Assessment of Risk Factors for Iatrogenic Genitourinary Injuries During a Proctectomy

BACKGROUND

It is critical to avoid iatrogenic injuries affecting genitourinary organs in order to prevent postoperative urinary or sexual dysfunction, which lead to lengthier recovery and possibly reoperation.

METHODS

Using the 2016-2019 American College of Surgeons National Quality Improvement Program (ACS NSQIP) Targeted Proctectomy Database, we collated 2577 patients with non-metastatic rectal cancer who underwent a laparoscopic or open proctectomy. Univariate analysis was used to identify differences in perioperative factors and genitourinary injuries (GUIs) between operative approaches, and multivariate logistic regression was used to identify independent risk factors for sustaining an intraoperative GUI.

RESULTS

The rates of preoperative comorbidities were significantly higher among patients who received an open operation. The proportion of GUIs was also significantly higher in this patient population. Multivariate logistic regression demonstrated that patients who underwent a laparoscopic proctectomy were associated with a 51.4% lower risk of sustaining a GUI. Furthermore, >10% body weight loss in the past 6 months and ASA class 3 status were independently associated with a higher risk of GUI regardless of operation type.

CONCLUSION

Patients who undergo a laparoscopic proctectomy are associated with a lower risk of GUI. On the other hand, patients with >10% body weight loss and ASA class 3: Severe Systemic Disease were associated with a higher risk of GUI.

Prophylactic ureteral stent placement for the prevention of genitourinary tract injury during hysterectomy for placenta accreta spectrum: systematic review and meta-analysis

OBJECTIVE

This study aimed to assess the effectiveness of prophylactic ureteral stent placement for the prevention of genitourinary tract injury at the time of cesarean hysterectomy for placenta accreta spectrum. The secondary objectives were to assess mean blood loss, operative time, number of packed red blood cells transfused, and rates of urinary tract infection among patients undergoing cesarean hysterectomy for placenta accreta spectrum with and without prophylactic ureteral stent placement.

DATA SOURCES

The search was performed using PubMed, Cochrane Library, and ClinicalTrials.gov from inception to February 2022 to December 2022. The protocol for this review was registered with the International Prospective Register of Systematic Reviews before data collection (registration number: CRD42022372817).

STUDY ELIGIBILITY CRITERIA

All studies that examined differences in the rate of genitourinary tract injury among women undergoing cesarean hysterectomy for prenatally suspected placenta accreta spectrum with and without placement of prophylactic ureteral stents were included. Genitourinary injury was defined as cystotomy, ureteral injury, and/or bladder fistula. Cases of both intentional and unintentional genitourinary injuries were included in the analysis.

METHODS

For all studies meeting the inclusion criteria, the following data were extracted: number of included patients, maternal demographic information, obstetrical history, type of invasive placentation, placement of stents (yes or no), type of stent placed, blood loss, operative time, genitourinary tract injury, and urinary tract infection. Pooled data analysis was completed using the Review Manager (version 5.3; Nordic Cochrane Centre, Copenhagen, Denmark; Cochrane Collaboration, 2014). The summary measures were reported as summary relative risk or as summary mean difference. The quality and risk of biases of the included studies were assessed according to the Newcastle-Ottawa Scale.

RESULTS

Overall, 9 studies, including 848 patients, fulfilled our inclusion criteria and were included in our analysis. Moreover, 523 patients (61.7%) had prophylactic ureteral stents placed, and 325 patients (38.3%) did not. Genitourinary injury occurred in 138 of 523 patients (26.4%) in the ureteral stent group vs 83 of 325 patients (25.5%) in the no ureteral stent group (relative risk, 0.94; 95% confidence interval, 0.74-1.20). The mean number of packed red blood cells transfused did not differ between the 2 groups. The pooled analysis demonstrated decreased blood loss among patients who received prophylactic ureteral stents, with a mean difference of 392 mL (95% confidence interval, 52.74-738.13).

CONCLUSION

Our systematic review and meta-analysis demonstrated no difference in the rates of genitourinary tract injury with the use of prophylactic ureteral stent placement among cases of prenatally suspected placenta accreta spectrum undergoing cesarean hysterectomy.

Genitourinary Considerations in Reoperative and Complex Colorectal Surgery

Genitourinary structures are at risk of injury during colorectal surgery. The incidence of injury is low; however, the risk is higher in cases involving severe inflammatory or infectious processes, locally advanced or recurrent cancer, previous radiation, and reoperation. Consideration of the anatomical relationship between the genitourinary system, and the colon and rectum is crucial to avoid injuries. Intraoperative diagnostic techniques such as intravenous pyelogram (IVP), fluoroscopic cystogram, or retrograde urethrogram can aid in identifying suspected injuries. Early recognition and repair of injuries decrease the morbidity of an injury. Repair of injuries depends on the location and extent of the injury. Simple injuries may be repaired primarily, while complex injuries may require more advanced repairs such as a flap reconstruction.