Urinary Tract Injuries Secondary to Gynecologic Laparoscopic Surgery: Analysis of 75 Cases

摘要

Objective: Ureteral and bladder injuries constitute one of a triad of major laparoscopic complications. This report analyzes the causative factors, the mechanism of injuries, and prophylactic measures, with an eye aimed at avoiding lower urinary tract damage. Design: This is a retrospective study of patients who sustained urinary tract injuries in the course of a variety of laparoscopic operations. Methods: Over a period of 24 years, 75 cases of bladder and ureteral injuries were compiled. Essential data included type of operations, description of clinical pathology, details of the surgical procedure(s), type of injury to bladder or ureter, instrument(s) or device(s) utilized, signs and symptoms, time of diagnosis, diagnostic tests, corrective procedures(s), results of repair, morbidity, follow-up data, and timelines. The majority of cases were associated with major laparoscopic operations (e.g., hysterectomies) and involved multiple abdominal entry sites. Results: Thirty-three (33) bladder injuries and 42 ureteral injuries were identified. Twelve (12) entry (trocar) complications damaged the bladder but only 1 ureteral injury could be attributed to this factor. Virtually every ureteral injury (41) was related to the operative procedure as were 21 of the 33 bladder incidents. Only 27% (20) complications were identified in-traoperatively, whereas 50% were diagnosed in the late postoperative period or in the remote postoperative follow-up period. Three (3) vesicovaginal fistulas and 2 ur-eterovaginal fistulas were diagnosed in the late postoperative period. Adhesions secondary to prior operative procedures or prior infections and adhesiolysis were the most significant etiological factors associated with both bladder and ureteral damage. Energy devices and stapling tools accounted for the majority of urological injuries (28 ureteral and 13 bladder). Clinical symptoms and signs pointing to urinary tract disruption ranged widely from dysuria, urgency, and flank pain, to no symptoms or signs (11 of 75). The locations of injuries to the ureter within the pelvis varied relative to the type of surgical procedure and nature of the complications (e.g., 5 of 8 stapling injuries occupied at the infundibulopelvic ligament), whereas thermal injuries were more or less evenly distributed relative to location. Transection and ligation injuries were more common at or below the uterine vessels. Conclusions: The risk of injuries, especially to the ureter, is increased with the laparoscopic approach. The reasons for the aforesaid include: lack of tactile sensations; decreased mobility for manipulation; reduction of the visual field; reluctance of the gynecologist to gain entry into the retroperitoneal space; suboptimal knowledge of pelvic anatomy; and reliance on hemostatic energy devices and stapling tools.