Search

Objective: To identify clinical features of urinary tract injuries detected during or after gynecologic surgeries, with a specific focus on incidence and role of surgeon and surgical route on urinary injury.Study design: The institutional database from January 2009 to January 2017 was reviewed with respect to gynecologic (non-obstetric) surgeries and urinary injuries.Results: A total of 8719 gynecologic surgeries were identified. Of these, 46 (0.52%) were found to be complicated with a bladder (N=34, 0.38%), ureteral (N=11, 0.12%) and/or urethral injury (N=1, 0.01%). Bladder injuries occurred mostly at the superior part of the bladder, while ureteric injuries at the most distal part of the ureter. Ureteric injuries were mostly delayed (81.8% vs. 5.9%, P

Injury to the bladder and/or ureters is the cause of significant morbidity, and efforts to reduce these injuries are important. This debate presents arguments that both support, and refute, the value of routine cystoscopy at the time of benign hysterectomy. Proponents of routine cystoscopy state that injuries are more likely to be detected and repaired when cystoscopy is routinely performed. Dissenters counter that the available evidence does not support routine cystoscopy at the current rates of lower urinary tract injury, and the cystoscopy should be performed only when injury is suspected or when performing hysterectomy with concurrent procedures that increase the risk of lower urinary tract injury.

Background Ureteric injury is a complication of gynaecological surgery that can cause significant morbidity for the patient and is a leading cause of litigation in many countries. Objectives To determine patient characteristics, peri-operative circumstances and clinical and legal outcomes of ureteral injuries associated with gynaecological surgery. Patients and methods This is a retrospective review of 20 cases of ureteric injury during benign gynaecological surgery. Main outcome measures All cases were assessed for the following variables–patient characteristics, indications for surgery, injury, postoperative symptoms and presentation, and clinical and legal outcomes. Results Risk factors associated with ureteric injury included obesity, previous laparotomic pelvic surgery, pelvic adhesions, large pelvic masses and intra-operative bleeding. 70% (14/20) of ureteral injuries were diagnosed after discharge. 50% (10/20) of patients had a complicated post-operative course and 45% (9/20) of cases resulted in unfavourable legal outcomes (settlement or lost at trial) for the surgeon. The conduct of surgery and the failure to act in a timely fashion postoperatively were the most frequent reasons for adverse clinical and unfavourable litigation outcomes for the surgeon. Conclusions Intra-operative surgical consultation and ureteral identification should be considered if there is concern for ureteral involvement in the surgical field. Ureteric injury may not constitute negligence if it is demonstrated that the surgeon provided reasonable care that would be expected during the peri-operative phases. What is new This review identifies patient characteristics and peri-operative variables that correlate with poor clinical and legal outcomes after ureteric injury.

Introduction: Total laparoscopic hysterectomy is a common surgical procedure performed by a gynaecological endoscopic surgeon. Urinary tract injuries, though rare, is a serious complication requiring early detection and management. The aim of this study is to determine the incidence and risk factors for injury to the lower urinary tract during total laparoscopic hysterectomy and the role of cystoscopy in diagnosing the injury. Materials and Methods: All patients who underwent total laparoscopic hysterectomy for benign disease from January 1, 2017, to November 1, 2019, at the Institute of Kidney Diseases and Research Centre were included. Intraoperative cystoscopy with oral Pyridium given before surgery was routinely performed. Relevant data were abstracted to determine the incidence of lower urinary tract injury, predictors of injury and post-operative complications and the role of cystoscopy. Results: Total laparoscopic hysterectomy was performed in 150 consecutive subjects. Out of the encountered 6 cases (4%) of renal injuries in our study, two (1.3%) cystotomies were noted and repaired. An absent ureteral spill of Pyridium was detected in one subject, ureteral injury that was detected and confirmed with retrograde pyelography and managed with percutaneous nephrostomy and ureteric implantation. Three patients had a ureteric injury which was missed initially with a cystoscope. Later on, the patient presented with a urinary leak. The injury was identified and managed surgically. Only 25% (1/4) of injuries were recognised with the use of cystoscopy with Pyridium. All patients recovered with no long-term complications on follow-up. Conclusions: Renal injuries are relatively uncommon during total laparoscopic hysterectomy. Nevertheless, when an injury does occur, quick recognition of the problem and a working knowledge of its location and treatment are essential in providing patients with optimal medical care. Surgeons should consider performing cystoscopy at the time of total laparoscopic hysterectomy.

Study Objective Discuss the most common causes of ureteral injury during gynecological surgery. Discuss the avoidance of ureteral injury. Demonstrate, with surgical videography, traditional laparoscopic and robotic assisted laparoscopic retroperitoneal entry and ureteral identification/dissection. Design N/A Setting 6 minute surgical video reviewing traditional and robotically assisted laparoscopic techniques to identify and dissect the ureter. Patients or Participants Education for Medical Students, OB/GYN Residents, OB/GYN Fellows, and Attending Physicians. Interventions N/A Measurements and Main Results N/A Conclusion A keen understanding and knowledge of gynecological and urological anatomy plays an important role in the prevention of urinary tract injury during gynecologic surgery. The primary approach to prevention of ureteral injury is careful surgical dissection and knowledge of the position of the urinary tract structures within the surgical field.

Video Objective To review the use of cystoscopy by OB/GYN generalists for detection of lower urinary tract injury during hysterectomy. This includes the basic steps to diagnostic cystoscopy, the relevant anatomy, indications and limitations. Setting Cystoscopy is routinely used in prolapse and incontinence repair procedures due to the relatively high risk of bladder or ureteral injury during these surgeries. While some recommend the routine use of intra-operative cystoscopy as a part of laparoscopic hysterectomy to detect bladder or ureteral injury, this is still not routine practice among OB/GYNs generalists. Whether this is due to decreased familiarity with the technique, or it's limitations in sensitivity for detection of ureteral injury, remains unclear. To achieve the above objectives, this video reviews the details of the equipment involved, relevant anatomy, role of the bladder survey and visualization of ureteral jetting. Tips for detecting jetting and restoring normal anatomy are discussed. A brief review of the literature is used to outline indications for cystoscopy in general gynecology as well as its limitations. Interventions NA Conclusion Intra-operative cystoscopy is a useful tool for the general gynecologist. Simple steps can be taken to make it straightforward and diagnostic. However, it's also important to realize the limitations of cystoscopy, particularly in the detection of non-obstructive ureteral injury.

Midurethral slings are the mainstay of treatment for stress urinary incontinence. The role of cystourethroscopy to detect lower urinary tract injury following retropubic midurethral slings is well-established; however, its role following transobturator or single-incision sling placement remains controversial. Some advocate “routine” whereas others advocate for “selective” cystourethroscopy. This paper reviews the arguments for and against cystourethroscopy to detect lower urinary tract injury following transobturator and single-incision slings.

Introduction: Previously, external hemipelvectomy was the mainstay of treatment for pelvic tumors. However, with technological advancements, limb salvage procedures such as internal hemipelvectomy have emerged as a viable alternative. However, there is limited literature available on long-term outcomes and complications of internal hemipelvectomy, especially from developing countries. Therefore, the objective of this study was to share our experience of internal hemipelvectomy at a tertiary care center in a developing country. Materials and methods: A retrospective review was conducted in which all 24 patients undergoing internal hemipelvectomy from January 1, 2005 to December 31, 2015 at our institution were included. Medical record files were reviewed for intraoperative and early and late postoperative complications, and functional outcomes were assessed by contacting each patient on telephone. Results: Ewing sarcoma was found to be the most common diagnosis, followed by osteosarcoma as the second most common. The mean follow-up period was 18.7 ± 13.9 months. Intraoperatively there were 4 cases of iatrogenic neurovascular injury and 2 cases each of urinary tract injury and dural tear. Four patients developed early wound infections, 7 developed late wound infections, and 2 developed flap necrosis. Three patients developed recurrence, whereas 7 patients developed metastasis postoperatively. The mean survival was calculated to be 28 months and the mean Musculoskeletal Tumor Society score was 19.3 ± 5.2. Conclusions: Outcomes and prevalence of complications shown in this study are comparable to those in the international literature, which suggests that hemipelvectomy is a viable option in developing countries also. However, more such studies are warranted to validate the findings and to identify the challenges and morbidities associated with hemipelvectomy in Asian and developing countries.

Robotic surgery was developed to expand the patient population being offered a minimal invasive approach while retaining the associated advantages of minimal invasive surgery. Robotic surgery has been suggested to be particularly beneficial in surgery for malignant disease or in the presence of extensive intraabdominal adhesion, severe endometriosis, large uteri, high burden of comorbidity, or obesity. In addition to the surgeon’s and the assistant’s level of experience, these are all risk factors for the development of complications.

Hysterectomy is the second most frequently performed gynecological surgery. It is therefore relevant to perform an assessment of factors associated with urological surgical morbidity. Hysterectomy is associated with injuries to the ureter (0-3.97%) and bladder (0-2.8%). The incidence of urologic complications has been declining, as well as the difference between surgical approaches. There are some studies that demonstrate an increased risk of urologic injuries with laparoscopic and radical hysterectomy. Controversy remains on which are the real benefits of subtotal hysterectomy. No differences were found between intrafascial and extrafascial techniques. Concomitant salpingophorectomy doesn't lead to a greater risk of injuries.

Management of ruptured uterus depends on the cause, the presentation, the need to preserve the uterus, and the part of the uterus involved in the rupture.

Background Gynecologists debate the optimal use for intraoperative cystoscopy at the time of benign hysterectomy. Although adding cystoscopy leads to additional up-front cost, it may also enable intraoperative detection of a urinary tract injury that may otherwise go unnoticed. Prompt injury detection and intraoperative repair decreases morbidity and is less costly than postoperative diagnosis and treatment. Because urinary tract injury is rare and not easily studied in a prospective fashion, decision analysis provides a method for evaluating the cost associated with varying strategies for use of cystoscopy. Objective The objective of the study was to quantify costs of routine cystoscopy, selective cystoscopy, or no cystoscopy with benign hysterectomy. Study Design We created a decision analysis model using TreeAge Pro. Separate models evaluated cystoscopy following abdominal, laparoscopic/robotic, and vaginal hysterectomy from the perspective of a third-party payer. We modeled bladder and ureteral injuries detected intraoperatively and postoperatively. Ureteral injury detection included false-positive and false-negative results. Potential costs included diagnostics (imaging, repeat cystoscopy) and treatment (office/emergency room visits, readmission, ureteral stenting, cystotomy closure, ureteral reimplantation). Our model included costs of peritonitis, urinoma, and vesicovaginal/ureterovaginal fistula. Complication rates were determined from published literature. Costs were gathered from Medicare reimbursement as well as published literature when procedure codes could not accurately capture additional length of stay or work-up related to complications. Results From prior studies, bladder injury incidence was 1.75%, 0.93%, and 2.91% for abdominal, laparoscopic/robotic, and vaginal hysterectomy, respectively. Ureteral injury incidence was 1.61%, 0.46%, and 0.46%, respectively. Hysterectomy costs without cystoscopy varied from $884.89 to $1121.91. Selective cystoscopy added $13.20–26.13 compared with no cystoscopy. Routine cystoscopy added $51.39–57.86 compared with selective cystoscopy. With the increasing risk of injury, selective cystoscopy becomes cost saving. When bladder injury exceeds 4.48–11.44% (based on surgical route) or ureteral injury exceeds 3.96–8.95%, selective cystoscopy costs less than no cystoscopy. Therefore, if surgeons estimate the risk of injury has exceeded these thresholds, cystoscopy may be cost saving. However, for routine cystoscopy to be cost saving, the risk of bladder injury would need to exceed 20.59–47.24% and ureteral injury 27.22–37.72%. Model robustness was checked with multiple 1-way sensitivity analyses, and no relevant thresholds for model variables other than injury rates were identified. Conclusion While routine cystoscopy increased the cost $64.59–83.99, selective cystoscopy had lower increases ($13.20–26.13). These costs are reduced/eliminated with increasing risk of injury. Even a modest increase in suspicion for injury should prompt selective cystoscopy with benign hysterectomy.

To review the frequency of iatrogenic urological injury during obstetric and gynaecological operations carried out between January 2009 to January 2013 at Government Medical College, Haldwani. Each case was reviewed for predisposing factors, location, type of injury, time of injury, method of recognition and management. 12 injuries were documented in 1063 gynaecological procedures and 3079 obstetric procedures. All were bladder injuries and occurred while separating the bladder. Pelvic adhesions was the most common factor. INTRODUCTION: The reproductive and urinary tracts in women are closely related anatomically and embryologically. Injury to the urinary tract involves injury to the ureters, bladder and urethra (1). The overall rate of urinary tract injury associated with pelvic surgery in women is associated with pelvic surgery in women is approximately 1% (2). Bladder injury is more common than ureteral injury (3). However, the exact incidence of these injuries is difficult to ascertain. Urological injuries in gynaecological surgeries result due to difficult surgery, active infection, endometriosis, enlarged uterus, previous pelvic surgery, pelvic adhesions, ovarian neoplasms, distorted pelvic anatomy, cervical fibroids, broad ligament fibroids, tubo-ovarian mass, advanced malignancies, previous surgery. Such a history should caution on risk of injury and suggest for further preoperative evaluation (4, 5). Diagnosis of urological injuries can be made intraoperatively or postoperatively. Majority of bladder injuries are diagnosed intraoperatively. Intraoperative identification of urological injuries enables prompt repair and is associated with decreased morbidity.

Gynaecology surgery is the commonest cause of iatrogenic injury of the urinary tract. Rapidly evolving surgical techniques and gynaecological training involving less surgical experience compared to previous years means there is a need to proactively minimise this risk. If ureteric injury is unrecognised it can result in prolonged morbidity and potential loss of organ function. Injuries may be avoidable by preoperative assessment, attention to risk factors and meticulous surgical technique. Counselling patients regarding potential injury is important especially if there are pre-existing risk factors. A high index of suspicion and prompt evaluation may improve immediate recognition and thereby improve prognosis. Any delay in postoperative recovery especially with flank pain should raise the suspicion of urinary tract injury and prompt diagnostic evaluation should be undertaken. Surgical repair should be done by specialists with sufficient expertise and woman should be debriefed and followed up to improve patient satisfaction and reduce litigation rates.

To calculate the rates of urinary tract injury detected during and after benign gynecologic surgery. To explore the role of routine intraoperative cystoscopy and determine if it helps in reducing injuries detected postoperatively.We conducted a literature search for urinary tract injuries at benign gynecologic surgery in PubMed, EMBASE, ClinicalTrials.gov, and Web of Science from January 2004 to August 2014. We combined our results with a database from a previously published systematic review to include earlier studies.A total of 79 studies met our inclusion criteria. Excluded were letters to the editor, studies involving only selective cystoscopy in higher risk patients, case reports, and reports that included injuries resulting from obstetric or oncologic procedures.Data from each report were classified according to type of surgery into vaginal hysterectomy, abdominal hysterectomy, laparoscopic hysterectomy, other (nonrobotic) gynecologic and urogynecologic surgery, robotic hysterectomy, and other robotic gynecologic and urogynecologic surgery. We determined the ureteric and bladder injury rates for each surgery type from studies in which routine intraoperative cystoscopy was performed and separately from studies in which it was not performed. Intraoperatively detected rates of ureteric and bladder injury were markedly higher with routine intraoperative cystoscopy. We obtained an adjusted ureteric injury rate of 0.3% and a bladder injury rate of 0.8%. The estimated postoperative ureteric injury detection rates per 1,000 surgeries were 1.6 without routine cystoscopy and 0.7 with routine cystoscopy. Postoperative bladder injury detection rates per 1,000 surgeries were 0.8 without routine cystoscopy and 1.0 with routine cystoscopy.Although routine cystoscopy clearly increases the intraoperative detection rate of urinary tract injuries, this systematic review of 79 mostly retrospective studies shows that it does not appear to have much effect on the postoperative injury detection rate.

Recent studies using universal cystoscopy have demonstrated a higher rate of urinary tract injury at major gynaecological procedures than previously thought. These injuries are associated with significant medical and medico-legal implications. The sensitivity of visual inspection is low and cystoscopic screening with intravenous dye improves detection. We review the evidence for intra-operative cystoscopy in gynaecology, with emphasis on rates of urinary tract injury and the use of intravenous contrast dye.

The past 50 years have been a time of rapid progress in the control of mortality and morbidity of pelvic fracture. Early understanding of the anatomic features of the fracture and the potential for major, life-threatening arterial hemorrhage in a small proportion of patients led to multidisciplinary approaches designed to control hemorrhage and temporarily stabilize the fracture. Progress in the diagnosis and management of lower urinary tract injuries has resulted in maintenance of urinary continence and sexual function in a large proportion of patients with pelvic fracture-associated urinary tract injury. Finally, definitive open reduction and fixation of the fracture has led to permanent pelvic stability and pain-free walking in most patients. With successful combination of these approaches, survival and return to a satisfactory level of function is now the rule rather than the exception for patients with severe pelvic fracture.

Background and objectives Laparoscopic hysterectomy poses the risk of lower urinary tract injury, and intraoperative recognition of urinary tract injury is often difficult. We sought to evaluate sodium fluorescein coloration of ureteral jets during cystoscopy after laparoscopic hysterectomy and to evaluate surgeons' satisfaction with this method of injury detection. Methods This was an observational study, in which data were collected prospectively. A total of 30 women who underwent laparoscopic hysterectomy from August 2016 to February 2017 at the Centre Hospitalier de l'Universite Laval (CHUL) de Quebec. Twenty-five milligrams of 10% intravenous sodium fluorescein was administered after vaginal cuff closure. Cystoscopy was then systematically performed, and the time to visualization (time from injection to coloration of ureteral jet), the quality of coloration, and the duration of cystoscopy were recorded. Side effects were systematically recorded and rigorously analyzed. Results Most frequent indications for hysterectomy were fibroids and endometriosis with uterine weight from 76 to 885 g. Ninety-three percent of patients (n = 28) had bilateral ureteral jet coloration, whereas 1 patient had no coloration bilaterally, and another patient had a complete unilateral obstruction immediately diagnosed and resolved intraoperatively after removal of the vaginal sutures. In 90% of cases (n = 27), surgeons were highly satisfied with the use of sodium fluorescein. The average time between visualization of both left and right ureteral jets was 1 minute. Side effects included hypotension (n = 3) and yellow coloration of urine (n = 15). Conclusion Our study suggests that sodium fluorescein is an effective dye for documenting ureteral patency and improving visualization of ureteral jets during cystoscopy upon completion of laparoscopic hysterectomy.

To estimate the incidence and location of injury to the urinary tract during hysterectomy for benign gynecologic disease.This was a prospective clinical study in an academic environment performed at three sites. Diagnostic cystourethroscopy was performed on all patients after hysterectomy for benign disease.Eight hundred thirty-nine patients were enrolled. The incidence of urinary tract injury associated with hysterectomy for benign disease was 4.3% (39 of 839 cases). The rate of bladder injury was 2.9% (24 of 839 cases), and rate of ureteral injury was 1.8% (15 of 839 cases). There were three cases of simultaneous bladder and ureteral injuries, resulting in a cumulative injury rate of 4.3%. The injury detection rate using intraoperative diagnostic cystoscopy was 97.4% (817 of 839 cases). The most common site of injury to the ureter was at the junction of the ureter and the uterine artery in 80% (12 of 15 cases) of ureteral injuries. Transection and kinking injuries were the most frequent type of injury. There were 21 cases of subnormal dye efflux from the ureteral orifices, with no subsequent injury detected on further evaluation.Ureteral injury occurred most commonly at the level of the uterine artery, and transection and kinking injuries were most frequent. Diminished dye efflux from ureteral orifices was not associated with injury.III.

Objectives To evaluate the management and intermediate-term follow-up of posttraumatic posterior urethral strictures in children. Methods From March 2000 to November 2006, the surgical records of 28 children (≤18 years) who had been admitted for treatment of posttraumatic posterior urethral strictures were retrospectively reviewed. The patients had been followed up for a median of 36 months (range 3-58). The cause of trauma, extent of urinary tract injury, radiologic examination findings, previous treatment, and its effect on the final outcome, treatment complications,, and failures were evaluated. Results The mean age of the patients was 12.1 years (range 5-18) at the injury. The estimated radiographic mean stricture length before surgery was 3.41 cm (range 2-6). Of the 28 patients, 27 were treated with transperineal anastomotic urethroplasty, with a success rate of 75%. All treatment failures were at the anastomotic site and occurred within the first year of anastomotic urethroplasty. The failed repairs (7 cases) were successfully managed endoscopically in 4 patients and by redo urethroplasty in 3, for a final success rate of 100%. Of the 28 patients, 15 (80%) with urethral manipulation before anastomotic urethroplasty had a satisfactory result compared with 69.3% of patients without previous surgical treatment. The difference was not statistically significant. Conclusions Most posttraumatic posterior urethral strictures in children can be managed through the perineal route. The transpubic approach should be reserved for more complex posterior strictures. Previous urethral manipulations did not affect the intermediate-term results of anastomotic urethroplasty.

Use of urethral slings in the treatment of incontinence started in the early 20th century. An evolution in understanding the pathogenesis of urinary incontinence led to development of the midurethral sling, which was designed to replace the natural suburethral vectors of support, as described in the integral theory. Since the introduction of tension-free vaginal tape in 1995, multiple other commercially available types of midurethral sling have been introduced. In general, these sling types share the common characteristics of using a thin, type I synthetic mesh inserted at a midurethral level and applied without tension. The midurethral sling procedure has subsequently undergone multiple technical modifications, predominantly alterations to the technique and route used for sling insertion. Despite the variety in techniques, available evidence suggests that all sling types provide efficacious and durable outcomes. Several adverse effects have been reported that are specific to certain techniques, and include the risk of vascular, enteric or nerve injury, lower urinary tract injury, urinary retention or voiding dysfunction, and vaginal erosion. Nonetheless, the midurethral sling provides a safe surgical option overall, and represents a notable advance in the treatment of stress urinary incontinence.

The proximity of the urinary tract to the reproductive organs puts it at risk of injury and incontinence as a consequence of gynaecological surgery. Incontinence to urine after gynaecological surgery is distressing to both the patient and the surgeon; in particular, formation of a urinary fistula after surgery is seen as a disaster by both. It also has long-term medicolegal implications. In this review. the main emphasis is on the prevention, evaluation, diagnosis and management of urinary tract injury. Other causes of postoperative incontinence are addressed briefly.

Study objective To evaluate the incidence and characteristics of urinary tract injury after laparoscopic-assisted vaginal hysterectomy (LAVH). Design A retrospective study that evaluated all cases of urinary tract injury at the time of LAVH in an 11-year period. Parameters including surgical indication, site of injury, time of diagnosis, method of treatment, and long-term follow-up were analyzed. (Canadian Task Force classification II-2). Setting Tertiary care university hospital. Patients A total of 38 urinary tract injuries were found in 7725 LAVH. Intervention LAVH and repair of urinary tract injuries with transvaginal or transabdominal approach. Measurements and main results The incidence of urinary tract injury after LAVH was 4.9/1000 procedures: 3.9/1000 for urinary bladder injury and 1.0/1000 for ureteral injury. Prior cesarean section was the most common risk factor for bladder injuries. Ninety-six percent (29/30) of urinary bladder injuries were detected and treated during surgery. Half (4/8, 50%) of the ureteral injuries were identified during surgery. Of the 38 complications, 28 (75.7%) occurred in surgery. Conclusion Most urinary tract injuries in LAVH were identified during surgery and are associated with the surgeon’s experience. Bladder injury can be repaired either transvaginally or abdominally; ureteral injury can be repaired abdominally.

Objectives: The goals of our study were to review all cases of urethral and bladder trauma that presented to the University of California, Los Angeles (UCLA) Medical Center between January 1998 and August 2005 and determine (1) the clinical characteristics of patients with urethral and/or bladder injuries as well as the sensitivities of those clinical characteristics; (2) whether or not a blind attempt to insert a urethral catheter was performed; and (3) whether there is any evidence that a blind attempt to insert a urethral catheter worsened the initial urinary tract injury. Methods: This is a retrospective chart review. Results: The study cohort comprised 46 patients with a mean age of 30 years, including 36 men (78.2%) and 10 women (21.8%). Bladder tears were found in 33 patients, 10 patients had urethral lacerations, and 3 patients had combined bladder and urethral lacerations. The most sensitive finding for urinary bladder or urethral injury was the presence of gross hematuria in the urethral catheter (100%, 95% confidence interval [CI] 0.63–0.89). Blinded insertion of a urethral catheter was attempted in 30 (90.9%, 95% CI 0.75–0.98) patients who suffered from urinary bladder injury, 6 (50%, 95% CI 0.26–0.87) patients who suffered from urethral injury and 1 (33%, 95% CI 0.0–0.9) patient who suffered from a combined urinary bladder and urethral injuries. We did not find evidence that a blind attempt to insert a urethral catheter worsened the initial urinary injury. Conclusion: Gross hematuria in the urethral catheter was the most sensitive sign for the presence of a urethral or urinary bladder injury in our study cohort, and often the only sign of such an injury. We found no evidence that a blind attempt to insert a urethral catheter in patients suffering from urethral and or urinary bladder injuries worsened the initial injury. Larger studies will be needed to determine the safety of blind urethral catheterization in patients that are suspected to suffer from a lower urological trauma. It is our opinion that the current guidelines should be revised to better reflect the current knowledge, technologies, and clinical practice.

To estimate the rates of urinary tract injury after benign gynecologic surgery. To explore the role of routine intraoperative cystoscopy at benign gynecologic surgery.We conducted a systematic MEDLINE search for urinary tract injuries at gynecologic surgery for the period from November 1998 to May 2004 and combined this with a previous systematic review performed in the same fashion for the period from January 1966 to October 1998.There were 47 studies that fit our inclusion criteria: 29 that did not use routine intraoperative cystoscopy, 17 that used routine intraoperative cystoscopy, and 1 that reported the frequency of urinary tract injury separately, with and without routine intraoperative cystoscopy. We determined the crude and fitted ureteric and bladder injury rates for each surgery type from the studies where routine intraoperative cystoscopy was not performed and then from the studies where routine intraoperative cystoscopy was performed.From studies without routine cystoscopy, combined ureter and bladder injury rates varied according to the complexity of the surgery, ranging from less than 1 injury per 1000 for subtotal hysterectomy with or without bilateral salpingo-oophorectomy to as many as 13 injuries per 1000 surgeries for laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy and for other gynecologic and urogynecologic surgeries. Injury rates were higher when routine intraoperative cystoscopy was used, but the confidence intervals were wider.The reasons for higher injury detection rates when routine cystoscopy was performed are unclear. Further study is needed to identify the scenarios where routine cystoscopy is warranted after major gynecologic surgery.

Today laparoscopic hysterectomy (LH) can be performed safely and effectively, even for women with a previous history of cesarean section (CS). However, it is unclear whether the risk of urinary tract injury increases with previous CS during LH. PubMed and Embase databases were searched for all studies on previous history of CS and risk of urinary tract injuries during and after LH. Reference lists of the identified studies, reviews, and other relevant publications were also searched. Urinary tract injuries or related complications were the outcomes of interest. Meta-analysis was conducted using an inverse-variance weighted random-effects model. A total of 7 studies including 3,191 patients were identified in the meta-analysis. Overall, the pooled relative risk (RR) and the corresponding 95 % confidence interval (CI) of urinary tract injury were 3.48 (1.86–6.50) for previous CS compared with no previous CS. However, only two studies reported sufficient data on ureteral injury, and the combined RR was 1.83 (95 % CI 0.19–17.26). All seven studies reported the outcomes of bladder injury, and the pooled RR was 3.75 (95 % CI 1.96–7.17). Stratified analyses showed a basically consistent result with the overall analysis except for that by 1–2 times of previous CS (RR 2.32, 95 % CI 0.56–9.56). Previous CS is significantly associated with development of bladder injury during LH. No significant association was found yet between previous CS and risk of ureteral injury. Given the limited number of studies, more future studies are required to confirm the associations.