European Journal of Cardiovascular Medicine

The close embryological development and anatomical proximity of the urinary and genital systems in females predispose the urinary tract to injury during surgical procedures in the pelvic region. Estimating the true incidence of such injuries remains challenging; reported rates of ureteral injuries in gynaecological surgeries range from 0.2% to 0.5%, with a mean incidence of approximately 0.43% (1), while bladder injuries are cited at 0.5% to 1% [2]. In obstetric procedures, the incidence is comparatively lower, with ureteral and bladder injuries occurring at rates of 0.25% and 0.3%, respectively [3].

Research by Ushma J. Patel et al. (2021) indicates that the incidence of urinary tract injuries during benign hysterectomy may be higher than previously recognized, with rates reported at 2.4%. This underscores the critical need for preventive strategies and emphasizes the importance of early detection and timely intervention in the context of iatrogenic complications [4]. A systematic review by Jacqueline MK Wong et al. (2018) further elucidates this issue, reporting an overall incidence of urinary tract injuries at 0.33%, with bladder injuries occurring at a rate of 0.24%—three times more frequent than ureteral injuries, which occur at a rate of 0.08%. Notably, laparoscopic hysterectomy demonstrated elevated incidence rates (1.8%), compared to 1% for laparoscopic-assisted vaginal hysterectomy (LAVH). Among the causes of these injuries, electrosurgery accounted for 33.3% of ureteral injuries, while adhesiolysis was responsible for 23.3% of bladder injuries. Moreover, ureteral injuries were predominantly diagnosed postoperatively (60%), whereas bladder injuries were often identified intraoperatively (85%) [5].

The type and surgical approach employed during gynaecological procedures significantly influence the incidence of urinary tract injuries. For example: Radical hysterectomy: ~50%, Abdominal hysterectomy: 40%, Vaginal hysterectomy: <5%, Vaginal Vs Open Vs Laparoscopic Route, Experience Level of Surgical team. [6]

Pelvic organ prolapse reconstructive procedures also carry risks for urinary tract injuries. Failure to recognize these injuries can lead to severe complications such as peritonitis, fistula formation, and loss of renal function [7].

Iatrogenic urological injuries in obstetrics and gynaecology are frequent due to the close anatomical relationship between these systems, with 75% of such injuries originating from gynaecological procedures [17]. The overall incidence of urological injuries during gynaecological surgeries is estimated to range from 0.2% to 1% [18]. Despite their relatively low occurrence, the associated morbidity can be substantial, manifesting as haemorrhagic complications necessitating transfusion, extended surgical durations, increased febrile morbidity, prolonged hospital stays, and, in some instances, additional surgical interventions.

Several key predisposing factors that contribute to urological injuries during obstetric and gynaecological procedures include:

1. Congenital anomaliesof Urogenital tract
2. Uterine displacementresulting from: Enlarged uterus (>12 weeks), Large ovarian cysts or tumors, Pelvic organ prolapses
3. Adhesionsarising from: Endometriosis, Pelvic inflammatory disease, Prior intra-abdominal or pelvic surgeries, Radiation therapy, Advanced malignancy
4. Distorted pelvic anatomy
5. Additional contributing factors encompass significant intraoperative haemorrhage, concurrent bladder injuries, technical challenges, non-awareness, non-anticipation, and variations in experience level of surgical team.

This institutional review seeks to assess the incidence, mechanisms, and management of bladder and ureteric injuries during obstetric and gynaecological surgeries, thereby enhancing clinical understanding and promoting improved patient outcomes.

This study represents a Retrospective Analysis of Obstetrics and Gynaecological Surgeries conducted over a two-year period from January 2022 to January 2024, encompassing a total of 1,872 patients. The research was undertaken in the Department of Obstetrics and Gynaecology at the Raipur Institute of Medical Sciences, Raipur, Chhattisgarh, in collaboration with the Department of Surgery.

Inclusion Criteria-

The study included cases involving various Obstetrics and Gynaecological procedures, including Major Vaginal, Laparoscopic and Open Surgeries, performed during the specified time frame.

This included Obstetric Surgeries like LSCS, Hysterotomy, Laparotomy for Obstetric Hysterectomy, Ectopic Gestation, Puerperal Sepsis.

Gynaecological Vaginal, Open and Laparoscopic Surgeries like Hysterectomy (TAH, VH, Wertheim’s, LAVH, TLH), Myomectomy, Sling Surgeries, Laparotomies for Ovarian/ adnexal masses, Endometriosis, Burst Abdomen, Bladder Repair, Sacro Spinous Colpopexy, Vault Surgeries.

Exclusion Criteria-

Patients undergoing Minor Obstetrics and Gynaecological Procedures, where the risk of urological injury is minimal, were excluded from the analysis.

This included Medical Termination of Pregnancy (MTP), Cervical Cerclage, And Gynaecological Interventions Such as Dilatation and Curettage (D&C), Conization, and Laparoscopic Tubal Ligation.

Among the patient cohort, 60 individuals were diagnosed with Bladder, Ureteric or Concurrent injuries during the surgical procedures.

Bladder Injury- Classification was performed according to established grading criteria:

Grade 1: Contusion, intramural hematoma, or partial-thickness laceration.

Grade 2: Extra or Intraperitoneal laceration ≤ 2 cm

Grade 3: Extraperitoneal laceration > 2 cm

Grade 4: Intraperitoneal laceration > 2 cm

Grade 5: Intra or extraperitoneal bladder wall laceration involving trigone or bladder neck.

In cases suspected of bladder injury, a cystogram was performed using X-ray imaging after the injection of a contrast medium to evaluate for extraperitoneal injuries (Grade 2). In the absence of complicating factors, treatment involved the insertion of a Foley catheter for a duration of 7 to 14 days. Injuries classified as Grade 3 to Grade 5 typically necessitated surgical intervention for repair. Closed suction drains were routinely employed post-repair, with suprapubic tube placement being unnecessary in most instances.

For injuries involving the ventral bladder, dome, or posterior wall, the mucosa was approximated with a running suture using 3-0 Vicryl, followed by a seromuscular running suture with 2-0 Vicryl. The bladder was then irrigated to confirm watertight closure. In cases deemed at elevated risk for fistula formation or when a leak was detected, a third layer using the Lembert suture technique was employed. In the laparoscopic setting, a one-layer closure was executed using 2-0 Vicryl to secure all layers of the bladder, with an additional Lembert layer utilized for more extensive injuries.

Ureteral Injury- Classification: These injuries are classified into 5 grades as described by Moore et al (16)

Grade I-Hematoma (contusion or hematoma without devascularization)

Grade II -Laceration (< 50% transection)

Grade III -Laceration (2 50% transection)

Grade IV-Laceration (complete transection with < 2 cm)

Grade V-Laceration (avulsion with > 2 cm of devascularization)

Advance one grade if multiple lesions exist.

Treatment decisions depend on time, type, extent, site, duration of injury & general condition of patient [13], & the urological expertise available. The goals of management principally include renal unit preservation with adequate drainage by stenting or nephrostomy and minimization of surgical morbidity.

1. Mucosa Sparing wall injury- oversewing with absorbable sutures
2. Thermal Injury- Resection & further management as per transection.
3. Ureteral Ligation- Deligation, Assessment of Viability, Stent Placement
4. Transection-
5. Minor Injury- Stent, Ballon dilatation, Open repair
6. Partial- Primary Repair Over Stent
7. Total-
8. Upper/Middle Third-

Uncomplicated- Uretero-Ureterostomy Over Stent, Transuretero- Ureterostomy,

1. Complicated-Uretero-Ileal Interposition

Lower Third- Uretero-Neo Cystostomy with Psoas Hitch Over Stent, Ureteral Reimplantation

5. Fistula repair

The collected data were systematically entered into a Microsoft Excel worksheet, from which percentages, injury grades, types of repairs, and complications were analysed. This comprehensive analysis aims to enhance understanding of urological injuries in the context of obstetric and gynaecological surgeries and thereby improve surgical outcomes.

TABLE NO 1- DEMOGRAPHIC FACTORS

In this study mean age of bladder injury is 34.8 years and for ureteric injury 35 years. Parity for bladder injury 2.4 and for ureteric injury 3. BMI is 28.5 in bladder injury and 29 in ureteric injury patients. Bladder injury was noted in H/O previous surgery in 2/10 obstetric and 7/37 gynaec cases, while 1 ureteric injury occurred in previous surgery case.

TABLE 2; PREDISPOSING RISK FACTORS AND INDICATIONS FOR SURGERIES

Among the patients who experienced bladder injury due to obstetric indications, 3 were primigravida—each with one case of placenta previa (PP), placenta accreta spectrum (PAS), and cephalopelvic disproportion (CPD)—while 7 cases involved patients with previous caesarean sections (P. CS).

In the cohort of patients who suffered bladder injury for gynaecological indications, a total of 35 cases were observed. The predominant causes included massive intraoperative haemorrhage in 6 cases, surgeon-related factors (inexperience, non-anticipation, non-awareness) in 5 cases, and complications from pelvic surgeries in another 6 cases. Additionally, injuries attributed to uterine prolapse, broad ligament pathology, and endometriosis occurred in 3 cases each. Two cases were linked to large uterus size or large ovarian cysts, while single instances were associated with pelvic inflammatory disease (PID), vesicovaginal fistula (VVF) repair, advanced malignancy, and technical difficulties.

Regarding ureteric injuries due to gynaecological indications, a total of 13 cases were identified. The primary causes were massive intraoperative haemorrhage and large uterus size, each accounting for 2 cases. Other contributing factors included pelvic surgeries, uterine prolapse, broad ligament pathology, endometriosis, large ovarian cysts, cervical fibroids, PID, technical difficulties, and surgeon inexperience, with each of these factors resulting in one case each.

Among the 2 patients who sustained both ureteric and bladder injuries for gynaecological indications, one case was related to endometriosis and the other to surgeon inexperience.

TABLE NO 3- PROCEDURE & INJURY CLASSIFICATION

1872 patients included in the study were as follows-

1. Obstetric Surgeries - LSCS- 1365, Hysterotomy- 28, Others- 15 (Laparotomy for Obstetrics Hysterectomy (OH)-5, Puerperal Sepsis-3, Ectopic Gestation-7)
2. Gynaec Open Surgeries- Hysterectomy- TAH 122, VH 148, Extended Hysterectomy/ Wertheim’s- 12, Laparotomy (Ovarian/ Adnexal masses)- 44, Myomectomy-25, Sling-18, Miscellaneous- 18 (Endometriosis- 7, VVF repair- 3, Bladder repair- 3, Burst Abdomen- 3, Vault (Sacrospinous fixation (SSF)- 2)
3. Laparoscopic surgeries- TLH/ LAVH- 67, Others- 10 (Endometriosis, ovarian/adnexal masses)

Among all patients who underwent caesarean section 0.7% [10] suffered from bladder injury, 0% ureteric injury and 0% for ureteric and bladder injury.

Total 464 patients operated for gynaecological procedures in which 387 patients- open procedure and 77 patients- laparoscopically managed. Among all patients who underwent gynaec procedure 7.5% [35] suffered from bladder injury, 2.8% [13] ureteric injury and 2 [0.8%] with concurrent injuries.

Overall incidence of bladder injury is 2.4% [45], ureteric injury 0.7% [13] and bladder with ureteric injury in 0.1% [2] cases.

TABLE 4- LOCATION OF INJURY IN BLADDER

In bladder injury total 47 cases are found, most of the cases are bladder dome 37 cases, posterior wall 7 cases, lateral wall 3 cases and none cases in bladder neck injury.

TABLE 5- TYPE OF URETERIC INJURY

In ureteric injury, most of the cases mucosal sparing types 5 cases, thermal injury and ureteral injury found in 3 cases each, partial transection and fistula formation found in one case each. Total 15 cases are found ureteric injuries.

TABLE 6 TYPE OF MANAGEMENT

Most bladder injuries were repaired using a triple-layer Vicryl technique with suprapubic catheter (SPC) insertion in 20 cases, while 9 cases involved triple-layer repair without SPC insertion. Additionally, 13 cases were managed with Foley catheterization alone.

Ureteric injuries were addressed through double-J (DJ) stent insertion with repair in 6 cases, and ureteric repair via oversewing or conservative management in 5 cases. Fistula repair was performed in 1 patient. A total of 6 patients were lost to follow-up.

A systematic review conducted by Jacqueline MK Wong et al. (2018) revealed an overall incidence of Urinary Tract (UT) injuries during gynaecological surgeries at 0.33%, with bladder injuries occurring at a rate of 0.24%, rendering them three times more prevalent than ureteral injuries (0.08%). Laparoscopic hysterectomy exhibited a notably higher UT injury incidence (1.8%) compared to laparoscopic-assisted vaginal hysterectomy (1%). Most ureteral injuries were attributable to electrosurgery (33.3%), while adhesiolysis was implicated in most bladder injuries (23.3%). Furthermore, 60% of ureteral injuries were identified postoperatively, in contrast to the 85% of bladder injuries diagnosed intraoperatively.

The incidence of UT injuries varies significantly by surgical approach and procedure type. For instance, radical hysterectomy has reported rates of approximately 50% while abdominal hysterectomy has an incidence of 40% and vaginal hysterectomy records less than 5%. Surgical interventions for pelvic organ prolapse also present a risk, with undetected injuries leading to severe complications such as peritonitis, fistula formation, and potential deterioration of renal function.

The implications of such injuries are profound. Undiagnosed injuries can result in serious, life-altering consequences, and alarmingly, only one-third are typically identified intraoperatively. This oversight contributes significantly to the prevalence of litigation in contemporary medical practice. Notably, more than half of ureteral injuries occur without identifiable risk factors, even in ostensibly straightforward hysterectomies.

Several risk factors predispose patients to these injuries, including congenital anomalies of the ureter and kidney, uterine displacement due to enlarged fibroids or tumors, and the presence of adhesions stemming from conditions such as PID, Endometriosis or prior surgeries, H/O Radiation etc. Distorted pelvic anatomy, significant intraoperative haemorrhage, concomitant bladder/ureteric injuries, and variations in surgical skills and experience further compounds the risks.

Recognizing these factors and employing effective detection methodologies are essential for enhancing surgical safety and improving patient outcomes. Continuous education and awareness among surgical teams regarding the potential for UT injuries will be vital in mitigating complications during gynaecological surgeries.

Bladder Injury- Types & Presentation-

While traumatic events are the leading cause of bladder injuries, iatrogenic injuries are not uncommon and can be

classified into three categories: internal bladder procedures, such as endoscopic urological interventions; external surgeries near the bladder, including pelvic gynaecological, general, and urological procedures; and hysterectomy, which is the most prevalent cause. In one institution, iatrogenic bladder injuries were attributed to obstetric and gynaecological surgeries (65%), general surgeries (22%), and urological surgeries (13%)[15].

Clinical presentation of bladder injuries varies based on the nature of the injury. External bladder injuries are often recognized intraoperatively—approximately 80% of cases—through direct visualization of tissue injury, the presence of urine in the operative field, air in the Foley catheter collection bag, or direct visualization of the Foley catheter itself. Conversely, intraoperative internal bladder injuries may manifest as new-onset abdominal distension, difficulty maintaining bladder distension with instilled fluid, or visualization of urine outside the bladder.

Perioperative bladder injuries can present with a range of clinical signs and symptoms, including suprapubic pain, haematuria, and oliguria. Gross haematuria and abdominal tenderness are particularly common in patients with bladder injury. Patients may also experience worsening abdominal pain due to urine extravasation, emphasizing the need for a cystogram prior to catheter removal, even in cases of simple, small bladder injuries.

Ureteral Injuries: Types & Presentation-

Ureteral injuries can be categorized into five primary types. Firstly, Mucosa-Sparing Wall Injury occurs when the mucosa remains intact, but the muscularis or serosal layers are damaged. Secondly, Thermal Injury results from damage caused by thermal energy transfer. Third- Ureteral Ligation involves unintentional encircling or tying of the ureter, compromising blood flow, and potentially leading to ischemic damage or obstruction. Fourth- Transection injuries are classified further: Minor (<50% circumference), Partial (50-90% circumference), and Total (complete severance), with locations categorized as Upper/Middle Third (uncomplicated or complicated) and Lower Third. Lastly, Fistula Repair involves surgical correction of abnormal communications between the ureter and adjacent organs or skin, often resulting from untreated or complicated ureteral injuries.

Common Mechanisms of Ureteral Injury-

Ureteral injuries often result from various mechanisms during surgical procedures. One common cause is crushing from clamp misapplication, which can occur when surgical instruments are improperly placed or applied with excessive force. Additionally, suture ligation can inadvertently encircle and constrict the ureter, compromising blood flow. Transection, either partial or complete, is another frequent mechanism, often resulting from mistaken identity or improper handling of tissues. Angulation of the ureter with secondary obstruction can also lead to injury, as can ischemia caused by ureteral stripping or electrocoagulation. Furthermore, ureteric segmental resection, although sometimes necessary, carries inherent risks of injury to the ureter.

Postoperative Evaluation Signals and Investigations

More than two-thirds of urogenital injuries are diagnosed postoperatively. Key signals for evaluation include:

1. Costo-vertebral angle tenderness or flank pain.
2. Unexplained fever.
3. Persistent abdominal distension or ileus.
4. Unexplained haematuria.
5. Watery discharge from the vagina, drains, or wounds.
6. Lower abdominal pain or a palpable mass.
7. Oliguria or anuria, which is a hallmark sign of bilateral ureteral injury.
8. Elevated creatinine levels.

Diagnostic investigations are essential for confirming injuries:

1. Blood testsindicating raised white cell counts, urea, electrolytes, and creatinine levels.
2. Intravenous pyelogram (IVP):The gold standard for assessing non-visualization of a urinary segment, dilatation, delayed dye spillage, peritoneal extravasation, or urinoma formation.
3. Retrograde or antegrade ureterogramfor fistula identification.
4. Ultrasound of the abdomen and pelvisto detect hydronephrosis, urinomas, or ascites.
5. CT scanfor confirmation of ultrasound findings.
6. Fistulogramor Double/Triple Dye Test (Tampon Test) for diagnosing fistulas.
7. Cystoscopy with C-armor ureteroscopy to visualize urinary spurring or fistulas and to localize injuries.
8. Fluid analysisof drain or ascitic fluids to assess for urine or inflammatory markers.

These evaluations and investigations are crucial for timely identification and management of postoperative bladder and ureteral injuries

Timing of intervention-

1. Conservative-stent via PCN & fluoroscopic guidance/cystoscopically for 6-8 weeks
2. If within 14days, operate immediately
3. After 14 days plan after 6 weeks, till tissue oedema, inflammation subsides Interim measures to preserve renal function, PCN, if required is to be carried out.

Prevention of UT Injuries- [6]

1. Primary-Anticipate & Avoid Insult-

• Intra Venous Urogram (IVU)
• USG
• Pre-op evaluation of tract, identification of anatomic variations, hydronephrosis, kinking etc
• Pre-op, prophylactic catheterisation in selected cases, use of fluorescent dyes etc

2. Secondary- Intraoperative Recognition and Repair of Ureteral and Bladder Injuries-

The primary approach to preventing urogenital injuries during surgery involves meticulous surgical dissection and thorough knowledge of the urinary tract's anatomical positions within the surgical field. Key practices include:

1. Intraoperative Identification:Surgeons must clearly identify the bladder and ureters to avoid inadvertent injury.

1. Operative Techniques:
2. Utilize appropriate operative routes and approaches, including the lateral window technique, while maintaining adequate traction and counter-traction by lifting the uterus and pedicles before clamping, staying close to uterus, lifting the uterus/ pedicles before clamping, use of appropriate manipulators (vaginal or myoma screws) etc
3. Maintain sufficient exposure and conduct inspection of vascular pedicles and ureteric structures.
4. Avoid blind clamping and ligation of blood vessels, ensuring the bladder is mobilized away from the operative site before clamping.

1. Dissection Practices:
2. Stay outside the ureteric vascular sheath (adventitia) during dissection.
3. Direct visualization of the ureters is crucial, especially at critical points such as the pelvic brim and the bifurcation of the common iliac artery. The left side may present more challenges; therefore, using peristalsis as a guide can be beneficial.
4. Rest course is followed in broad ligament, peristalsis to be looked for, in open surgeries- palpation of ureter can be a guiding tool. In non-visualisation cases, stay flush to the uterus.
5. Social Distancing helps! Avoid unnecessary dissection of the ureters to prevent adventitial damage and potential ischemic insults, which can lead to postoperative fibrosis and complications like hydronephrosis.

1. Injury Awareness and Diagnostic Techniques:
2. Be vigilant for signs of injury, such as urine in the operative field.
3. The retrograde filling of the bladder with dyes (e.g., methylene blue) during complex dissections can aid in the early detection of injuries.
4. Routine cystoscopy is recommended in high-risk cases to enhance injury detection.

Specific Anatomic Sites for Injury Prevention:

1. Pelvic Brim: Infundibulum-pelvic clamp should be lifted before clamping.
2. Bifurcation of Common Iliac Artery: Pay special attention during intra-abdominal lateral approaches (IIAL).
3. Lateral Pelvic Wall: Maintain caution above the uterosacral ligaments.
4. Uterine Pedicle: Keep dissection flush to the uterus.
5. Base of Broad Ligament: Recognize that the ureter lies beneath the artery.
6. Ureteric Canal During Wertheim's Procedure: Exercise caution in this area.
7. Upper Vagina/Vaginal Vault: Be mindful during vaginal angle clamping.
8. Intramural Portion of Ureter: Focus on the area near the trigone insertion at the bladder base.

Considerations During Vaginal Surgeries:

1. Ensure adequate vesical-uterine space by utilizing cervical traction and counter-traction with a Sim's speculum.
2. Employ small bites before clamping and avoid deep sutures or double clamping, especially at uterosacral fixation points.
3. Conduct vaginal oophorectomy with caution.

Anterior Colporrhaphy Techniques:

1. Perform meticulous dissection and consider using hydro dissection to minimize bladder injuries.
2. Continuous drainage through a catheter can help avoid bladder damage.
3. Limit lateral dissection to safeguard the ureters, especially avoiding deep sutures near the apex where the distance to the ureter may be as minimal as 0.9 cm.

Burch Procedure, TVT, TOT Considerations:

1. Ensure clear dissection angles to protect the ureters.
2. Position the guiding vaginal finger adequately to prevent bladder injury, and conduct postoperative cystoscopy checks.

Laparoscopic Techniques:

1. Loosely move fallopian tubes from pelvic side walls before clamping.
2. Use uterine manipulators to avoid injury to the uterine pedicle.
3. Control bleeding at the uterosacral junction with clips/sutures rather than electrocoagulation.
4. In LAVH, exercise caution when using electrocoagulation on the uterus.
5. Lateral spread of devices should be understood before using
6. Dissect, Expose then coagulate. Limit zone of coagulation, keep safe distance (1cm), use for short duration, do not char tissues, use perpendicular approach for coagulation.
7. Restore anatomy before coagulation in cases of broad ligament fibroids, endometriosis.

Intraoperative Diagnosis and Management-

• Clarify any suspicions during the procedure, as delayed diagnosis can significantly decrease repair success.
• Promptly identify the nature and severity of any insult:
• Utilize dye tests, intraoperative cystoscopy, and peri-operative ultrasound for real-time evaluations.

Contrast and Fluid Use for Suspected UT Injuries:

1. Intra Vesical Agents:
2. Methylene blue
3. Sterile infant formula (used by urologists)
4. Mannitol (promotes visualization of ureteral jets, not easily available)
5. Normal saline (not useful for assessing injuries)
6. 50% dextrose (historically used, linked to increased post-op UTIs)

1. Oral/IV Agents for Suspected Ureteral Insults:
2. Phenazopyridine (100mg PO, 1 hour pre-op)- urine becomes reddish orange
3. Vitamin B complex- urine yellowish, inconsistent results.
4. Sodium fluorescein (10%, 1ml IV)- urine Fluorescent yellow 9 Opti mark)
5. Indigo carmine (2.5ml, 0.8%), urine- Blue, not freely available.
6. Methylene blue (not for IV use due to risks, >7 mg/kg causes methemoglobinemia, serotonin syndrome.)
7. IV Fluid bolus and furosemide 20 mg with head up, may help confirm ureteral patency
8. Furosemide vs placebo, furosemide helps confirm ureteral patency, a minute faster. (86.5) vs 165 sec)
9. Mannitol bladder distension media has been reported to provide the most surgeon satisfaction, in comparison to phenazopyridine, sodium fluorescein, and normal saline distension.

Ultimately, the surgeon should make the final decision about which agent is used based on his/her preference and institutional availability [7].

Routine Cystoscopy/ Ureteroscopy: -Screening for injury-

• Routine intra-op cystoscopy increases detection rate of urinary tract injury up to 5-fold compared with no cystoscopy group.
• A systematic review (79 studied) &meta-analysis by Teeluckdharry B et al, found the detection rate of ureteric & bladder injuries increased to 95% with cystoscopy from 18 & 79% without cystoscopy (8).
• Also, Ibeanu OA et al in 2009, stated that most ureteral injuries are not detected by visual inspection alone [9].
• Alice M Chi et al in 2016, published retrospective study at their centre with policy of universal cystoscopy after benign hysterectomy. Urologic injury rates were 2.6% & 1.8% in pre- policy & post policy groups. Also delayed injury detection decreased significantly from 0.7% to 0.1%, suggesting a decreased post-op urologic complication and in turn decreased consequent morbidity [10].
• Peter L, in International Urogynaecology Journal (2010), found, though urinary tract injuries are less in gynaec operations, only 1/10 ureteral & 1/3 bladder injuries are detected intra-op without cystoscopy, rest all are left undiagnosed causing significant post-op morbidity for patient & Litigations for gynaecologists. Hence, there is an urgent need for all gynaecologists to become competent in cysto-urethroscopy & perform it intra operatively, at least in all high-risk surgeries [11].
• Beware!!- non-obstructive, partially obstructive, or late injuries due to ischaemia/ avascular necrosis can be missed on cystoscopy. It is not to be substituted for a good operative technique & vigilant post-operative care!!
• A retrospective review of 700 consecutive patients who underwent surgery for anterior vaginal wall and/or vaginal vault prolapse with concomitant universal cystoscopy found an intraoperative ureteral obstruction rate of 5.1%, with a positive predictive value for intraoperative cystoscopy of 99.3%. There was a sensitivity of 94.4% & specificity of 99.5% [12].
• Intraoperative bladder injury should be repaired by open surgery unless expertise and pre-existing approach allows a laparoscopic or robot-assisted laparoscopic repair. Consider ureteric injury and if there is any suspicion of ureteric injury bilateral retrograde ureterograms should be performed. Drainage after repair should be with urethral and preferably suprapubic catheterisation. Exceptions may include a simple, small injury to the bladder. If a bladder injury is discovered postoperatively, several patient factors will determine if or when bladder repair should be performed.

3. Tertiary- Post-Operative Diagnosis and Treatment of Injury-

Principles of Open Repair
Bladder-Effective surgical management of urological injuries involves several critical techniques: achieving adequate exposure, performing urethral catheterization, mobilizing the bladder, and meticulously closing bladder injuries using absorbable sutures. The closure must be performed without tension, either in a continuous or interrupted fashion, often with the interposition of omentum. A suprapubic catheter should be placed unless the injury is minor and straightforward, while a non-suction drain is recommended. Postoperatively, a cystogram should be conducted at 2 to 3 weeks prior to catheter removal.

Ureteric-The primary goals of surgical treatment are to preserve function and reestablish anatomical continuity, with decisions informed by factors such as the timing, type, extent, site, duration of injury, patient condition [13], and available urological expertise. Successful management aims to protect the renal unit while ensuring adequate drainage via stenting or nephrostomy, all while minimizing surgical morbidity.

Specific Surgical Interventions in Ureteric Injuries-

1. Mucosa Sparing Wall Injury: Oversewing with absorbable sutures.
2. Thermal Injuries: Resection and management like transection protocols.
3. Ureteral Ligation: Deligation, assessment of viability, and stent placement.
4. Transection:
5. Minor Injury:Manage with stenting, balloon dilation, or open repair.
6. Partial:Repair over a stent.
7. Total Injuries:
8. Upper/Middle Third:

Uncomplicated—uretero-ureterostomy over a stent or transuretero-ureterostomy.

Complicated—uretero-ileal interposition.

1. Lower Third:Uretero-neo-cystostomy with psoas hitch over a stent, or ureteral reimplantation.
2. Fistula Repair:Address as per standard repair protocols.

Principles of Ureteric Reconstruction [14]- In ureteric reconstructive surgery, adherence to key principles is vital:

1. Careful mobilization of the ureter while preserving the adventitia and blood supply.
2. Debridement of all necrotic tissue to ensure clean margins.
3. Wide spatulation of the ureteric lumens.
4. Tension-free repair over a J stent utilizing absorbable sutures, with a non-suction drain placed adjacent to the repair.
5. Isolation of the reconstruction, when possible, using omentum or peritoneum.
6. Decision-making regarding refluxing versus non-refluxing anastomosis should depend on the clinical scenario and surgeon's expertise.

Surgeons strive to perform procedures with utmost precision and minimal complications; however, unforeseen issues may arise, affecting patient outcomes. Continuous analysis of surgical errors and maintaining thorough records are crucial for adapting protocols and improving future surgery. While urological injuries are infrequent, they can lead to significant morbidity. Bladder injuries are more common than ureteral injuries, with the former typically resulting in less morbidity due to early detection and repair. Conversely, ureteral injuries, though less frequent, are associated with substantial morbidity. Prompt diagnosis and intervention are essential to prevent serious complications in gynaecological surgery. Effective resolution of such problems requires close collaboration between Urologists and Gynaecologists.

"In surgery, you become a true surgeon when you manage complications effectively," – Professor Owen H. Wangensteen.

Educational Tools to Improve Training

1. Surgical training under supervision for freshly graduated surgeons.
2. Utilization of videos, lectures, and electronic resources to enhance anatomical understanding.
3. Training on pelvic trainers and simulators, alongside exposure to animal models and human cadavers.
4. Fellowship opportunities in endoscopy and urogynaecology.
5. Continuing education, such as conferences and research initiatives, will support ongoing training.

1. Thompson RH. Ureteral injuries in pelvic surgery. Bull Dept Gynecol Obstet Emory U 1980; 11:93.   
2. Mattingly RF, Thompson JD. In: “TeLinde's Operative Gynaecology”. Ed. 6th. Philadelphia: JB Lippincott Co; 1985.
3. Park RC, Duff WP. Role of caesarean hysterectomy in modern obstetric practice. Clinics in Obstet Gynaecol 1980; 23:601-620.  
4. Urinary Tract Injury During Gynaecologic Surgery Prevention, Recognition, and Management Ushma J. Patel, MDa, Christine A. Heisler, MD, MS Obstet Gynecol Clin N Am 48 (2021) 535–556 https://doi.org/10.1016/j.ogc.2021.05.007
5. Wong JMK, Bortoletto P, Tolentino J et al. Urinary Tract Injury in Gynaecologic Laparoscopy for Benign Indication: A Systematic Review. Obstet Gynecol. 2018; 131:100.
6. Anju Kumari Rani, Dr. Brijesh Singh and Shobhit Kumar. Urological injuries in gynaecological surgery: A review. International Journal of Clinical Obstetrics and Gynaecology 2020; 4(2): 409-412.
7. Cohen, Seth A. MD; Carberry, Cassandra L. MD, MS; Smilen, Scott W. MD. American Urogynecologic Society Consensus Statement: Cystoscopy at the Time of Prolapse Repair. Female Pelvic Medicine & Reconstructive Surgery 24(4): p 258-259, 7/8 2018. | DOI: 10.1097/SPV.0000000000000529
8. Teeluckdharry B, Gilmour D, Flowerdew G. Urinary Tract Injury at Benign Gynaecologic Surgery, and the Role of Cystoscopy: A Systematic Review and Meta-analysis. Obstet Gynecol. 2015; 126:1161.
9. Ibeanu OA, Chesson RR, Echols KT et al. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol. 2009; 113:6.
10. Alice Chi M, Curran DS, Morgan DM, Fenner DE, Swenson CW. Universal Cystoscopy After Benign Hysterectomy: Examining the Effects of an Institutional Policy. Obstet Gynecol. 2016 Feb;127(2):369-75. Doi: 10.1097/AOG.0000000000001271. PMID: 26942367; PMCID: PMC4780351.
11. Peter Dwyer, P.L. Urinary tract injury: medical negligence or unavoidable complication? Int Urogynaecology J21, 903–910 (2010). https://doi.org/10.1007/s00192-010-1175-4.
12. Bahadur A, Mundhra R, Kashibhatla J, Chawla L, Ajmani M, Sharma S, Zaman R, Sri MS. Intraoperative and Postoperative Complications in Gynaecological Surgery: A Retrospective Analysis. Cureus. 2021 May 7;13(5): e14885. Doi: 10.7759/cureus.14885. PMID: 34104610; PMCID: PMC8180178.
13. Glaser, Laura M. MD; Milad, Magdy P. MD, MS. Bowel and Bladder Injury Repair and Follow-up After Gynaecologic Surgery. Obstetrics & Gynaecology 133(2): p 313-322, February 2019. | DOI: 10.1097/AOG.0000000000003067.
14. Sahai, A., Ali, A., Barratt, R., Belal, M., Biers, S., Hamid, R., Harding, C., Parkinson, R., Reid, S., Thiruchelvam, N. and (2021), British Association of Urological Surgeons (BAUS) consensus document: management of bladder and ureteric injury. BJU Int, 128: 539-547. https://doi.org/10.1111/bju.15404
15. Esparaz AM, Pearl JA, Herts BR, LeBlanc J, Kapoor B. Iatrogenic urinary tract injuries: aetiology, diagnosis, and management. Semin Intervent Radio. 2015 Jun;32(2):195-208. Doi: 10.1055/s-0035-1549378. PMID: 26038626; PMCID: PMC4447880.
16. Idowu Pius Ade-Ojo, Olatoyosi Tijani. A Review on the Aetiology, Prevention, and Management of Ureteral Injuries During Obstetric and Gynaecologic Surgeries. International Journal of Women’s Health 2021:13 895–902.
17. Thompson JD. Operative injuries to the ureter: prevention, recognition, and management. TeLinde's operative gynecology.8th ed. Philadelphia: Lippincott Williams and Wilkins; 1997:1135-1174.
18. Gilmour DT, Dwyer PL, Carey MP. Lower urinary tract injury during gynaecologic surgery and its detection by intraoperative cystoscopy. Obstet Gynecol. 1999; 94:883-9.