Review

Urinary incontinence Incontinence to urine after gynaecological surgery, particularly

the formation of a urinary fistula, is distressing to both the patient

following gynaecological and the surgeon, and has long-term medicolegal implications.
Injury to the bladder is a risk whenever surgery, whether

surgery abdominal, vaginal or laparoscopic, is performed for cancer, endo-

metriosis or inflammatory disease. Surgical access after previous
pelvic surgery is another risky situation. The frequency of injury
Tahira Naru to the female bladder, urethra or ureter cannot be appreciated by
reading the literature only, because most of these injuries are unre-
Fauzia Haq ported and are recognized and repaired at the time of operation.
A significant number of lower urinary tract injuries are missed
Javed H Rizvi and are discovered as vesicovaginal fistulae several days after the
procedure. If the fistula is small, the vaginal loss may be mistaken
as simply physiological or an infective discharge. Careful evalu-
ation of this complaint is needed to prevent further embarrass-
Abstract ment for the patient and help the surgeon in decision ­making.
The proximity of the urinary tract to the reproductive organs puts it
at risk of injury and incontinence as a consequence of gynaecological
Effects of gynaecological surgery on the urinary tract
surgery. Incontinence to urine after gynaecological surgery is distressing
to both the patient and the surgeon; in particular, formation of a urinary Prospective longitudinal studies have revealed the effect of sim-
fistula after surgery is seen as a disaster by both. It also has long-term ple abdominal or vaginal surgery, radical hysterectomy, laparo-
medicolegal implications. In this review. the main emphasis is on the scopic hysterectomy and oophorectomy on lower urinary tract
prevention, evaluation, diagnosis and management of urinary tract in- symptoms and incontinence. Problems occur not just because of
jury. Other causes of postoperative incontinence are addressed briefly. anatomical damage to the urinary tract but also because of inter-
ruption of the autonomic nerve supply to the urinary bladder
Keywords evaluation counseling; gynaecological surgery; injury to (L4, L5, S1–4) and due to disruption of mid-urethral support. In
­urinary tract; urinary incontinence; vesicovaginal fistulae patients undergoing radical hysterectomy, 21–30% tend to have
more prolonged and severe lower urinary tract symptoms than
in those undergoing simple hysterectomy. This is attributed to
aggressive disruption of the vesical autonomic plexus mecha-
Introduction
nism. In oophorectomy, though the evidence is not convincing,
Urinary incontinence following gynaecological surgery may occur oestrogen deficiency could be a trigger factor. Laparoscopy-
in patients who were incontinent before surgery, or in patients assisted vaginal hysterectomy and total laparoscopic hysterec-
who were not previously incontinent and developed this com- tomy are associated with four times more urinary tract injuries
plaint after vaginal or abdominal surgery. than other modes of hysterectomy.
In the former group, the surgery was undertaken to address
this problem. Reasons for failure could be:
Patients who had incontinence before surgery
• inadequate evaluation and counselling before surgery
• inappropriate procedure or operative technique Evaluation and counselling
• development of de novo detrusor instability Cystometrography remains the key investigation in the evaluation
• unrecognized injury to the lower urinary tract. of patients who present with urinary incontinence. It not only
In the latter group, incontinence develops as an undesired out- helps in making a diagnosis but is also helpful in deciding the
come of surgery. This may be due to: type of procedure required and future management. The value of
• retention with overflow in the immediate postoperative this investigation is now well established in developed countries,
­period though in many developing countries where this test is not avail-
• inadequate evaluation before vaginal surgery, which unmasks able consultants usually make decisions to operate on the basis of
occult incontinence the history and examination alone. Many still follow the dictum
• unrecognized injury to the lower urinary tract. “do a vaginal procedure first and if it fails, go to the top”.
In the absence of urodynamic studies, surgery can be justi-
fied if there is a ‘clean’ history of stress incontinence alone
without any additional symptoms of nocturia, urgency or urge
Tahira Naru MD is Associate Professor, at the Department of Obstetrics incontinence. However, this policy has shortfalls. On the basis
and Gynaecology, Aga Khan University, Karachi, Pakistan. of the history alone, the risk of making the wrong diagnosis Is
around 30%. In incontinence surgery, the law of diminishing
Fauzia Haq FCPS is Senior Instructor, at the Department of Obstetrics returns operates, meaning that the best chance of cure is with
and Gynaecology, Aga Khan University, Karachi, Pakistan. the primary procedure, the chances of success diminishing with
each successive operation. There is general agreement that the
Javed H Rizvi FRCOG FACS is Professor, at the Department of Obstetrics observation of detrusor instability suggests that the results of
and Gynaecology, Aga Khan University, Karachi, Pakistan. ­incontinence surgery will be poor. Surgery may be offered to a

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:9 266 © 2007 Elsevier Ltd. All rights reserved.
 Review

patient with genuine stress incontinence and detrusor instability, i­ncontinence with women who are scheduled for hysterec-
but only after addressing the detrusor instability and provided tomy. Meta-­analysis has revealed that hysterectomy increases
that she understands the limited chances of success. the odds ratio of having urinary incontinence by 30%; this is
mostly in the form of urge urinary incontinence. A possible
Failed incontinence surgery reason is super-sensitivity of detrusor muscles as a result of
Surgery for incontinence may fail to give the desired results due partial denervation. During hysterectomy, blunt dissection of
to inadequate evaluation, previous bladder neck surgery, the the bladder from the uterus and cervix may damage the detru-
presence of detrusor instability, greater patient age, an incorrect sor innervation, and division of cardinal ligaments may inter-
choice of operation or failure to elevate/support the bladder neck. rupt the main branches of the sensory vesical plexus. Stress
Although making the correct diagnosis is essential, the surgical incontinence may be due to changes in structures such as the
skill and experience of the operator also plays a vital role. pubourethral ligament, the pubococygeous muscle and the
suburethral vaginal wall support.
Development of de novo detrusor instability Various trials have compared the effectiveness of total abdom-
Few patients develop this problem after successful surgery for inal hysterectomy with that of sub-total abdominal hysterectomy
genuine stress incontinence. Studies have revealed that de novo and found no significant effect on sexual and urinary dysfunction
detrusor instability occurs in 18% of patients undergoing a TVT at 12 and 24 months’ follow-up.
vaginal tape procedure, in 8–16% following Burch colposuspen-
sion and in 3–11% following sling procedures. Patients undergo-
Urinary tract injuries
ing these procedures should be appropriately counselled. It is
likely that a small number of cases reflect pre-existing detrusor Injury to the urethra
instability that was not detected at preoperative cystometry. Urethral injury during gynaecological surgery is uncommon,
because the urethra is partly protected by the pubic symphysis
and is not as firmly anchored as the male urethra.
Patients who did not have incontinence but developed
Injury to the urethra may occur at during anterior colporrha-
this complaint after surgery
phy or dissection of the urethra and bladder neck in operations
Retention with overflow for urinary incontinence such sling and TVT procedures. Such
The effect of regional anaesthesia or pain, whether abdominal, injuries may lead to almost total incontinence. Diagnosis of these
vaginal or perineal, in the postoperative period can cause reten- injuries is not difficult and is usually made by cystourethroscopy.
tion of urine. If this goes undetected, the bladder over-distends If the defect is fresh. prompt repair is needed. If the injury shows
and the patient starts dribbling urine, complaining of continu- signs of inflammation. diversion of bladder urine with a suprapu-
ous wetness or of passing small amounts of urine frequently. bic catheter may be needed before repair.
The diagnosis is not difficult; an over-distended bladder can be Most urethral injuries require suturing. Because of the rich
felt in the lower abdomen, which is tender on compression, and blood supply in this area, the lacerations tend to bleed freely.
leakage of small amounts of urine can be demonstrated. A pelvic Fine polyglycolic acid sutures are used. Urethral loss (slough-
examination should be performed to exclude perineal, vaginal or ing of the entire urethra) occasionally follows colporrhaphy or
vault haematoma. a suburethral sling procedure. In these cases, a strip of anterior
Retention with overflow can be managed by giving adequate vaginal wall is made into a tube over a catheter. It is impor-
analgesia and leaving an indwelling catheter in place for 48 tant to insert plication sutures behind the bladder neck if conti-
hours. It can be prevented by catheterizing the patient before nence is to be achieved. The interposition of a graft between the
surgery and leaving the catheter in situ for 24 hours or by ensur- new urethra and the vaginal wall closure fills the potential dead
ing that the patient voids urine 6–8 h after surgery. space and improves continence by ensuring mobility of the blad-
der neck. If continence is still not achieved, an artificial urinary
Occult incontinence sphincter may be needed.
Patients presenting with urogenital prolapse may not complain of
urinary incontinence. Some develop stress and urge incontinence Injury to the urinary bladder
after operative correction of the prolapse. It therefore seems The urinary bladder is the most common site of injury during
prudent that, at the time of examination, the prolapse should gynaecological surgery. It is relatively resistant to injury when
be reduced before provocative tests are undertaken to demon- collapsed, so the first line of defence is drainage by a catheter.
strate urinary incontinence. At the time of urodynamic studies, a This procedure should be performed in all cases before abdomi-
vaginal pessery is inserted to correct the anatomical defect. This nal, vaginal or laparoscopic surgery. When inflammation. endo-
helps to guide the surgeon as to whether a continence procedure metriosis or cancer is present in the region, the bladder becomes
is required at the time of pelvic floor repair. fixed and injury is more common. Loss of normal tissue planes,
In women with uterovaginal prolapse, surgical options such as occurs in patients who have undergone previous surgery, or
as vaginal hysterectomy with pelvic floor repair, abdominal injudicious surgical dissection that proceede despite haemor-
sacrocolpopexy and sacrohysteropexy are available. Studies have rhage may cause trauma to the bladder.
shown better urinary control and less urge incontinence following Hysterectomy-associated injuries may occur during abdomi-
vaginal hysterectomy than following abdominal ­sacrocolpopexy. nal or vaginal procedures. Such injuries are usually recognized
It was recently suggested that practitioners should dis- immediately, but this may be delayed in certain cases. The injury
cuss the possibility of an increased likelihood of urinary is typically located just above the trigone, but may involve the

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:9 267 © 2007 Elsevier Ltd. All rights reserved.
 Review

ureter and may be extensive. Injuries recognized during the ini- of dye-stained saline solution. If a leak occurs, it should be closed
tial surgical procedure can be repaired adequately. immediately with interrupted figure-of-eight sutures. The blad-
The incidence of bladder injury during laparoscopic proce- der should then be drained continuously using a transurethral
dures ranges from 0.02% to 8.3%, which is high compared with Foley catheter, which should be left in situ for 10–14 days. If
the reported rates of some classical pelvic operations. The blad- there is significant infection or the patient has undergone radio-
der dome has been reported to be the most common location of therapy, drainage of the bladder may need to be prolonged for
bladder injury during laparoscopic surgery. Laparoscopic injury 2–3 weeks.
to the bladder occurs due to fixation of the bladder following Sometimes, a surgical laceration may escape detection and is
previous surgical procedures or inadequate emptying of the blad- discovered in the immediate postoperative period. If the patient
der before the introduction of the laparoscope. Injury is most is found to have haematuria, two possible courses of action are
common with instruments connected to an electrocautry unit fol- available to the surgeon. Most minor lacerations close spontane-
lowed by blunt dissection. ously if the bladder is kept on continuous free drainage, and
the bleeding usually stops. A three-way Foley catheter is used
Early recognition of injury so that the bladder can be irrigated to avoid clot retention. Only
Since 1990, the use of intraoperative cystoscopy to detect occult small amounts (30–50 ml) of irrigating fluid should be used. The
urinary tract injuries has increased. Gilmour et al. have reviewed indwelling catheter should remain for at least 2 weeks to allow
the literature and concluded that the prevalence of urinary tract good healing. The second option is to perform cystoscopy.
injury was 1.6/1000 without cystoscopy and 6.2/1000 with cys- Occasionally, a non-absorbable suture penetrates the bladder.
toscopy. An analysis of 13 prospective studies revealed that Non-absorbable sutures are used for suprapubic bladder neck
5.8/1000 ureteric injuries and 10.9/1000 urinary bladder injuries suspensions, as in the Stamey and Marshall–Marchetti–Krantz
might be missed without the use of intraoperative cystoscopy. procedures and Burch’s modification. A non-absorbable suture
However, there have been cases in which bladder or ureteric that is penetrating the bladder or urethra should be cut trans-
injuries were missed despite cystoscopic examination. Recent vesically and removed. Sometimes, the stitch retracts out of the
prospective studies have recommended intraoperative cystos- lumen once it is cut. Failing this, a retroperitoneal suprapubic
copy, but there is no consensus on whether it should be per- cystostomy may be necessary to remove the ligature. Leaving
formed during every major gynaecological procedure. such foreign bodies in situ leads to intractable cystitis and even-
Injury to the bladder during laparoscopic, vaginal or abdomi- tual stone formation.
nal procedures can take the form of a clean cut into the blad- If a large laceration is found at the time of cystoscopy, as
der lumen due to distorted anatomy, or laceration and tearing of sometimes occurs after a difficult vaginal hysterectomy when an
bladder due to difficult dissection. enlarged uterus is removed vaginally, this should be repaired
immediately using a suprapubic transvesical approach. When-
During abdominal surgery ever there is doubt about the possibility of bladder injury during
Closure of bladder injury should be performed in a watertight surgery, continuous urinary drainage should be instituted and
manner, in two layers. The usual material for repairing bladder continued for 4–10 days. There is no harm in explaining to the
injuries is 2/0 or 3/0 polyglycolic acid sutures. Non-absorbable patient that this is a safety precaution.
sutures should not be used as they may cause local irritation and
subsequently become a nidus for stone formation. The bladder During laparoscopic surgery
mucosa should be closed separately from the muscular layer; this Bladder repair can be performed via a laparoscope by adapting
minimizes bleeding into the bladder. An interrupted layer is used a classic gynaecological surgery technique with fine absorbable
to close the mucosa and a continuous second layer can repair the polyglycolic acid sutures tied with a two-turn flat knot. This can
muscular layer. be done in one layer or in two layers. Laparoscopic staples can
If the bladder has been opened and there is any question also be used to repair bladder defects.
of injury to the ureter, the incision in the bladder should be
enlarged. A catheter should then be passed up the ureteric orifice Late recognition of injury
and the course of the ureter visualized to ensure that no injury to Vesicovaginal fistulae may occur as late as 15 days postopera-
the ureter has occurred. tively, but are most commonly discovered 4–8 days after surgery.
Total urinary incontinence after surgical trauma suggests that a
During vaginal surgery fistula has formed between the bladder and the vagina. If the
If the bladder is opened during vaginal surgery, cystoscopy after patient is incontinent after surgery, but is also able to empty her
plugging of the injury is helpful in delineating the extent of the bladder at regular intervals, a ureteric fistula is more likely.
bladder injury and demonstrating the ureteral orifices and their Other cases of delayed trauma may result from formation of
relationship to the injury. Passage of a catheter up the ureters a haematoma under the bladder, which may become infected. If
before closure of the bladder reassures the surgeon that no por- it cannot escape through the vaginal vault, tension builds up in
tion of the ureter is included in the repair. If required, retrograde the cavity and the neighbouring bladder wall undergoes necrosis.
urethropyelography can be performed before closure. Ultimately, a urinary fistula may form between the bladder base
Filling the bladder with dilute methylene blue solution or ster- and the vaginal vault. This sometimes occurs after a straightfor-
ile milk may be helpful in demonstrating suspected injuries. Fol- ward, uncomplicated operation.
lowing completion of bladder repair, the bladder should be tested When a patient starts leaking urine in the postoperative period,
for watertightness. This can be achieved by installing 200–300 ml it is usually unwise to make a detailed examination per vaginum

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:9 268 © 2007 Elsevier Ltd. All rights reserved.
 Review

to localize the fistula. Cystoscopic evaluation should be avoided, • maintenance of free postoperative urinary drainage with a
and more simple efforts should be made to determine the nature transurethral or suprapubic catheter.
of the fistula. A vaginal tampon is inserted in the vagina and a
solution of methylene blue dye is installed into the bladder via a Postoperative residual incontinence following urinary fistula
transurethral catheter. Leakage of urine can be confirmed by the repair
presence of dye on the vaginal tampon; this finding suggests that Stress incontinence after fistula repair is almost as frustrating
a vesicovaginal fistula is present. If the methylene blue fails to to the fistula surgeon as surgical failure. There is little in the lit-
stain the tampon but the tampon becomes wet with clear urine, erature about this issue, but the reported prevalence in different
a ureteric fistula should be suspected. Intravenous urography is a series is 8–16% and some authors have published figures as high
useful investigation to exclude upper urinary tract abnormalities as 33% based on urodynamic investigations. This sign or symp-
and ureteral involvement. tom is likely to occur when there has been damage and/or tissue
Vesicovaginal fistulae should initially be treated conserva- loss In the region of bladder neck and the urethra.
tively. Natural healing reduces their size and some close spon- The management of post-fistula stress incontinence is
taneously. This may be encouraged by continuous drainage extremely difficult. Waaldijk has advocated a modified Martius
through a urethral catheter for up to 6 weeks. During catheteriza- procedure, securing the graft retropubically. Hudson and Hen-
tion, the patient can be ambulant and even discharged from the drickse advocated a vaginal urethral suspensory procedure. Con-
hospital. Rest in bed or assuming the prone position usually does ventional bladder neck elevation procedures have limited value.
not promote healing of the fistula. If most of the urine drains Recently, Browing described the use of a fibromuscular sling dur-
through the fistula rather than through the catheter, or the fistula ing fistula repair to prevent residual stress incontinence.
tract fails to heal within 4–6 weeks, further catheter drainage is
unlikely to help. Catheter drainage is annoying to the patient and
Injury to the ureters
is a constant reminder to her of the undesirable outcome of the
procedure. Role of imaging in the prevention of urinary tract injuries
If the patient continues to leak urine after the catheter has Preoperative imaging is not necessary for every case, but intra-
been removed, the catheter should not be re-inserted, to allow venous urography (IVU) or contrast-enhanced CT might be
any irritation or infection that has occurred to subside. Any con- considered if distorted anatomy is anticipated or previous uri-
sideration of surgical correction of the fistula should be deferred nary compromise is suspected. A review of the experience of a
for 4–6 weeks, though this concept has recently been challenged; university-based gynaecology service, where IVU was per-
Waaldijk has published his experience of early closure of fistulae formed routinely as a preventive preoperative measure, showed
with a 95% success rate. that previous pelvic surgery, uterine size equivalent to more
The skin of the vulva and thighs must be protected from exco- than 12 weeks’ gestation and adnexal masses of more than
riation. A silicon barrier cream, zinc and castor oil cream or par- 4 cm were most likely to be associated with abnormal IVU. A
affin gel is suggested. During this waiting period, oedema and decision analysis was formulated; using a baseline prevalence
infection have subsided and the tissues become soft, pliable and of ureteric injury of 0.5%, the authors predicted an extra cost
workable. Use of cortisone does not significantly accelerate the of $166,600 in preventing a single ureteric injury if preoper-
process. In post-menopausal patients, a short course of oestrogen ative IVU were used In all patients. Estimating a real dollar
improves the condition of the vaginal skin and its blood supply. charge of $200 per IVU to the patient suggested that $166,600
would be spent to avoid one ureteric injury. The marginal cost-
Fistula repair effectiveness of a IVU strategy over a no IVU strategy is that
The presence of vaginal scarring appears to be important in 833 pyelograms must be obtained to avoid one ureteric injury.
determining the likelihood of both successful fistula closure and Hence, routine use of IVU is questionable. Normal IVU does not
the development of debilitating urinary stress incontinence after remove the surgeon’s responsibility to identify the ureters in all
successful repair. For extensive repair, vaginal flaps and tissue pelvic operations.
grafts are often used to close the fistula. The route of repair,
whether abdominal or vaginal, depends on the site of the fistula. Role of ureteric catheterization in the prevention of ureteric
A suprapubic abdominal approach does not necessarily improve injuries
success rates, but it does however increase morbidity. A vaginal The decision to place ureteric catheters before gynaecological
approach is therefore preferred. surgery should be made on an individual basis. Their routine use
Every operator develops his or her own techniques for repair- to prevent ureteric injury is a controversial issue. Proponents of
ing fistulae based on well-established general principles: prophylactic ureteric stenting say that they improve prevention
• allowance of sufficient time for spontaneous healing and mat- and recognition of injury. Detractors cite no advantage in terms
uration of the fistula of prevention of injury and list possible complications such as
• examination under anaesthesia to evaluate the site and nature urinary tract infection, ureteral spasm, reflex anuria, injury dur-
of the fistula ing catheterization and haematuria. A review of ureteric cath-
• adequate exposure of the fistula surgically before closure eterization has shown no statistical significant difference in the
• repair of the fistula without any tension on the suture line incidence of operative ureteric injury, but an added cost of $1465
• protection of the ureter with ureteral stents per case.
• a watertight closure, which should be confirmed at the end of In gynaecological surgery, the ureters are usually injured at a
the operation relatively high level near the pelvic brim, where they lie adjacent

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:9 269 © 2007 Elsevier Ltd. All rights reserved.
 Review

to the ovarian vessels, or low down beside the cervix, where they should be corrected. Since there is often some obstruction at the
are crossed by the uterine vessels. The ureters may be included site of ureteric injury, IVU usually shows dilatation of the ureter
in ligatures that are used to tie off these vessels, may be crushed and often of the calyces on the side of the lesion. If there is no
in clamps and subsequently undergo necrosis, or may be par- obstruction above the fistula, the ureter and kidney may look
tially or completely divided. These complications are most likely normal.
to occur in the presence of dense adhesions, pelvic inflammatory The injured side is identified by cystoscopy and observation
disease or endometriosis, or when the normal anatomy of the of the presence of efflux from the ureteric orifice of the intact side
pelvis is distorted; for example, by fibroids or ovarian tumours and the absence of efflux on the injured side. This test is facili-
growing into the broad ligament, which may displace the ureter tated by adequate hydration, achieved by giving intravenous flu-
from its normal position. Occasionally, the ureter becomes devi- ids and then intravenous diuretic with or without indigo carmine.
talized and sloughs after extensive pelvic dissection, as in Wert- The site of the lesion may be further confirmed by attempting to
heim’s hysterectomy, due to interference with its blood supply, pass a ureteric catheter up the non-effluxing side.
particularly after previous pelvic irradiation. Rarely, the extreme The level of the site of the injury can be recognized on high-
lower end of the ureter is caught in high stitches inserted beside dose IVU with screening or delayed films, which usually show
the cervix during pelvic floor repair or vaginal hysterectomy. the lower limit of the intact ureter and sometimes the exact site
of the leakage, and may show filling of the vagina. If the site
Early recognition of injury of injury is not clear on IVU, percutaneous nephrostomy under
If the ureter is injured during surgery, or there are grounds for ultrasound control, descending ureterography or cystoscopy and
suspecting that it may have been crushed, divided or included in ascending ureterography will show it more exactly.
a ligature, an adequate length of the ureter is exposed above and Once the nature of the lesion has been defined, a decision on
below the injury to define its nature and extent. If injury to the the best form of management can be made. In some early cases,
extreme lower end of the ureter is suspected, the bladder should simple ureteric drainage with a double J stent may allow a small
be opened without hesitation by anterior cystostomy and the fistula to heal. If it does not dry up quickly, operative interven-
appropriate ureteric orifice catheterized. If the catheter ascends tion is necessary and there is little point in further delay. If the
easily and no injury is found. the bladder is simply closed in two ureter is completely obstructed, reconstruction or re-­implantation
layers as described previously. A urethral catheter is left in situ should be undertaken as soon as possible if worthwhile kidney
for 7–10 days. If the ureter is partially damaged or obstructed, function is to be preserved.
a ureteric stent is left in situ for 6 weeks. Complete transection The operative approach to the repair of ureteric injuries pro-
of the ureter requires reconstruction or re-implantation, which ceeds in a manner similar to that described earlier. The ureter
can proceed without delay. The lower end of the ureter is dis- is generally approached extraperitoneally and repaired or re-
sected out and may be re-implanted directly in the nearest part implanted, with or without Boari’s flap. If a considerable defect
of the bladder or, preferably, the is opened and the ureter is re- must be bridged, it is occasionally necessary to perform a high
implanted with a reflux-preventing procedure into the posterior transuretero-ureterostomy.
or lateral wall.
When high ureteric injury is found, direct end-to-end anas-
Medicolegal aspects of urinary tract injuries
tomosis is performed. The circumference of the cut ends of the
ureter is increased by a 1 cm vertical incision and they are joined The medicolegal aspects of urinary tract injuries are an increasing
using fine polyglycolic acid sutures. The anastomosis is best per- area of concern. An individual who sustains a urinary tract injury
formed over a ureteric splint. A double J stent or a fine (8 FG) is 91-fold more likely to undertake medical litigation. Patients
infant’s oesophageal feeding tube passed up from the bladder may start litigation against a surgeon for various reasons, includ-
is ideal for this purpose. The most important technical point is ing physical and psychological suffering due to the unexpected
to ensure that there is no tension at the site of the anastomosis. surgical outcome. A literature search reveals a litigation rate of
A suction or corrugated drain is left near the site of anastomo- 3% in gynaecological surgery with urological injuries compared
sis and removed after 4 or 5 days. The ureteric stent is usually with 0.03% without injuries.
removed after 4–6 weeks.
Conclusion
Late recognition of injury
Ureteral damage is usually recognized postoperatively. Early There are three levels of prevention of urinary tract injuries in
signs and symptoms of injury in the postoperative period are gynaecological surgery. Primary prevention comprises avoid-
non-specific and comprise fever, ileus, flank or abdominal pain, ing lower urinary tract injuries by careful surgical technique,
persistent hematuria or the appearance of a mass that is usually including identifying the ureters and bladder during major gyn-
suspected to be hematoma by the surgeon. Often, the injury is aecological surgery. Secondary prevention is the intraoperative
not suspected until an obvious urinary fistula occurs. recognition and repair of injury. Tertiary prevention, or minimiz-
When evidence of ureteric injury becomes apparent in the ing the morbidity and sequelae once urinary tract injuries become
postoperative period, the precise nature of the injury should be symptomatic in the postoperative period, usually involves fur-
defined before deciding on the best approach to repair. A cath- ther diagnostic and surgical intervention to confirm and man-
eter specimen of urine should be sent for bacteriological culture age the injuries. Compared with tertiary prevention, primary and
and a sensitivity study. Blood urea and electrolytes should be secondary prevention are often easier and more successful and
checked routinely and dehydration or electrolyte imbalances cause less morbidity.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:9 270 © 2007 Elsevier Ltd. All rights reserved.
 Review

Postoperative urinary incontinence is an undesirable outcome Tapp A. Genitourinary fistulae. In: Cardozo L, ed. Urogynecology. New
of gynaecological surgery. Patients undergoing surgery for uri- York: Churchill Livingstone, 1997, p. 401–13.
nary incontinence or urogenital prolapse should be appropriately Thakar R, Ayers S, Clarkson P, Stanton S. Outcome after total versus
evaluated and counselled. The bladder should be emptied before subtotal abdominal hysterectomy. N Eng J Med 2002; 347: 1318–25.
surgery and left on continuous drainage for 12–24 hours postop- Vaart CH, Bom JG, Leeuw JRJ, Roovers WR. The contribution of
eratively. If an injury to the bladder or the ureter is recognized at hysterectomy to the occurrence of urge and stress urinary
the time of surgery, primary repair gives the best results. When incontinence symptoms. BJOG 2002; 109: 149–54.
the damage becomes evident later, extreme care must be exer- Vakili B, Chesson R, Kyle BL, et al. The incidence of urinary tract injury
cised to locate the injury accurately and then to choose the opti- during hysterectomy a prospective analysis based on universal
mal timing and technique for repair. Cystoscopy. Am J Obstet Gynecol 2005 May; 192(5): 1599–604.
Injury to the urinary tract is a recognized complication of gyn- Walsh K, Stone AR. How is the lower urinary tract affected by
aecological surgery and therefore appropriate training of pelvic gynaecological surgeries? BJU 2004; 94: 272–75.
surgeons is of prime importance. Adherence to standard surgical
principles and knowledge of techniques of repair and palliative
procedures gives confidence to the surgeon and minimizes the
occurrence of this morbidity. ◆

Further reading
Baessler K, Stanton SL. Prolapse and urinary incontinence. Curr Opin Practice points
Obstet Gynecol 2005; 17(5): 547–55.
Bidmead J, Cardozo LD. Surgery for genuine stress incontinence. In: • Postoperative urinary incontinence is a undesirable outcome
Studd J, ed. Progress in Obstetrics & Gynaecology, vol. 14. London: of gynaecological surgery
Churchill Livingston, 2000, p. 329–51. • Patients undergoing surgery for urinary incontinence must be
Brown JS, Sawaya G, Thom DH, Grady D. Hysterectomy and urinary appropriately evaluated and counselled
incontinence: a systematic review. Lancet 2000; 356: 535–39. • Patients requiring surgery for urogenital prolapse should
Gilmour DT, Baskett TF. Disability and litigation from urinary tract be evaluated for urinary incontinence after reduction of the
injuries at benign gynaecologic surgery in Canada. Obstet Gynaecol prolapse
2005; 105(1): 109–14. • The urinary bladder should be emptied and preferably the
Kuno K, Menziz A, Kauder H, Sisan C, Gal D. Prophylactic ureteric catheter left on continuous drainage during any major pelvic
catheterization in gynaecological surgery. Urology 1998; 52(2): surgery
1004–08. • If an injury to the urinary tract is recognized during surgery, it
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