Tuesday, August 14, 2012
Urinary Tract Complications/Injury after Laparoscopic Hysterectomy
Gynecologic surgery is performed for many reasons, such as cervical, uterine or ovarian cancer, abnormal or severe menstrual bleeding, ovarian cysts, pelvic pain, large fibroids and endometriosis. Urological or urinary tract injury can be a serious complication of these surgeries and can lead to significant morbidity, loss of work time and permanent injury or need for corrective surgery. Laparoscopic surgery is a great advance and is used in gynecology as well as other specialties and affords great benefit to the patient such as: less post-operative pain, quicker recovery, shorter hospital stay, better cosmetic results, and quicker return to work. However it can be technically challenging, and may not be appropriate for all gynecological surgery. Such complications can even occur in the most experienced hands. The key to treatment is early appreciation, identification, and correction of injuries to minimize long term problems.
What are some of the most common complications that can occur?
The most common organ to be injured is the bladder. It is a floppy, hollow organ that lies on top of the vagina and must be separated from it during hysterectomy. The bladder can be inadvertently entered leading to a “hole” that requires closure. This injury is often recognized right away and can be easily closed in most cases, but it does require a bladder catheter to drain the bladder and allowing healing for at least a week.
The ureters are delicate thin tubes carrying urine from the kidneys to the bladder. Unfortunately, often these can be missed, misidentified and injured inadvertently during hysterectomy or ovary removal. They run beneath important arteries to the uterus. They can be cut, incorporated in sutures, or injured by heat/cautery. Often ureter injury in not appreciated right away and most commonly presents as pain, or obstructed kidney function, fever, flank pain or a combination of these several days after surgery. If the injury is recognized at the time of gynecological surgery the ureter can be repaired, but if the injury is noted later then the ureter or kidney on the affected side will require drainage with a tube or stent to allow for surgical inflammation to resolve over time and then delay repair the ureter till a later time.
Sometimes, and more rarely, if the bladder or ureter are injured by heat or incorporated into suturing of the vagina during surgery, a fistula can develop a week or so after surgery. The abnormal fistulous connection between the bladder/ureter and vagina will present sometimes with pain, blood in the urine and fever, but will most often present with fluid leaking from the vagina; this fluid being urine. A thorough exam of the vagina, bladder exam with x-ray and scope, and ureters with x-ray as well, all must be undertaken to determine where and how many injury points exist. Repair of the damaged ureter or bladder is then undertaken.
It is prudent and important for the female patient to ask her gynecologist prior to surgery which surgical approach is better or safer- this will depend on the problem at hand, how experienced the doctor is and what type of patient characteristics may predispose to injury.
An open incision for surgery may take longer to heal but if large fibroids are present or severe endometriosis exists, it may be safer. If the cervix is cancerous but not bulky, a laparoscopic surgery may do just fine. Laparoscopic surgery requires a special skill set and is itself a minor risk for urological injury. Large patient body size/high BMI, prior C-section, multiple fibroids, pelvic adhesions and severe endometriosis are considered risks during laparoscopic surgery. That is not to say that these injuries cannot occur if the surgery is done “open”, as they certainly can and unfortunately do occur from time to time.
The best defense is a good offense. Select the appropriate surgeon, review the best method of surgery based on the disease and patient limitations. And, don’t be afraid to ask how many cases a surgeon has done.
Posted by Matthew E. Karlovsky, M.D. at 10:05 PM