Avoiding and Managing Urologic Injury - LIGO …...2017/03/16 · A Case for Universal Cystoscopy?...
Transcript of Avoiding and Managing Urologic Injury - LIGO …...2017/03/16 · A Case for Universal Cystoscopy?...
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Avoiding and Managing Urologic Injury
Jubilee Brown, MD Professor & Associate Director, Gynecologic Oncology
Levine Cancer Institute at the Carolinas HealthCare System Charlotte, North Carolina
No relevant financial disclosures
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Objectives • Review anatomy related to identification and
dissection of the ureter and bladder • Identify and manage urologic injury • Review stenting, cystoscopy, and ureteral repair • Show ureterolysis and resection of endometriosis
from ureter • Demonstrate cystotomy repair & stent placement
Importance of the Ureter
• 19% of unplanned consults to Gyn Onc were for inability to identify the ureter
• Incidence of injury during LH (2004-14): • Overall: 0.73% • Bladder injury: 0.05 - 0.66% • Ureteric injury: 0.02-0.4%
Aviki EM Gynecol Oncol 137(1):93-97, 2015 Adelman MR, JMIG 21(4):558-66, 2014
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Learning curve during TLH
Brummer THI, Human Reproduction 23(4):840, 2008 Makinen JJ, BMJ Open 10:1-8, 2013
• Learning curve reaches significance at 30 cases
Improvement: 1996 compared with 2006 in all hospitals in Finland
Makinen JJ, BMJ Open 10:1-8, 2013
• Incidence of urinary tract injury fell • 1996: 2.6% (n = 58 / 2434) • 2006: 0.7% (n = 22 / 1679) (p<0.001)
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Improvement: 1996 compared with 2006 in all hospitals in Finland
Makinen JJ, BMJ Open 10:1-8, 2013
• 1.3 to 1% (ns)
• 1.1 to 0.3%(p<0.005)
• International legal issue:
• 2005-10: 95% of 130 iatrogenic ureteric injury claims in New Zealand settled in favor of plaintiff
• Basis for claim: “ res ipsa loquitur” = “the thing speaks for itself”
Jha S, BJOG 122(4):499, 2015
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Review anatomy related to identification and dissection of the ureter and bladder
Pelvic Ureter
Can always find at the pelvic brim - make the incision higher if you are struggling!
Ovarian vessels are tortuous & ALWAYS close to the ureter - must differentiate!
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Types of Ureteral Injury Review of 70 reports in 2,491 cases of laparoscopy
Unknown
48%
Transection 28%
Laceration 5%
Obstruction 8%
Stenosis
5%
Fistula 5%
Burn 1%
Ostrazenski A, Obstet Gynecol Surv 58:793, 2003
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Iden%fy the ureter
• Remember the course of the ureter • Open the retroperitoneum in a safe, lateral
loca%on – remember the “triangle” • Always safe to go lateral and cephalad • Higher is be@er • Adherent to the medial leaf of the
peritoneum • Use more suc%on, less (no) irriga%on
Right Pelvic Sidewall
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Right Pelvic Sidewall
IP ligament
Internal Iliac A
External Iliac A
URETER
Ureter and Appendix
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Ureter and Appendix
Ureter
Appendix
Ureter Under the Uterine Artery
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Ureter Under the Uterine Artery
Uterosacral Lig Uterine Artery
Ureter
Iden%fy the ureter
• Remember the course of the ureter • Open the retroperitoneum in a safe, lateral
loca%on – remember the “triangle” • Always safe to go lateral and cephalad • Higher is be@er • Adherent to the medial leaf of the
peritoneum • Use more suc%on, less (no) irriga%on
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The Triangle (Right Side)
The Triangle (Right Side)
Round Ligament
Fallopian Tube
Iliac Vessels
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Iden%fy the ureter
• Remember the course of the ureter • Open the retroperitoneum in a safe, lateral
loca%on – remember the “triangle” • Always safe to go lateral and cephalad • Higher is be@er • Adherent to the medial leaf of the
peritoneum • Use more suc%on, less (no) irriga%on
Iden%fy the ureter
• Remember the course of the ureter • Open the retroperitoneum in a safe, lateral
loca%on – remember the “triangle” • Always safe to go lateral and cephalad • Higher is be@er • Adherent to the medial leaf of the
peritoneum • Use more suc%on, less (no) irriga%on
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Iden%fy the ureter
• Remember the course of the ureter • Open the retroperitoneum in a safe, lateral
loca%on – remember the “triangle” • Always safe to go lateral and cephalad • Higher is be@er • Adherent to the medial leaf of the
peritoneum • Use more suc%on, less (no) irriga%on
Iden%fy the ureter
• Lyse adhesions as needed to iden%fy the course of the ureter
• Important at the level of the IP • Important at the level of the uterines • At the level of the IP, stay lateral! Lateral is
safe
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Path of the Ureter
DANGER ZONES!
42%
33%
25%
Prevent Injury at the Pelvic Brim
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Finding the Ureter
Prevent Injury at the Uterine Artery and Pelvic Sidewall
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Prevent Injury at Uterine Artery
• Do NOT go below Koh ring • Have strategies to deal with bleeding
from uterine artery – Seal vessel WITHOUT tension – Hemostatic agents – Ligation of uterine artery at origin
• Isolation of ureter in difficult cases
Prevent Injury at the Vaginal Cuff
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Cross Sectional Anatomy
The Koh Ring and Ureter Position
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Ways to Injure the Ureter at the Cuff
Ureters and Bladder
Ureter enters bladder at the edge - BE CAREFUL!
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Identify and manage urologic injury
Ureteral Injury • Detection
– Intra-operative dye injection – Intra-operative ureteral catheterization – Ureteral jet ultrasonography – IVP – Dissection of the ureter – Retrograde ureteral dye study
• Cannot always detect crush injuries; partial obstruction; delayed thermal injuries
Hurt WG, Gynecologic and Obstetrical Surgery (Nichols DH ed), Baltimore, Mosby, 1993
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Benefit to early detection • 15 patients with ureteral injuries
• 7 patients detected by intraop cystoscopy or early postoperative ureteral jet US
• 5 patients detected by signs or symptoms • 3 patients developed injury despite
normal cysto/US • Diagnosed earlier (1.7 vs. 19.9 days) • OR of 10 for more conservative treatment -
1/7 early patients required preimplantation vs. 5/8 late diagnosis patients
Wu HH, JMIG 13:403, 2006
Injury Documented with Methylene Blue
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Intra-operative Recognition
– Remove clamp – Inspect for integrity – Stent (2-6 wk) – Drain (7-10 d) – Close Peritoneum
• What if a clamp is placed across the ureter?
Drain for Urinary Injury
• Output should be less than 50 ml per day • Check creatinine prior to removal -
should be same as serum value • Might leave longer if worried about
necrosis or devascularization injury
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Early Diagnosis • Flank pain/CVA tenderness • Unexplained fever • Persistent ileus • Lower abdominal mass • Urinary discharge from vagina • Decreased urinary output • Unexplained hematuria
• Normally urine/plasma creatinine is 30:1 to 100:1
• However, may equilibrate fast
• May be as low as 2:1 • Non-urine ascitic
fluid would be 1:1
Sakellariou P Eur J Obstet Gynecol Rep Biol 101(2):179, 2002
Urinoma, Urinary Ascites
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Review stenting, cystoscopy, and ureteral repair
Google “repair”
This is the only female repair image you get….
Review stenting, cystoscopy, and ureteral repair
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Review stenting, cystoscopy, and ureteral repair
Indications for ureteral stents
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Stents
• Stents can be placed prior to difficult procedures – Make identification of ureter easier – They have not shown a reduction in injury
• Lighted stents cannot often be seen when field is illuminated during surgery
– May decrease unrecognized injury
• Wood: 7/92 stented patients had olig/anuria compared with 0/400 unstented patients
• Merritt: Successfully placed in 313/397 patients • Placement time = 5.4 min for experienced
surgeon; 8.4 min for inexperienced surgeon • Complications:
• UTI 1.5% • ARF 0.6% • Ureterovaginal fistula 0.3%
Wood EC, JAAGL 3(3):393, 1996 Merritt AJ, Arch Gynaecol Obstet 288:1061, 2013
Stents: Routine use is controversial
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Cystoscopy
A Case for Universal Cystoscopy?
• 471 hysterectomies in 3 centers - Prospective study • 24 urinary tract injuries (5.3%)
– 8 ureteral (1.7%) – 17 bladder (3.6%)
• Ureteral injury associated with prolapse surgery (7.3% vs 1.2%; P = 0.03)
• Bladder injury associated with incontinence surgery (12.5% vs 3.1%; P = 0.05)
• Only 12.5% of ureteral injuries and 35.3% of bladder injuries were detected before cystoscopy
Vakili B, Am J Obstet Gynecol 192, 1599, 2005
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Universal cystoscopy? • Peristalsis and detection of ureteral caliber are
insufficient to detect ureteral injury • 839 hysterectomy cases • Prospective study, universal cystoscopy • 97.4% ureteral injuries detected • Negative cystoscopy did not exclude all cases due
to partial obstruction or injury with residual patency (Burn injury)
Ibeanu et al, Int Urogynecol J Pelvic Floor Dysfunct 2003
Universal cystoscopy?
• Retrospective study compared 140 cases with and 109 cases without routine cystoscopy after robot assisted gynecologic surgery
• No difference in groups - incidence of urologic injury in both groups was zero Hard to show a benefit with a rare complication
Nguyen ML, JSLS 18(3), 2014
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Universal cystoscopy? • Retrospective study compared • 1982 patients, hysterectomy 2009-2010 • No intraoperative ureteral injuries detected
whether cystoscopy was used or not • 5 patients (0.25%) had a ureteral injury detected
postoperative – All were MIS cases – None had cystoscopy at time of surgery
• Recommended selective cystoscopy with low threshold - low volume surgeons, complex cases
Sandberg EM Obstet Gynecol 120(6):1363-70, 2012
Indications for ureteral repair
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Ureterolysis
Bladder Injury • Two layer closure
– Monofilament on mucosa • 3-0 suture
– Can use braided on muscularis • 2-0
• Barbed suture is ok • Catheter for 7-10
days
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Closure of cystotomy
Thank you!