Gynaecology surgery is the commonest cause of iatrogenic injury of the urinary tract. There is a need to minimize this risk with rapidly evolving surgical techniques and gynaecological training involving lesser surgical experience compared to previous years. Ureteric injury can often be unrecognized
and results in prolonged morbidity and potential loss of organ function. Risk factors exist in most cases and injuries may be avoidable by preoperative assessment and meticulous surgical technique. Counselling
patients regarding potential injury is important especially if there are pre- existing risk factors. A high index of suspicion and prompt evaluation may improve immediate recognition and thereby improve prognosis. Any
delay in postoperative recovery especially with flank pain should raise the suspicion of urinary tract injury and prompt diagnostic evaluation should be undertaken. Surgical repair should be done by specialists with sufficient expertize and woman should be debriefed and followed up to improve patient satisfaction and reduce litigation rates.
Introduction
Incidence
Risk factors for urinary tract injuries
C Patient related factors
Previous pelvic surgery
Pelvic inflammatory disease
Large pelvic mass
Endometriosis
Pelvic irradiation
Obesity
Adhesions
Urinary tract abnormalities
C Procedure related factors
Laparoscopic hysterectomy
Malignancy
Pelvic reconstructive surgery
C Surgeon related factors
Experience of the surgeon
Learning curve
Fatigue
C Combined factors
Excessive blood loss
Length and difficulty of operation
Emergency procedure
Pathogenesis
Prevention of urinary tract injuries
Immediate presentation
Delayed presentation
Management
Ureteric injuries
Bladder injury
Urethral injury
Medicolegal implications of urinary tract injuries
Conclusion
Even though the incidence is low, urinary tract injury will remain
one of the inevitable risk of gynaecology surgery. Preoperative
risk factors exist in most cases and preoperative identification of
these will help in patient counselling and planning. Cystoscopy
reduces the incidence of postoperative presentation of urinary
tract injury; therefore training gynaecologists in this procedure is
beneficial and cost effective. It is difficult to defend an injury
which occurred in the presence of normal anatomy especially if
there was failure of recognition during the operation.