Injury to Bladder during Laparoscopic Surgery
Laparoscopy associated damage to the bladder or ureter may occur secondary to mechanical or thermal trauma. Vesical injury is often secondary to a trocar entering the undrained bladder, but may also occur during dissection of the bladder, either from other adhered structures or from the anterior aspect of the uterus. The proliferation of laparoscopically directed retropubic suspension for urinary incontinence will likely be associated with bladder injury. Ureteric injury is more commonly encountered secondary to thermal damage. However, more recently; there have been descriptions of ureteric trauma secondary to other causes, such as mechanical dissection or the use of linear stapling devices.
Diagnosis
If urinary bladder is injures intraoperative identification of the injury is the most important aspect of management. The surgeon may be cognizant of entering a hollow viscus or may note the presence of urine in the operative field. If an indwelling catheter is in place, hematuria or pneumaturia (CO2 in the indwelling drainage system) may be noted. Existence of a bladder laceration may be confirmed with the injection of sterile milk or a dilute methylene blue solution via a catheter. Thermal injury to the bladder may not be initially apparent, presenting later in the patient’s postoperative course.
Unfortunately, although intraoperative recognition of ureteric injury has been described, diagnosis is usually delayed until some time following the procedure. Ureteric lacerations may be proven intraoperatively with the injection of indigo carmine. Thermal injury will present, 24 hours to 14 days following surgery with one or a combination of fever, abdominal or flank pain, and the clinical findings of peritonitis. A leukocytosis may be present and an intravenous pyelogram (IVP) will demonstrate extravasation of urine or urinoma. Intraoperative recognition of mechanical obstruction, with staples or a suture, will be made only by direct visualization. Not surprisingly, cases of laparoscopy associated ureteric obstruction seem to present at a time similar to those that follow laparotomy based procedures a few days to a week following the operation. These patients present with flank pain and may have fever. The diagnosis may be suggested by abdominal ultrasound, but an IVP can be more precise at identifying the site and completeness of the obstruction.
Uretero or vesicovaginal fistula will present in a delayed fashion with incontinence or discharge. Confirmation of bladder fistula will be by direct visualization and/ or the leakage of instilled methylene blue onto a tampon. Ureterovaginal fistula will not pass the methylene blue from the bladder, but will be demonstrated with the intravenous injection of indigo carmine.
Prevention
Before start of surgery patient should void urine. Trocar- related cystotomies are generally preventable with routine preoperative bladder drainage. Additional caution must be exercised in the patient previously exposed to abdominal or pelvic surgery, where there is a tendency for the bladder to be pulled above the level of the symphysis pubis. The urachus, although rarely present, should be avoided if possible. It is likely that the placement of an indwelling catheter, at least for prolonged or difficult cases, will reduce the incidence of injury resulting from dissection. Surgical separation of the bladder from the uterus or other adherent structures requires good visualization, appropriate retraction, and excellent surgical technique. Sharp mechanical dissection is preferred, particularly when relatively dense adhesions are present.
If the surgeon cannot, with assurance, steer a wide path from its course, the ureter must be directly visualized. This is especially true when laser, electrosurgical, or stapling techniques are employed. Frequently, the ureter can be seen through the peritoneum of the pelvic sidewall between the pelvic brim and the attachment of the broad ligament. However, because of patient variation, or the presence of pathology, the location of the ureter can become obscured. In such instances, the ureter can usually be visualized through the peritoneum at the pelvic brim, although the maneuver is slightly more difficult on the left because of the location of the sigmoid mesentery. If CO2 laser energy is to be employed, fluid injected at an appropriate location between the peritoneal surface and the ureter can provide a degree of protection from thermal injury.
If entry into the retroperitoneal space is required for exposure, there should be no hesitation to undertake such dissection. The surface of the peritoneum should be breached with scissors at the closest level proximal, and anterior, to the most distal site of planned dissection where the location of the ureter is known or anticipated. If the ureter is seen through the peritoneum, it may be grasped with a Babcock forceps to minimize trauma while the peritoneum is incised. Careful sharp and blunt dissection then may be applied to provide adequate exposure in the operative field. If the ureter cannot be seen through the peritoneal surface, a fine, toothed forceps should be employed to grasp and elevate the peritoneum allowing careful entry into the retroperitoneal space.
The techniques used for retroperitoneal dissection are also important in reducing the risk of ureteric injury. Blunt dissection can be facilitated with the instillation of fluid into the retroperitoneal space under pressure. Others have advocated the selective preoperative placement of ureteric stents including those that are illuminated, to provide additional safety. We prefer instead the use of mechanical (sharp or blunt) dissection with sharp-curved scissors and a narrow, pointed grasping forceps attached to an electrosurgical generator. The assistant is provided with a narrow, pointed, and toothed grasping forceps as well as a suction irrigation system to use, as requested, through an ancillary cannula. Dissection proceeds, respecting the blood supply of the ureter by minimizing direct manipulation and by preserving the integrity of its sheath. If electrical energy is used, it must be applied judiciously, at safe distances from the ureter and its blood supply. The narrow, pointed grasping forceps facilitates precise and safe desiccation of small caliber blood vessels.
Treatment
Most of the injury of the bladder can be managed conservatively. Small caliber injuries to the bladder (1-2 mm) may be treated expectantly, with prolonged catheterization for 7 to 14 days. However, in such cases the duration of catheterization can be reduced or eliminated if repair is undertaken intraoperatively. When a more significant injury to the bladder is identified, it may often be repaired under laparoscopic direction, provided the presence of adequate surgical skill and a location that is amenable to laparoscopic technique. Further evaluation of the location and extent of the laceration may be provided by direct laparoscopic examination of the mucosal surface of the bladder. Should the laceration be near to or involve the trigone, open repair may be preferable. In making this evaluation, the mechanism of injury should be considered, as desiccation resulting from electrical energy may extend beyond the visible limits of the lesion.
A purse string closure may be fashioned using any of a number of synthetic absorbable sutures of 2-0 to 3-0 caliber, tying the knot either intra-or extracorporeally. For linear lacerations, the defect is preferably closed in two layers. If there is significant thermal injury, it may be valuable to excise the coagulated segment. Postoperative catheterization with either a large caliber urethral or suprapubic catheter should be maintained for 5 to 7 days for simple fundal lacerations, and for two weeks for those closer to the trigone, the vaginal vault, or those that may be associated with significant thermal injury.
During minimal access surgery intraoperative diagnosis of ureteric injury provides the opportunity for intraoperative management. If damage is less it may respond adequately to the passage of a ureteric stent for about 10 to 20 days. However, in most instances, repair is indicated. The principles should follow those previously established for open cases. While laparoscopically directed repair of ureteric lacerations and transections have been described , such maneuvers should be practiced only by those with exceptional surgical skill and experience. Even in these cases it is advisable to consult intraoperatively with a specialist in urology.
When the diagnosis of ureteral injury is delayed until following surgery, the imperative is to establish drainage. Some obstructions or lacerations, if incomplete or small, may be successfully treated with either the retrograde or anterograde passage of a ureteral stent. Urinomas may be drained percutaneously. If a stent cannot be successfully manipulated across the lesion, a percutaneous nephrostomy should be created and plans should be made for operative repair.
Laparoscopy associated damage to the bladder or ureter may occur secondary to mechanical or thermal trauma. Vesical injury is often secondary to a trocar entering the undrained bladder, but may also occur during dissection of the bladder, either from other adhered structures or from the anterior aspect of the uterus. The proliferation of laparoscopically directed retropubic suspension for urinary incontinence will likely be associated with bladder injury. Ureteric injury is more commonly encountered secondary to thermal damage. However, more recently; there have been descriptions of ureteric trauma secondary to other causes, such as mechanical dissection or the use of linear stapling devices.
Diagnosis
If urinary bladder is injures intraoperative identification of the injury is the most important aspect of management. The surgeon may be cognizant of entering a hollow viscus or may note the presence of urine in the operative field. If an indwelling catheter is in place, hematuria or pneumaturia (CO2 in the indwelling drainage system) may be noted. Existence of a bladder laceration may be confirmed with the injection of sterile milk or a dilute methylene blue solution via a catheter. Thermal injury to the bladder may not be initially apparent, presenting later in the patient’s postoperative course.
Unfortunately, although intraoperative recognition of ureteric injury has been described, diagnosis is usually delayed until some time following the procedure. Ureteric lacerations may be proven intraoperatively with the injection of indigo carmine. Thermal injury will present, 24 hours to 14 days following surgery with one or a combination of fever, abdominal or flank pain, and the clinical findings of peritonitis. A leukocytosis may be present and an intravenous pyelogram (IVP) will demonstrate extravasation of urine or urinoma. Intraoperative recognition of mechanical obstruction, with staples or a suture, will be made only by direct visualization. Not surprisingly, cases of laparoscopy associated ureteric obstruction seem to present at a time similar to those that follow laparotomy based procedures a few days to a week following the operation. These patients present with flank pain and may have fever. The diagnosis may be suggested by abdominal ultrasound, but an IVP can be more precise at identifying the site and completeness of the obstruction.
Uretero or vesicovaginal fistula will present in a delayed fashion with incontinence or discharge. Confirmation of bladder fistula will be by direct visualization and/ or the leakage of instilled methylene blue onto a tampon. Ureterovaginal fistula will not pass the methylene blue from the bladder, but will be demonstrated with the intravenous injection of indigo carmine.
Prevention
Before start of surgery patient should void urine. Trocar- related cystotomies are generally preventable with routine preoperative bladder drainage. Additional caution must be exercised in the patient previously exposed to abdominal or pelvic surgery, where there is a tendency for the bladder to be pulled above the level of the symphysis pubis. The urachus, although rarely present, should be avoided if possible. It is likely that the placement of an indwelling catheter, at least for prolonged or difficult cases, will reduce the incidence of injury resulting from dissection. Surgical separation of the bladder from the uterus or other adherent structures requires good visualization, appropriate retraction, and excellent surgical technique. Sharp mechanical dissection is preferred, particularly when relatively dense adhesions are present.
If the surgeon cannot, with assurance, steer a wide path from its course, the ureter must be directly visualized. This is especially true when laser, electrosurgical, or stapling techniques are employed. Frequently, the ureter can be seen through the peritoneum of the pelvic sidewall between the pelvic brim and the attachment of the broad ligament. However, because of patient variation, or the presence of pathology, the location of the ureter can become obscured. In such instances, the ureter can usually be visualized through the peritoneum at the pelvic brim, although the maneuver is slightly more difficult on the left because of the location of the sigmoid mesentery. If CO2 laser energy is to be employed, fluid injected at an appropriate location between the peritoneal surface and the ureter can provide a degree of protection from thermal injury.
If entry into the retroperitoneal space is required for exposure, there should be no hesitation to undertake such dissection. The surface of the peritoneum should be breached with scissors at the closest level proximal, and anterior, to the most distal site of planned dissection where the location of the ureter is known or anticipated. If the ureter is seen through the peritoneum, it may be grasped with a Babcock forceps to minimize trauma while the peritoneum is incised. Careful sharp and blunt dissection then may be applied to provide adequate exposure in the operative field. If the ureter cannot be seen through the peritoneal surface, a fine, toothed forceps should be employed to grasp and elevate the peritoneum allowing careful entry into the retroperitoneal space.
The techniques used for retroperitoneal dissection are also important in reducing the risk of ureteric injury. Blunt dissection can be facilitated with the instillation of fluid into the retroperitoneal space under pressure. Others have advocated the selective preoperative placement of ureteric stents including those that are illuminated, to provide additional safety. We prefer instead the use of mechanical (sharp or blunt) dissection with sharp-curved scissors and a narrow, pointed grasping forceps attached to an electrosurgical generator. The assistant is provided with a narrow, pointed, and toothed grasping forceps as well as a suction irrigation system to use, as requested, through an ancillary cannula. Dissection proceeds, respecting the blood supply of the ureter by minimizing direct manipulation and by preserving the integrity of its sheath. If electrical energy is used, it must be applied judiciously, at safe distances from the ureter and its blood supply. The narrow, pointed grasping forceps facilitates precise and safe desiccation of small caliber blood vessels.
Treatment
Most of the injury of the bladder can be managed conservatively. Small caliber injuries to the bladder (1-2 mm) may be treated expectantly, with prolonged catheterization for 7 to 14 days. However, in such cases the duration of catheterization can be reduced or eliminated if repair is undertaken intraoperatively. When a more significant injury to the bladder is identified, it may often be repaired under laparoscopic direction, provided the presence of adequate surgical skill and a location that is amenable to laparoscopic technique. Further evaluation of the location and extent of the laceration may be provided by direct laparoscopic examination of the mucosal surface of the bladder. Should the laceration be near to or involve the trigone, open repair may be preferable. In making this evaluation, the mechanism of injury should be considered, as desiccation resulting from electrical energy may extend beyond the visible limits of the lesion.
A purse string closure may be fashioned using any of a number of synthetic absorbable sutures of 2-0 to 3-0 caliber, tying the knot either intra-or extracorporeally. For linear lacerations, the defect is preferably closed in two layers. If there is significant thermal injury, it may be valuable to excise the coagulated segment. Postoperative catheterization with either a large caliber urethral or suprapubic catheter should be maintained for 5 to 7 days for simple fundal lacerations, and for two weeks for those closer to the trigone, the vaginal vault, or those that may be associated with significant thermal injury.
During minimal access surgery intraoperative diagnosis of ureteric injury provides the opportunity for intraoperative management. If damage is less it may respond adequately to the passage of a ureteric stent for about 10 to 20 days. However, in most instances, repair is indicated. The principles should follow those previously established for open cases. While laparoscopically directed repair of ureteric lacerations and transections have been described , such maneuvers should be practiced only by those with exceptional surgical skill and experience. Even in these cases it is advisable to consult intraoperatively with a specialist in urology.
When the diagnosis of ureteral injury is delayed until following surgery, the imperative is to establish drainage. Some obstructions or lacerations, if incomplete or small, may be successfully treated with either the retrograde or anterograde passage of a ureteral stent. Urinomas may be drained percutaneously. If a stent cannot be successfully manipulated across the lesion, a percutaneous nephrostomy should be created and plans should be made for operative repair.
