Systematic review of urological injury during caesarean section and hysterectomy

The application of transperineal ultrasonography combined with shear wave elastography in the evaluation and monitoring of pelvic floor function in the early stage after total hysterectomy

BACKGROUND

To investigate the combined effect of transperineal ultrasound and Shear Wave Elastography (SWE) in the evaluation and monitoring of pelvic floor functions after total hysterectomy.

METHODS

Fifty-two women who planned to undergo total hysterectomy from January 2019 to December 2022 in Nantong Third People's Hospital were selected, and the pelvic floor functions were assessed using transperineal ultrasound combined with SWE. The dynamic alterations in pelvic floor functions at different time points were compared after hysterectomy. The differences in pelvic floor parameters were compared between Transabdominal Total Hysterectomy (TAH) and Laparoscopic Total Hysterectomy (LTH).

RESULTS

The Posterior Urethravesical Angle at rest and Valsalve maneuver (R-PUA, V-PUA), antero-posterior diameter of the hiatus at rest and Valsalve maneuver (R-HAPD, V-HAPD), and elastic modulus of left and right puborectalis at rest (R-L-PRE, R-R-PRE), the Urethral Rotation Angle (URA)were obviously higher at 3 mon after surgery than before surgery and at 1-mon after surgery; the bladder neck-symphyseal distance at rest and Valsalve maneuver (R-BSD,V-BSD), and the difference in elasticity between the left and right puborectalis muscles (L-∆E, R-∆E) were markedly lower at 3 mon than before surgery and at 1 mon after surgery; V-BSD, L-∆E, R-∆E were obviously decreased and the Bladder Neck Descen (BND), URA, V-PUA were obviously increased in the TAH group in comparison with the LTH group.

CONCLUSION

Pelvic floor functions start to be weak at 3 months after total hysterectomy. TAH causes more significant damage to the structures and functions of the pelvic floor.

Overactive Bladder Syndrome Following Cesar ean Hysterectomy for Placenta Accreta Spectrum, A Cohort Study

INTRODUCTION AND HYPOTHESIS

The increasing incidence of placenta accreta spectrum (PAS) has emerged as a significant concern in obstetrics. This cohort study is aimed at assessing the overactive bladder and other lower urinary tract symptoms (LUTS) in women who underwent cesarean hysterectomy for PAS.

METHODS

Between 2022 and 2023, a total of 84 consecutive patients with pathologically confirmed diagnosis of PAS at our academic hospital, Mashhad, Iran, were enrolled and compared with a control group of 42 women who had cesarean section (CS) without hysterectomy, matched for age, gravidity, and number of prior CSs. Symptoms were evaluated using a questionnaire 6-30 months postoperatively.

RESULTS

The median age of the cohort was 35 years (interquartile range, 31-38). In the cesarean hysterectomy group, cystotomy occurred in 17 (20.2%), ureteral injury in 5 (6.0%), and bladder fistula in 1 (1.2%), whereas none was observed in the cesarean group. In women who underwent cesarean hysterectomy, urinary urgency was the most prevalent symptom (48.8%), with the highest frequency and bother scores. Comparing patients who had cesarean hysterectomy with those in the control group, the urinary frequency was significantly more prevalent (34.5% vs 14.3%; p = 0.02), with higher frequency and bother scores (p = 0.017 and 0.005, respectively). Subgroup analysis within the cesarean hysterectomy group revealed that urinary frequency was significantly more prevalent in women who had placenta accreta with bladder invasion and experienced cystotomy compared to those without urinary tract injuries (p = 0.03).

CONCLUSIONS

Approximately half of patients undergoing cesarean hysterectomy for PAS experienced symptoms suggestive of overactive bladder 6-30 months postoperatively.

Return to theater following gynecologic surgeries: An institutional audit and review of the literature

OBJECTIVE

Return to theater (RTT) for reoperation following a primary surgery has significant implications for patients and the healthcare system. RTT following gynecologic surgeries is a critical clinical incident trigger for reporting and investigation of root cause analyses. Many of the causes of unexpected return to theater after surgery are avoidable and therefore provide essential learning opportunities to prevent future recurrence and to improve patient experience especially in those at risk of specific complications.

METHODS

The present study was a mixed method retrospective review of all unexpected reoperations following gynecologic surgeries over a 7-year period at Mid Yorkshire Teaching Hospitals NHS Trust and a review of the literature.

RESULTS

There were 24 RTTs following gynecologic surgeries during the period. The overall RTT rate was three per 1000. Hysterectomies accounted for 14 (58.3%) of the reoperations. Similarly, 11 (45.8%) of the reoperations were as a result of hemorrhagic complications. Other themes identified include port site hernia in three patients (12.5%), ureteric injury in two patients (8.3%), while three patients (12.5%) had no abnormality detected at reoperation.

CONCLUSION

Unexpected reoperation following gynecologic surgery is an uncommon complication at three per 1000 surgeries. Reactionary and secondary hemorrhages are the most common causes and hysterectomy irrespective of the approach remains the leading primary surgery. The causes are largely preventable.

Intra- and Postoperative Complications in 4565 vNOTES Hysterectomies: International Registry Cohort Study

OBJECTIVE

To present the rates of intra- and postoperative complications and conversions in a large cohort of unselected vNOTES hysterectomies, performed by surgeons with different levels of expertise.

DESIGN

International register-based cohort study.

SETTING

Hysterectomies in the iNOTESs registry, 2015 to January 2024, performed by 201 surgeons from multiple countries.

POPULATION

4565 patients undergoing vNOTES hysterectomy.

METHODS

Descriptive data are presented in frequencies (n) and percent (%).

MAIN OUTCOME MEASURE

Intra- and postoperative complications. Conversions.

RESULTS

Intraoperative and postoperative complication rates were 3.2% (n = 144) and 2.5% (n = 115), respectively. Conversions occurred in 1.6% (n = 72), of which 10 (0.2%) to laparotomy, and 82% of the conversions occurred within the first 50 cases of the surgeon's learning curve. The most common intraoperative complication was cystotomy, occurring in 1.3%, and almost half were performed by inexperienced surgeons. Other intraoperative organ injuries occurred in 20 cases (0.44%). Postoperatively, the most common complications were haemorrhage (n = 28), vault complications (n = 26) including 11 infected vault hematomas, cystitis (n = 18) and non-specific infections (n = 14). The vNOTES hysterectomies were performed by 201 surgeons, of which 9.5% had performed more than 50 vNOTES cases, representing 70% of the registered cases in the registry. The remaining 30% of the hysterectomies mainly represent learning curve data from 90% of the included surgeons. The complication rate decreased with increasing surgical experience.

CONCLUSIONS

The largest study population of vNOTES hysterectomies is presented, including both learning curve data and data from experienced surgeons, with acceptable rates of intra- and postoperative complications. No implication was found of vNOTES being inferior to other minimally invasive methods.

Urological injuries complicating pregnancy-related hysterectomy: Analysis of risk factors and proposal to improve the quality of care

PURPOSE

While strategies aimed at preventing urological injuries complicating hysterectomy for gynaecological indications and placenta accreta surgery have been proposed, a comprehensive model for pregnancy-related hysterectomy (PRH) is lacking. The aim of this study was to investigate risk factors for urological complications of obstetric hysterectomy, and to propose strategies to improve the quality of care.

METHODS

This retrospective study of patients undergoing PRH was conducted in an academic centre between 2009 and 2022. Surgical lesions of the urinary tract were defined by the need for direct repair or subsequent additional urological interventions. Univariate and multivariate analyses were performed to identify determinants of urological injuries.

RESULTS

Among 141 patients undergoing obstetric hysterectomy, 25 (17.7 %) experienced urological injuries (22 bladder lesions, three ureteral lesions). Bladder injuries were repaired intraoperatively, while ureteral lesions were diagnosed 2-5 weeks after surgery. After adjustment for confounding variables, the number of previous caesarean deliveries (p = 0.006) and intraoperative estimated blood loss (p = 0.002) were independently associated with urological complications.

CONCLUSION

The burden of urological complications during obstetric hysterectomy is high. Subtotal hysterectomy can be considered in selected cases to reduce the risk of ureteral injury, while postoperative ultrasonographic screening of the urinary tract and analysis of serum markers may facilitate early detection of undiagnosed ureteral complications.

Urinary Tract Injuries Following Obstetric Operations: A Retrospective Study in Iraqi Tertiary Care Center

Background: Urinary tract injuries (UIn) are commonly reported after obstetrical and gynecological operations. They contribute to higher morbidity rates, longer hospital stays, and lower patient life quality. Objective: To identify risk factors and predictors of UIn, as well as the best therapeutic techniques for preventing further harm and improving patient outcomes. Methods: A retrospective analysis examined UIn cases from obstetrical and gynecological procedures conducted at Yarmouk Hospital during 2021-2023. The records included information about the patients' demographics, operative data (surgery type, after diagnosis of UIn, and injury type, size, and confirmation), repair data (suture used, how many layers, and the use of suprapubic catheter), and post-operative complications (admission to intensive care, sepsis, renal failure, and maternal death). Results: 51.6% of the cases were between 30 and 40 years old. Cesarean hysterectomy was performed in 54.84% of instances, with 66.13% being diagnosed intraoperatively without the requirement for IVU, which was employed in just 30.65%. Bladder injuries account for 80.65% of all cases, with 48% of them measuring 3–5 cm. Injuries were healed in 77.4% of cases using two two-layer methods and Vicryle sutures. Most patients (69.35%) had a suprapubic catheter. 93.5% of cases had no serious problems. Conclusions: Early diagnosis during surgery, as well as a two-layer repair using Vicryle sutures and a suprapubic catheterization, are critical for reducing morbidity, enhancing recovery, and improving healthcare in high-risk settings.

Management of urological injuries following gynecologic and obstetric surgery: A retrospective multicenter study

OBJECTIVE

Urinary system injuries may occur iatrogenically during some surgical procedures especially gynecological and obstetrical surgeries. Unfortunately, these injuries can lead to serious complications in patients. In this multicentric study, we aimed to review and report our experiences and results of urinary tract injuries identified during gynecological and obstetrical surgery.

METHODS

We included women with urinary tract injuries during gynecological and obstetrical surgeries between January 2018 and October 2023 at four centers. Detailed data collected include patient demographics, surgical details, injury characteristics, diagnostic and treatment methods, timing of injury diagnosis and management reports of the patients. The incidence of bladder and ureter injuries was evaluated and the rate of intraoperative urological consultations was recorded.

RESULTS

In a total of 328 patients with a median age of 47 years (24-90), urinary tract injuries were diagnosed, including 227 (69.2%) iatrogenic bladder injuries (IBI) and 101 (30.8%) iatrogenic ureteral injuries (IUI). These injuries were diagnosed in 299 patients (91.2%) during surgery and in 29 patients (8.8%) after the surgical procedure. We observed intraoperative detection rates of 71.9% for IBI and 28.1% for IUI. IBI (71.9%) was diagnosed significantly more frequently than IUI (28.1%) (p=0.001). Cesarean section resulted in significantly more frequent IBI, whereas tumor debulking surgeries resulted in more IUI (n=52, 56.5%) than the other types of procedures (p<0.001).

CONCLUSION

Our study provides a comprehensive overview of iatrogenic urological injuries during gynecological and obstetrical surgeries. Although the bladder is the most frequently injured organ during gynecological and obstetric surgeries, early diagnosis and urological intervention are mandatory to prevent delayed complications. Surgeons must have a thorough understanding of the pelvic anatomy and appropriate surgical techniques to prevent iatrogenic injuries during surgery and ensure timely diagnosis and treatment of urinary tract injuries.

Intraoperative bladder visualization by indocyanine green filling and subsequent washout in endoscopic hysterectomy: ICG-Washout method

INTRODUCTION

Despite a potential risk of bladder injury in laparoscopic hysterectomy (LH) and robot-assisted LH (RaLH), an intraoperative method for delineating the entire bladder with indocyanine green (ICG) has not been established.

METHODS

We conducted a preliminary experiment using porcine bladders to verify the appropriate amount of ICG for intraoperative bladder visualization. Afterward, intraoperative bladder visualization was tried in LH and RaLH in two patients suspected of having adhesions around the bladder after previous abdominal surgery.

RESULTS

Although near-infrared (NIR) fluorescence was well observed through the wall of the porcine bladder filled with ICG solution at a concentration of 0.024 mg/mL, the subsequent replacement of the ICG solution with saline made the NIR fluorescence brighter. In both patients, the bladder was successfully delineated by NIR fluorescence after filling the bladder with ICG solution and the subsequent washout with saline.

CONCLUSION

The ICG-Washout method for locating the bladder by NIR fluorescence could be useful in LH and RaLH.

A delayed diagnosis of iatrogenic ureteral injury results in increased morbidity

This study aimed to register and analyse outcomes after iatrogenic ureteral injuries (IUI) with special emphasis on potential consequences of a delayed diagnosis, and further to analyse if the incidence of IUI has changed during the study period. 108 patients treated for an IUI during 2001-2021 were included. Injuries due to endourological procedures, planned tumour resection and traumatic injuries were excluded. All relevant information to answer the research questions were entered into a database. Chi-square and t-tests were used for categorical and continuous variables respectively. Regression analysis was used to evaluate potential change of incidence in IUIs over time. Our results showed that most IUIs (74, 69%) were caused by gynaecological surgery. 49 (45%) had a delayed diagnosis (not diagnosed intraoperatively). Younger age (mean 50 vs 62 years, p < 0.001) and benign indication for laparoscopic hysterectomy (OR 8.0, p < 0.001) predisposed for a delayed diagnosis. Patients with a delayed diagnosis had a higher number of secondary injury related procedures (mean 4.6 vs 1.7, p < 0.001), hospital admissions (mean 3.0 vs 0.8, p < 0.001) and longer hospital stays (mean 20.6 vs 3.9 days p < 0.001) compared to patients with an intraoperative diagnosis. There was complete recovery for 91% of the patients. We did not observe any changes in IUI incidence during the study period. In conclusion, our study underlines that IUI can cause major morbidity for the patient affected if not diagnosed intraoperatively. Benign indication and younger age are predictors for a delayed diagnosis. The prognosis is good, with 91% full recovery. No significant changes in incidence of IUIs were observed.

Urinoma Masquerading as Post-hysterectomy Hematoma: The Role of Accurate Diagnosis and Imaging-Guided Intervention

Although rare, ureteric injuries can occur during gynecological surgical interventions, and their diagnosis can be challenging, especially when delayed. If left untreated, missed ureteric injuries can lead to severe complications, including prolonged hospitalization, sepsis, renal damage, and potentially even loss of the affected kidney. We present a unique case of a urinoma caused by bilateral ureteric injuries following abdominal hysterectomy, which was initially misdiagnosed as an intraperitoneal hematoma. However, further radiological investigations enabled accurate diagnosis without the need for exploratory laparotomy, demonstrating the importance of thorough evaluation for all possible complications in patients presenting with post-operative issues. In cases of pelvic collections of unclear origin or ureteric injury, a computed tomography (CT) scan is the gold standard diagnostic modality, providing precise diagnosis and expedited management.

vNOTES hysterectomy using the lateral window technique in case of a ventrofixed uterus following previous cesarean sections: A video article

vNOTES uses the vagina as the surgical channel for endoscopy and achieves improved cosmesis compared to conventional laparoscopy as there are no abdominal incisions. Ventrofixation of the uterus to the abdominal wall following previous cesarean sections further adds to the surgeon's concern of bladder injury. In such cases, a modification of the technique is proposed: introducing the vNOTES port first, before the opening of the vesico-uterine peritoneal folds, thus carried out under endoscopic view. Medial anterior vesico-uterine adhesions are identified and circumscribed by creating a lateral window in the broad ligament on both sides. This allows the cutting of adhesions under endoscopic view to minimize the risk of bladder injuries. The aim of this technical note is to present this modification of the surgical technique for vNOTES hysterectomy in case of ventrofixed uterus.