surgery, 5 cases out of these 8 were managed gynecological surgery resulting in urinary tract injury
as shown in table3.
conservatively with bladder drainage with wide bore
catheter. Re-exploration needed in remaining 3
Table 4:Initial Diagnosis Leading to Obstetric &
cases. 3(1.8%) cases of bladder injury were Gynecologic Surgery
diagnosed in week 1-4 post operatively. 5(3.1%) Diagnosis Frequency % age
cases were diagnosed late after 4 weeks of Fibroid Uterus 81 36.8
operation. Prolonged Labour 80 36
Endometrial Ca/Ca Cervix 18 8
Table 1:Time of Diagnosis of Urinary Bladder Injury DUB- Dysfunctional
Time Frequency % age 14 6.3
Uterine Bleeding
Intra-operative 145 90 Rupture Uterus 12 5.4
1-7 days 08 3.6 Placenta Percreta 11 5
1-4 weeks 03 1.8 VVF/ UVF 04 1.8
> 4 weeks 05 3.1
The most common obstetric and gynecologic
Time of Diagnosis of Urinary Bladder Injury is surgery was total abdominal hysterectomy 104(47.2
shown above table 1. In 145(90%) patients, bladder %) followed by caesarian section 60(27.2%).
injury was diagnosed intra-operatively. In8(3.6%) Caesarian Hysterectomy 28(12.7%) and Sub-total

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 SajidMahmood, NaveedIqbal,ShumailaAslam

13
Hysterectomy 20(09%) also contribute significantly. whenever possible .In our study 11(5%) were
Common urological procedures performed are diagnosed as placenta Percreta. 4 were managed by
primary bladder closure, end to end ureteral resecting the bladder wall and primary closure. In 2
anastomosis and ureteric re-implantation into the cases bladder wall closure alone was done. In 5
urinary bladder. Minimal invasive intervention was DJ cases we had to ligate the internal iliac artery with
Stenting only. closure of bladder rent. Out of 11 cases 2 patients
In our studyFibroid Uterus 81 (36.8 %) was most went into acute renal failure because of hemorrhage.
common initial diagnosis followed by prolonged In spite of haemodialysis and other measure we
labour 80(36%), Endometrial Ca/Ca Cervix could not save these 2 patients. Bladder injuries are
18(8%),DUB- Dysfunctional Uterine Bleeding more common than ureteric injuries with ratio of 5 to
14(6.3%) and Rupture Uterus 12(5.4%). There were 1. Urinary tract injuries occur 0.28%of all cesarian
11(5%) cases of Placenta Percretaand 4 cases deliveries with 3 fold increase risk with repeat
(1.8%) of VVF/ UVF–3/1. Out of 220 cases, 4 delivery. In our study out of 161 cases with bladder
patients were expired. 2 with bilateral ureteric ligation injury, 145(90%) were diagnosed intra-operatively
and 2 with placenta percreta. and underwent primary repair with successful
outcome. The most common indication of pelvic
DISCUSSION surgery was fibroid uterus, and most common
surgery was transabdominal hysterectomy. So we
Close anatomical relations of female genital and concluded from our study that bladder injuries are
urinary system increases the chances of potential most common urinary tract injuries, but easy to
6
injury to urinary system during surgical procedure . diagnose and give successful outcome with primary
Injury to urinary tract is a common complication of repair.
7
obstetric and gynecologic surgery . Injury to urinary Ureteral injury is one of the most serious
tract in medical practice was first described on 1030 complications following obstetric and gynecologic
AD in the Opus called “ Al-Kanoun”. The world wide surgery.Ureteral injuries are for more serious and
8
incidence is 0.5 to 1.5 % . Nigerian study reported often associated with high morbidity, ureterovaginal
9
incidence 0.4% . Montz and associates reported fistula formation and potential loss of renal function
10
bladder injury between 0.5 to 1% . Bladder injuries especially when not recognized until first operation .
14

were most common urological injuries in our study. Ureteric injuries are difficult to diagnose intra-
Out of 220 patients, 161(73.1%) had bladder injury. operatively but can be suspected by observing the
They occur mostly during the separation of bladder leakage of urine in the operation field. But this is
from lower segment of uterus. Previous caesarian difficult in case of scarring, Ca cervix, large pelvic
makes this dissection difficult due to scarring and masses and hemorrhage. Ureteric injuries can be
more prone to bladder injury. In such circumstances confirmed by careful exploration of ureter along its
upward traction on vesico-cervical fascia will make pelvic course, with injection of diurectics and looking
the dissection between bladder and uterus safe. for urinary leakage, ureteric dilatation and
Bladder injury can be suspected by urine leakage 15
peristalsis . In difficult cases pre-operative bilateral
from vagina or wound, haematuria, large cystostomy ureteric stenting help in better ureteric exploration.
is easily detected while smaller tears can be detected Unfortunately about 2/3 of ureteric injury cases are
by filling the bladder with methylene blue mix with detected post operatively with variable clinical
11
saline . It is beyonddoubt that primary repair of features such as oliguria, anuria, persistent urine
bladder during operation has excellent results. In our leakage, flank pain, fever, haematuria and signs of
study majority of bladder injuries were easily detected 16
sepsis . In our study out of 220 cases, 48(21%) had
by the operating surgeon.Large fibroids, pelvic ureteric injuries. 16(33.3%) cases were diagnosed
malignancies distort the pelvic anatomy so increasing intra-operatively and managed by re-implantation of
12
the chances of urinary tract injury . Placenta ureter into the bladder and end to end ureteral
Percreta which can affect any pelvis organ is a life anastomosis with 4/0 vicryl over a DJ stent. The
threatening condition in which bladder is involved by general principles of repair of ureteric injury are
the placenta. A multi-disciplinary approach is needed ureteric dissection preserving adventitial sheath with
with the services of gynecologic surgeon, physician, its blood supply, tension free anastomosis, use of
urologist and radiologist. Efforts should be made to omentumor peritoneum to cover the anastomosis,
achieve an antenatal diagnosis to minimize blood ureteric stenting and drainage by a passive drain to
loss. Management of placenta Percreta may be prevent urine accumulation.Intra-operative
achieved with resection of part of bladder wall, identification of ureteric injury enables easy repair
ligation or embolization of internal iliac artery, and associated with decreased morbidity and
immediate hysterectomy or therapy with 17
negligible legal risks . In our study the most common
methotrexate and preservation of bladder tissue procedures used in ureteric injury were re-

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Assessment of Urological Complications Following Obstetric and Gynaecological Surgery

implantation of ureter into the bladder followed by 2. Obarisiagbon EO, Olagbujl, BM, Omuori VC, Oguike TC,
Ande AB (2011) Iatrojenic Urological Injuries complicating
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None of our cases required omental or peritoneal 52: 738-741.
covering. We removed DJ Stent after 6 to 8 weeks. 3. Gilmoure DT, Dwyer PL, Carey MP. Lower urinary tract
The most common part of ureter to be injured is injury during gynecological surgery and its detection by intra
operative cystoscopy, obstet gynecol. 1999. 94 (5pt 2): 883-
distal one third and it is liable to be injured 1. in broad
889. (PubMed).
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infundibulopelvic ligament and ovarian fossa and DL: Risk factors for bladder injury during cesarian delivery
3.where ureter lies on anterior vaginal wall before its obstetgynecol, 105: 156-60, 2005.
18 5. Siowa A, Nikam YA, NG C and Su Mc: urological
entry into the bladder . In our study, out of 48 cases
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with ureteric injury 11(22.9%) were diagnosed pot- review at KK Women and Childern Hospital Singapore. Med.
operatively within 7 days and managed by early J, 48 (3): 217-221, 2007.
intervention. In 14(29.1%) cases late intervention 6. Michael P, Arouson and Teresa M. Bose. Urinary tract injury
in pelvic surgery. Clim. Obstetr. Gynaecol, 45: 428-438,
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Two of these 5 cases went into obstructive uropathy 7. Ozdemir E, Ozturk U, etal (2011) urinary complications of
which did not resolve even after our intervention. gynecologic surgery: iatrogenic urinary tract injury in
These two patients died because of chronic renal obstetric and gynecology operations. ClinExpobstetGyne col
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8. Frankman EA, Wang L, Bunker Ch, Lowder JN (2010) lower
lower incidence of ureteric injury when compared to tract injury in women in United States 1979-2006. Am J
19
abdominal hysterectomy 9 Vs 1.7% .Patientswith obstetJynecol 202: 495.
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Ibadan: a 20 years review. Trop J obstetgynecol 20: 32-36.
2 weeks have high chance of success with 10. Montz FJ, etal injuries to the ureter: prevention recognition
endourological procedures, obviating the need of and Management. In: Lindes, operative gynecology, 9th
20 edition Philadelphia: LippinCott, William and Wilkins Page:
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1081 (2003).
stent only.When preventing measures fail, prompt 11. Carley ME etal: incidence, risk factors and morbidity of
recognition and early intervention can avoid long term bladder or ureter injury during the hysterectomy, int.
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21 12. El-tabey NA, Ali- El- Dein B, Shaaban AA, El- Kappany HA,
renal function . Intra-operative recognition should be
Mokhatar AA etal (2006). Urological trama after
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always possible. Post operative injury recognition 40: 225-231.
requires a high index of suspicion and vigilance. 13. RamdevKonijeti MD etal department of surgery, urology
division, David Geffen School of medicine Los Angeles CA
rev. urol: 2009 summer, 11 (3) 173-176.
CONCLUSION 14. Sandip P Vasavada, MD etal ureteral injury during
gynecologic surgery, December 29, 2016.
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16. Yossepowitch O, Baniel J, and Livne PM: urological injuries
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ruptured uterus, placenta percretaand previous management. J Urol, 172: 196-9, 2004.
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proceeding to obstetric and gynecologic prevention and recognition of urinary tract injuries in pelvic
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key to success to prevent occurrence of delayed 19. Sarah L Cohen MD, MPH, Janelle K Moulder MD: preventing
urinary tract injury at the time of hysterectomy: contemporary
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meticulous surgical technique by the surgeon as well ureteric injuries: presentation and outcome of management.
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