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Fistulas, bladder and ureteral damage: postoperative incontinence? Check for injuries.

BALTIMORE -- Have a high index of suspicion when it comes to injuries during pelvic surgery, Dr. Jerry Blaivas said at a urogynecology meeting sponsored by Johns Hopkins University.

Bladder injuries, fistulas, and ureteral injuries are among the common complications of urologic surgery that can result in incontinence.

"If you even think about the fact that you might have injured the bladder, rule it out, either by looking at it or by testing it," said Dr. Blaivas of Cornell University, New York.

If a patient is incontinent after an operation, have a high index of suspicion and check not only for fistulas, but also for prolapse. Dr. Blaivas said that he finds a bilateral retrograde pyelogram worthwhile even if it identifies one ureteral injury in 100 noninjured patients. Be positive that the ureters have not been injured because if they are, they must be repaired, he added.

For vesical injuries identified during surgery. Dr. Blaivas said he closes the bladder with a single running inverted layer of absorbable sutures. Make sure bladder drainage is adequate, and conduct a cystogram approximately 1 week after surgery, he said. He prefers the Connell stitch: sewing from the outside of the bladder to the inside of the bladder, then out, then over to the other side, and then from the outside to the inside again. This technique inverts the entire bladder in a single layer.

Urinary fistulas may be vesicovaginal, ureterovaginal, urethrovaginal, vesicouterine, or colovesical. Most fistulas stem from abdominal hysterectomies. Dr. Blaivas said he finds that a cystoscopy is the best way to diagnose a fistula. Associated pathology includes sphincteric abnormalities, secondary fistulas, urethral defects, and ureteral fistulas or obstructions.

As to the timing of surgery for a fistula, there is usually no need to wait longer than it takes for the site to be free of active inflammation or infection. If the fistula is small, however, postponing surgery for a month may allow it to heal on its own.

Vaginal repairs can be performed in most cases, but abdominal repair is indicated in cases of a ureteral fistula or obstruction, a small or scarred vagina, vesicoureteral reflux, and concomitant abdominal pathology.

The operative technique for a vaginal repair begins with dilation of the fistula, then passage of a Foley catheter through the fistula, and putting traction on the Foley catheter. The purpose of the catheter is to put traction on the fistula and pull it into the wound to allow good exposure. Next, a circumferential incision is made around the fistula and the flaps are dissected. Once the fistula appears in the operative field and is excised, close the fistula in layers, using a Martius, labial, or gracilis flap.

Dr. Blaivas reported that this technique resulted in a success rate of greater than 90% in several published series.

The main reasons repairs fail are technical, such as failure to mobilize the bladder, failure to attain tension-free closure, and failure to position the Martius flap at the distal margin of the fistula repair.

Ureteral injuries can also occur during urologic surgery, a hysterectomy, or a laparoscopic or endoscopic procedure. Predisposing factors for ureteral injury include prior pelvic surgery, cancer surgery, or endometriosis. Mechanisms of injury include crushing from a clamp, ligation with a suture, transsection or resection, and ureteral or periureteral scarring.

Patients with a ureteral injury after surgery may complain of flank pain, abdominal distention, nausea and vomiting, and incontinence, and they may present with elevated blood urea nitrogen and creatinine levels.

Initial management of these problems includes a CT scan to confirm the injury, followed by a retrograde pyelogram to delineate the anatomy for possible stent placement. Stents may solve the problem, but their success depends on the degree of obstruction, suture material, nutritional status, and bladder management. Alternatives to a stent include primary ureteroneocystostomy using a Boari flap or psoas hitch.


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Title Annotation:Gynecology
Author:Splete, Heidi
Publication:OB GYN News
Date:Jul 1, 2004
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