Surgical Injury, Part I: Bladder Injuries

/

Oh no…

  • Surgical injuries happen in OB/GYN. As you’ve probably shared in your surgical informed consent discussion previously, we often talk about risks like:

    • Bleeding

    • Infection

    • Damage to surrounding structures.

  • The “surrounding structures” are typically:

    • Bladder

      • Most common injury

      • ~0.3% of cesarean deliveries; ~1% of major GYN surgery

    • Bowel

      • Less than 1% of GYN surgeries

    • Ureters

      • About 0.5% of GYN surgeries

  • The best prevention for injury is preparation - know your anatomy!

What are risk factors to intraoperative injury?

  • Anything that increases surgical complexity, essentially!

    • More extensive “bigger” surgeries - hysterectomy in particular

    • Obesity

    • Age or chronic medical conditions that might limit exposure

      • Particularly in laparoscopy (i.e., less distension ability)

    • Emergent surgeries - more frequent bladder injuries in STAT cesareans, 2nd stage arrests

    • Adhesive disease from prior surgeries, infections, trauma, etc.

    • Patients with congenital or acquired anatomic differences

    • Oncology - invasive disease and altered vasculature/structures 

What should I do when I identify something that is / may be injured?

  • If safe to do so: pause and evaluate

  • Call for assistance: senior colleagues, consultants as needed

  • If awaiting assistance but need to move on (i.e., bleeding accreta case) – can use “tagging suture” to mark area of concern

    • Bladder / bowel: place a small, brightly-colored suture (i.e., dyed 2-0 or 3-0 Polysorb/Vicryl) and leave a long tail at the suspected site of injury, so it’s easy to find later on.

  • Try to identify the mechanism and extent of an injury:

    • Is it just a serosal tear, or was mucosa exposed?

    • Were any contaminated (i.e., gastric / intestinal) contents spilled?

    • Cold cut, or is there potential for thermal (and thus more expansive) injury?

Do I have to deal with this? Can’t I just leave some things unrepaired, and it’ll heal on its own?

  • In some cases of bladder and bowel injury, very small, non-thermal injuries can be left unrepaired:

    • Verees needle “clean poke” of small intestine or bladder

  • However, failure to recognize injury or leaving an injury that is too large or going to expand due to thermal damage unrepaired risks complications:

    • Early

      • Copious wound drainage

      • Abdominal pain - urinary ascites

      • Fever

      • Ileus

      • Peritonitis

        • Have a high index of suspicion in the postoperative period for a patient having an unrecognized injury, especially if they’re having lots of drainage from the incision or a lot of unexpected pain!

    • Delayed

      • Recurrent urinary tract infection

      • Urinary incontinence 

      • Pelvic pain

      • Fistula formation

        • This is of course a major dreaded complication of unrecognized injury.

        • Quick detour – why can cystotomies occurring in TVT procedures stay unrepaired?

          • These injuries occur extraperitoneally in the retropubic space. 

            • Simple extraperitoneal injuries almost always heal on their own and can usually just be managed with catheter drainage & won’t form fistula

          • Injury occurring intraperitoneally should be repaired and are at risk for fistula formation.

            • We’ve provided the two “windows” of injury for fistulas to form at the time of a hysterectomy with the opening to the vagina:

              • Vesico-vaginal (bladder-to-vagina, at hysterectomy)

              • Uretero-vaginal (ureter-to-vagina, at hysterectomy)

              • Entero-vaginal (bowel-to-vagina)

Bladder Injuries

  • Site and extent of injury

    • Most commonly, injuries occur to the dome of the bladder - makes sense anatomically.

    • Rarely, injuries can occur lower, into the trigone or base of the bladder - this is a danger zone for ureteral injury as well.

      • Always evaluate the extent of the injury - if limited to the dome, repair is usually possible without consultative assistance. If more extensive or unsure, urology should be notified.

    • You can use your cystotomy to look into the bladder and see relative anatomy – 

      • ie, visualize the foley, visualize the ureteral openings from above.

      • If you’re within the dome vs the trigone

        • If you’re within just a few centimeters of the ureteral openings… may be worth having a consult come by for repair assistance!

  • Technique of repair for dome injuries

    • Two layers with absorbable suture – typically use a 2-0 or 3-0.

      • Don’t use non-absorbable or very delayed absorbable – there will be suture material in the bladder, which acts as a nidus for infection.

      • First layer: mucosal closure, in a simple running fashion (but not locking).

      • Second layer: imbricating layer over serosa/muscularis, not entering mucosa (to limit amount of material in bladder).

    • After repair, check integrity of the bladder repair while you still have access to the abdomen:

      • A variety of materials can be used to backfill, but generally you want something that is going to have color so you can see a leak, if it’s present.

        • Sterile milk/formula – works! Though can make your cystoscopy quite cloudy later.

        • Crystalloid with methylene blue/indigo carmine/fluorescein added.

    • Many folks may choose to perform cystoscopy at the same time or after backfilling.

      • The cystoscopy is more for checking your ureteral patency – you’ll have a hard time determining bladder repair integrity from a cystoscopy view unless there’s a large defect.

        • That said, if your injury was in the dome and far away from ureters, and you could see the ureters from above, cystoscopy may not totally be necessary - as they’re unlikely to get kinked in your repair. 

    • Postop, the Foley needs to stay in place usually 7-14 days.

      • A void trial and a voiding cystogram should be performed to again demonstrate bladder repair integrity.

  • Technique of repair for trigone injuries

    • You should call urology / urogynecology for these.

    • You will need to assess the status of the ureters, as the ureteral orifices coming into the trigone may be damaged.

      • IV methylene blue, indigo carmine, or fluorescein along with small dose of furosemide.

        • If you see dye entering the bladder but not entering the retroperitoneal or intraabdominal space - likely no ureter injury.

      • Urologists on consultation with a trigone injury may go ahead and place stents to evaluate the ureters.

        • Placing the stents (and the relative ease or not of doing so) may help them to triage where a ureteral injury is at, and then with repairing the injury ensure the ureter is not incorporated.

        • Stents may remain in place postoperatively to keep ureters patent, as nearby tissue may swell and obstruct them otherwise.