Urinary Tract Injury in Gynaecological Surgery
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Direct answer
Urinary tract injury in gynaecological surgery is most often bladder injury during hysterectomy or caesarean section, while ureteric injury is less common but more serious when unrecognised. Bladder injury is usually recognised during surgery and repaired in two layers with catheter drainage. Ureteric injury often presents late with a fistula, obstruction or loss of renal function, and intra-operative dye tests and cystoscopy give the best chance of early recognition.
What you must remember
- Bladder injury: the commonest urinary injury, most often during hysterectomy or caesarean, and often recognised at surgery by haematuria or a visible defect.
- Ureteric injury: most often near the cervix during hysterectomy, where the ureter lies beside the uterine artery, and often unrecognised until fistula or obstruction develops.
- Bladder testing: retrograde filling with saline and dye such as methylene blue or fluorescein shows leakage from a defect.
- Ureteric testing: cystoscopy after intravenous fluorescein shows bilateral ureteric jets, and an absent jet on one side is a warning sign.
- Clinical clues: persistent leakage after surgery, a fall in urine output, flank pain or a rising creatinine suggest ureteric injury and need urgent imaging.
- Repair principles: the bladder is closed in two layers with fine absorbable suture and drained by catheter, while ureteric repair depends on the site and length, from stenting to end-to-end anastomosis or reimplantation.
A stepwise response to suspected ureteric injury
A 41-year-old woman has a total abdominal hysterectomy for a large fibroid uterus. On day three she has a constant leak of urine per vagina and a rising creatinine. The steps below show the usual approach from detection to repair.
- Suspect at surgery: Check the bladder and ureters when dissection is near the bladder base, broad ligament or cervix, especially with adhesions or distorted anatomy.
- Test the bladder: Fill the bladder retrogradely with saline and dye, with methylene blue or fluorescein, and look for leakage at the dissected area.
- Check the ureters: Cystoscopy after intravenous dye shows whether urine is seen from both ureteric orifices, and any absent jet needs investigation.
- Repair the bladder: Close in two layers with fine absorbable suture, and keep an indwelling catheter for about one to two weeks before a check cystogram.
- Repair the ureter: Choose a stent or end-to-end anastomosis for short injuries, and a psoas hitch, reimplantation or Boari flap for lower or longer defects, with a stent left for several weeks.
- Follow up: Monitor renal function and ultrasound for hydronephrosis, and refer early for urological input if a fistula develops.
Where the exam tries to catch you
Examiners test whether you recognise delayed presentations and choose the right test and repair.
- Trap: Leave a bladder defect unrepaired because it seems minor at caesarean. Correct: Any identified bladder injury must be repaired and tested, because leakage causes fistula and infection.
- Trap: Ignore an unexplained fall in urine output after hysterectomy. Correct: Reduced urine output, flank pain or a rising creatinine suggest ureteric ligation or injury and need prompt imaging.
- Trap: Attempt a simple suture repair of a transected ureter without expertise. Correct: Ureteric transection needs specialist repair, often with urology input and a stent, to avoid stricture.
- Trap: Treat a persistent leak as an ordinary wound problem. Correct: A vesicovaginal or ureterovaginal fistula needs imaging and dye studies to define it before definitive repair.
Frequently asked questions
What is the commonest urinary tract injury in gynaecological surgery?
Bladder injury is the commonest urinary tract injury in gynaecological surgery, most often occurring during hysterectomy or caesarean section. It is frequently recognised at surgery and can usually be repaired during the same operation.
Which intra-operative test confirms a bladder injury?
Retrograde filling of the bladder with saline and dye, such as methylene blue or fluorescein, confirms a bladder injury by showing leakage from the defect. Cystoscopy is also useful to assess both bladder integrity and ureteric efflux.
How is ureteric injury usually recognised after hysterectomy?
Ureteric injury after hysterectomy often presents late, with a fall in urine output, flank pain, a rising creatinine or a vaginal leak from a fistula. Imaging and dye studies then localise the defect, and early suspicion improves the outcome.
What is the usual approach to repairing a ureteric injury?
The repair depends on the site and length of the ureteric injury, with options including stent placement, end-to-end anastomosis and reimplantation. Specialist urology or gynaecology input is usually needed, and a stent is typically left in place for several weeks afterwards.