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Minimising urinary tract injury at gynaecological surgery for benign disease (1038)

Objectives

To provide guidance for those undertaking benign gynaecological procedures where there is a risk of urinary tract injury.

Scope

All healthcare professionals undertaking gynaecological procedures where there is a risk of urinary tract injury

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Background and rates of injury

Injury to the urinary tract at benign gynaecological surgery is uncommon as defined by the RCOG (1).

A systematic analysis found the rate of urinary tract injury in laparoscopic surgery for benign  gynaecological operations to be 3.3/1000.

Urinary tract injury is however more common at hysterectomy. RCOG consent advice (3) recommends quoting a rate of urinary tract injury of 7/1000 for abdominal hysterectomy procedures.

A retrospective study of almost 1000 hysterectomies for benign conditions in NHSGGC found the following rates of urinary tract injury (presented at ESGE 2018)

Rate of injury to bladderRate of injury to uterer
Laparoscopic hysterectomy1.3%1.9%
LAVH1%3%
Open hysterectomy0.8%0.6%

A retrospective analysis performed by the BSGE found a ureteric injury rate of 0.5% in excision of deep infiltrating endometriosis at endometriosis centres in the UK with 9.2% of procedures requiring stent insertion. (4)

Bladder injury is typically by incision of the bladder and is usually recognised at operation. Ureteric injury can occur by angulation, crushing, resection, division or damage by heat or devascularisation and may be less likely to be unrecognised (5). Ureteric injury may present late with urinary leakage being delayed after thermal or vascular damage with no apparent injury at the time of operation.

Pre-operative considerations

Alternatives to surgery should be discussed with each patient who is considering surgery.

The consent process should note any factors that may increase the rate of urological tract injury and this should be explicit in the consent process, such as but not exclusively:

Patient factors: BMI, previous pelvic surgery, previous caesarean section.

Pathology factors: pelvic abscess or endometriosis, malignancy, known hydronephrosis.

Pre-operative imaging to exclude hydronephrosis or hydroureter should be performed if there is disease suspected in the lateral pararectal fossa or a large pelvic mass. If hydronephrosis is confirmed on imaging then renography with MAG3 scanning should be performed to assess renal function. Pre-operative stent insertion should be considered and referral to urological colleagues made if hydronephrosis is confirmed or if disease processes involve the ureter.

Pre-operative request for urological opinion should be sought in these patients:

  1. Previous ureterolysis when operating in the lateral pararectal fossa is anticipated.
  2. Known hydronephrosis
  3. Known disease involving the ureter. Specialist urological radiology reporting may be needed in complex pathology.

Intraoperative considerations

The urinary bladder should be emptied to reduce the risk of urinary tract injury.

There is a difference in approach between gynaecologists and urologists when operating in proximity to the ureter. Gynaecologists do not use ureteric stents routinely when operating within the lateral pararectal space. It is recognised common gynaecological practice to visually identify the ureter prior to clamping and ligating pedicles (or using instruments for vessel sealing) or applying surgical heat at operation. Ureterolysis is performed by gynaecologists for up to 10cm of ureteric length without stent insertion. Surgeons should be familiar with the thermal effects of any energy device employed during surgery (6)

Ureteric stenting may reduce ureteric injury in two ways. Firstly it may help to identify the ureter if there is difficulty in visual identification. Secondly stenting may reduce ureteric injury leading to leakage when there has potentially been thermal or vascular damage to the ureter. Stenting may reduce the risk of hydronephrosis due to angulation injury. However stenting may alter the anatomy of the lateral pararectal fossa by straightening the ureter to a more medial position.

Urological colleagues are always happy to assist with stent insertion. Requests for an intraoperative urological opinion should be sought in these patients:

  1. If the ureter cannot be identified. Insertion of a temporary ureteric catheter may help a gynaecologist who is competent with their use to identify the ureter but may not protect against later ureteric leakage if there has been damage to the vascular supply to the ureter or thermal injury to it.
  2. If there is a bladder injury and the gynaecological surgeon does not have expertise to close the bladder.
  3. Any bladder injury where injury to the trigone is suspected.
  4. Any suspected ureteric injury.

Post-operative consideration

In patients who experience a urological complication of gynaecological surgery their operating gynaecology consultant should be the point of contact for urological colleagues.

A follow up appointment should be requested with the operating gynaecology surgeon via their secretary on patient discharge.

Editorial Information

Last reviewed: 14/07/2022

Next review date: 14/07/2027

Author(s): Chris Hardwick.

Version: 1

Approved By: Gynaecology Clinical Governance Group

Document Id: 1038

References

1. RCOG Clinical Governance Advice No. 7
2. Wong, Jacqueline M. K. MD; Bortoletto, Pietro MD; Tolentino, Jocelyn MD, MPH; Jung, Michael J. MD, MBA; Milad, Magdy P. MD, MS Obstetrics & Gynecology. 131(1):100-108, January 2018
3. Abdominal Hysterectomy for Benign Conditions (Consent Advice No. 4) (rcog.org.uk)
4. e018924.full.pdf (bmj.com)
5. Minas V, Gul N, Aust T, Doyle M, Rowlands D. Urinary tract injuries in laparoscopic gynaecological surgery; prevention, recognition and management. The Obstetrician & Gynaecologist 2014;16:19–28.
6. Bentham GL, Preshaw J. Review of advanced energy devices for the minimal access gynaecologist. The Obstetrician & Gynaecologist 2021;23:301–9. https://doi.org/10.1111/tog.12774