Recognition and intraoperative management of ureteric and bladder injury

You are doing a laparoscopic hysterectomy for a bulky fibroid uterus in a woman with deep endometriosis. The left ureter was hard to find all morning. You fired the bipolar across the cardinal ligament, and now there is an unsettling quiet where a jet should be. This is the moment that separates the fellowship registrar from the defendant — not the injury itself, which happens to competent surgeons, but whether you recognise it now, in the light, with the team beside you, or whether you discover it on day five when she leaks urine vaginally and her creatinine climbs. Lower urinary tract (LUT) injury rewards the surgeon who looks for it and punishes the one who assumes.^[1][3]

Overview and definition

Iatrogenic LUT injury is damage to the ureter or bladder sustained during pelvic surgery. The two are spoken of together but are different problems in incidence, recognition and consequence. ^[1][2]

• Bladder injury (cystotomy): commoner, more often obvious, and forgiving when repaired at once — a cut or tear of the bladder wall, most often the dome during dissection of the vesicouterine space or at port and Veress entry.^[1][10]
• Ureteric injury: far less common than bladder injury but far more often missed, and the source of most of the litigation, the fistulae and the lost kidneys in this field.^[2][3]

The definition that matters clinically is by timing of recognition: an injury found and repaired during the index operation is immediate; one found afterwards is delayed. The EAU systematic review of 1517 iatrogenic ureteric injuries stratified outcome by exactly this — the timing and modality of management — and timing is what drives renal salvage: recognised intraoperatively, a ureteric injury repaired by the book carries the success of elective reconstructive surgery; missed, it causes fistula, urinoma, hydronephrosis, sepsis and renal loss.^[1][15]

References22ShowHide

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