Urinary tract injuries in laparoscopic gynaecological surgery; prevention, recognition and management

Case Report: Iatrogenic trauma of the bladder due to long-term unidentified intrauterine device malposition inside the bladder with rectovesical fistula

According to reports, there are 1.9-3.6 incidences of IUD migration and uterine perforation for every 1000 IUD insertions. It is important to note that bladder perforation caused by a misplaced IUD is uncommon and is thought to happen most frequently during insertion. Here, we describe a patient who presented with symptoms related to the malposition of IUD inside the bladder. It is feasible to draw the conclusion that the cystoscopy technique should be taken into consideration as a suitable therapy option for such injuries in this organ. When a problem cannot be effectively treated by cystoscopy alone, laparotomy should be considered.

Pre-operative ureteric catherisation for major endoscopic gynaecological surgery

BACKGROUND

Several strategies have been implemented to better identify the course of the ureters intra-operatively due of the morbidity associated with ureteric injuries especially during gynaecological surgery. We described our experience with pre-operative ureteric catherisation in women who underwent major endoscopic gynaecological surgery.

METHODS

A case-controlled study of 862 women who underwent major endoscopic gynaecological surgery sourced from two health institutions were conducted. Two groups were compared: those who had pre-operative prophylactic ureteric catherisation (study group) and those who had routine cystoscopy performed immediately post surgery (control group).

RESULTS

There were no intra-operative ureteric injuries or associated complications noted in the study group. When compared to the control group, length of hospital stay (2 days vs 5 days; p < 0.05) and overall mean time for cystoscopy (11 min vs 35 min; p < 0.05) was significantly shorter in the study group. There was no long-term morbidity recorded in the study group.

CONCLUSION

Our experiences with prophylactic pre-operative bilateral ureteric catheterisation for major endoscopic gynaecological surgeries were favourable and are associated with low complication rates. Routine or adjunct use before major gynaecological and pelvic surgery combined with meticulous surgical technique can help reduce iatrogenic and unintentional ureteric injuries.

Abordaje laparoscópico exitoso de lesión vesical intraperitoneal ocasionada durante una cirugía ginecológica. Reporte de caso

Introduction: Urinary tract injuries are common in the context of pelvic surgery; however, there is little information in the medical literature on the management of these injuries using a laparoscopic approach. The following is the clinical case of a patient with intraperitoneal bladder injury secondary to gynecological pelvic surgery that was successfully treated using a laparoscopic approach. Moreover, a management algorithm is proposed based on the scientific data available. Case report. A 39-year-old female patient was admitted to the hospital with generalized abdominal pain and anuria three days after undergoing a left laparoscopic salpingectomy and resection of a migrated intrauterine device. Laboratory tests showed microhematuria, serum creatinine of 4.35mg/dL, and urea nitrogen of 35.2mg/dL. Computed tomography cystography showed a solution of continuity on the left posterolateral intraperitoneal bladder. The patient underwent successful laparoscopic treatment for the bladder injury, and two weeks later, retrograde cystography confirmed its adequate resolution. Conclusions. Based on the benefits of the laparoscopic approach and after extrapolating the outcomes of the laparoscopic management of bladder trauma, it can be concluded that the laparoscopic approach to surgical injuries of the bladder is a feasible therapeutic option.

X-ray-activated persistent luminescence nanomaterials for NIR-II imaging

Persistent luminescence is not affected by background autofluorescence, and thus holds the promise of high-contrast bioimaging. However, at present, persistent luminescent materials for in vivo imaging are mainly bulk crystals characterized by a non-uniform size and morphology, inaccessible core-shell structures and short emission wavelengths. Here we report a series of X-ray-activated, lanthanide-doped nanoparticles with an extended emission lifetime in the second near-infrared window (NIR-II, 1,000-1,700 nm). Core-shell engineering enables a tunable NIR-II persistent luminescence, which outperforms NIR-II fluorescence in signal-to-noise ratios and the accuracy of in vivo multiplexed encoding and multilevel encryption, as well as in resolving mouse abdominal vessels, tumours and ureters in deep tissue (~2-4 mm), with up to fourfold higher signal-to-noise ratios and a threefold greater sharpness. These rationally designed nanoparticles also allow the high-contrast multiplexed imaging of viscera and multimodal NIR-II persistent luminescence-magnetic resonance-positron emission tomography imaging of murine tumours.

Use of indwelling catheters and preventing catheter-associated urinary tract infections

Indwelling urinary catheters are considered an important healthcare intervention for many patients. However, these devices must be used with caution because they are associated with a risk of various potential complications such as catheter-associated urinary tract infections (CAUTIs), as well as a financial burden for healthcare organisations. This article outlines the various types of indwelling catheter that are available, explains the reasons for their use, and details the care required to prevent associated complications, particularly CAUTIs.

A zwitterionic near-infrared fluorophore for real-time ureter identification during laparoscopic abdominopelvic surgery

Iatrogenic injury of the ureters is a feared complication of abdominal surgery. Zwitterionic near-infrared fluorophores are molecules with geometrically-balanced, electrically-neutral surface charge, which leads to renal-exclusive clearance and ultralow non-specific background binding. Such molecules could solve the ureter mapping problem by providing real-time anatomic and functional imaging, even through intact peritoneum. Here we present the first-in-human experience of this chemical class, as well as the efficacy study in patients undergoing laparoscopic abdominopelvic surgery. The zwitterionic near-infrared fluorophore ZW800-1 is safe, has pharmacokinetic properties consistent with an ideal blood pool agent, and rapid elimination into urine after a single low-dose intravenous injection. Visualization of structure and function of the ureters starts within minutes after ZW800-1 injection and lasts several hours. Zwitterionic near-infrared fluorophores add value during laparoscopic abdominopelvic surgeries and could potentially decrease iatrogenic urethral injury. Moreover, ZW800-1 is engineered for one-step covalent conjugatability, creating possibilities for developing novel targeted ligands.

Iatrogenic injury of the ureters is a feared complication of laparoscopic abdominal surgery. Here the authors present the NIR fluorophore ZW800-1 as an intraoperative imaging agent for ureter mapping, showing its safety, pharmacokinetic properties, and efficacy in healthy volunteers and patients undergoing abdominopelvic surgery.

Laparoscopic excision of deeply infiltrating endometriosis: a prospective observational study assessing perioperative complications in 244 patients

PURPOSE

To examine peri-operative complications in patients undergoing laparoscopic excision of deeply infiltrating endometriosis (DIE).

METHODS

This was a prospective study of a case series of women having laparoscopic excision of deeply infiltrating endometriosis from September 2013 through August 2016 in a tertiary referral center for endometriosis and minimally invasive gynaecological surgery in Iran. Data collected included demographics, baseline characteristics, intraoperative and postoperative data up to 1 month following surgery.

RESULTS

We analysed data from 244 consecutive patients, who underwent radical laparoscopic excision of all visible DIE. Major postoperative complications occurred in 3 (1.2%) and minor complications in 27 (11.1%) of patients. 80.3% of our patient group had Stage IV endometriosis. Segmental bowel resection was performed in 34 (13.9%), disc resection in 7 (2.9%), rectal shave in 53 (21.7%). Joint operating between a gynaecologist and colorectal and/or urological colleague was required in 29.6% of cases. The mean operating time was 223.8 min (± 80.7 standard deviation, range 60-440 min) and mean hospital stay was 2.9 days (± 1.5 standard deviation, range 1-11). The conversion to laparotomy rate was 1.6%.

CONCLUSIONS

A combination of different laparoscopic surgical techniques to completely excise all visible DIE, within the context of a tertiary referral center offering multi-disciplinary approach, produces safe outcomes with low complication rates.

Novel Role of Dehydrated Human Amnion/Chorion Membrane in Healing of Denuded Ureter in Robot-Assisted Excision of Endometriosis

Ureteral injury is an uncommon but potentially morbid complication following any open or endoscopic pelvic procedure. Gynecologic surgeries alone make up 50 percent of nonurologic ureteral injuries leading to prolonged hospital stays, secondary interventions, and potential loss of renal function. The use of AmnioFix ® a processed dehydrated, immunologically privileged cellular amniotic membrane allograft has been well established in urologic and gynecologic procedures. These allografts contain human extracellular matrix components, growth factors, and cytokines that mediate inflammation and facilitate would healing. We report the first application of AmnioFix on a denuded ureter during a case of robotic-assisted excision of endometriosis. We include a literature review and discussion on the management outcomes of iatrogenic injury to the ureters.

The incidence, causes, and management of lower urinary tract injury during total laparoscopic hysterectomy

OBJECTIVES

Determining the incidence and causes of lower urinary tract injury in patients undergoing total laparoscopic hysterectomy and examining the procedures applied for management.

METHODS

Patients who underwent total laparoscopic hysterectomy in a large referral center between 1 January 2015 and 31 October 2017 for benign gynecological reasons were included in the study. Patients who underwent laparoscopic supracervical hysterectomy, laparoscopy-assisted vaginal hysterectomy and robot-assisted laparoscopic hysterectomy were not included in this study. The hospital records of all patients included in the study were examined and the incidence, causes and management of lower urinary tract injuries were reviewed.

RESULTS

Total lower urinary tract injury rate was found as 2.01%, and these injuries were evaluated separately as bladder and ureter injuries. All the bladder injuries had occurred on the posterior wall of the bladder during vesicouterine dissection; six cases were intraoperatively detected and one case was detected on the first postoperative day. Most of ureteral injury cases were detected in the early postoperative period (75%). The rates of previous cesarean section and endometriosis were significantly higher in patients with injury to the bladder and ureter than in the control group (p<0,001). There was no significant difference between the patients with lower urinary tract injury and the control group regarding uterine weight, estimated blood loss, bilateral salpingo-oophorectomy, the presence and location of fibroids, and laparoscopic or vaginal closure of the vaginal cuff.

CONCLUSION

Laparoscopic hysterectomy may be a good option in appropriate patients, but in case of previous cesarean section and endometriosis cases, patients should be informed about the possible complications in detail before the operation and care should be taken during dissection.

Urinary ascites in late onset of bladder injury post laparoscopic hysterectomy

Urinary tract injuries are unfortunate complications of pelvic surgery. With the increasing popularity of minimally invasive surgery, a thorough understanding of electrosurgical instrumentation and their thermal spread is important to reduce patient injuries. The index patient was a 50 year old woman who underwent a supracervical hysterectomy 5 years prior to her presentation with pelvic pain and dysuria. When her symptoms failed to improve despite antibiotic and analgesic therapy, an abdominal CT scan revealed an ovarian cyst and ascites. A subsequent laparoscopy disclosed the presence of a bladder fistula and a diagnosis of urinary ascites was made. The patient then underwent a subsequent bladder fistula repair. Vesicoperitoneal fistulae (VPF) are rare and should be included in the differential diagnosis of the patient with acute onset ascites following gynecologic surgery. This case is the first case report of a VPF occurring 5 years following surgery.