Urological injuries in OBG Practice DR.H.K.NAGARAJ M.B.B.S., M.S., M.Ch., F.I.C.S., Sr.Prof & Head, Urology Unit-1 M.S.Ramaiah Medical College And Hospital Bangalore-54.

Causes of injuries Hysterectomy open / Laparascopy – Bladder/ureteric Caesarian section C. Surgery for endometriosis/PID/Malignancy D. Obstructed Labour-Bladder and urethra E. Anterior Colporraphy F. Sling Surgery

Urological injuries Bladder injury leading to V.V.F. Ureteric injuries unilateral leading to ureterovaginal fistula or ureteric stricture Bilateral ureteral injury leading to uremia/urinary ascites

Symptoms/Presentation Silent Haematuria Urine leak per vagina - immediate / delayed Fever Sepsis Flank pain Vomiting Urinary ascites, Ileus

Intraoperative detection Excessive watery ooze Routine indigo carmine test Methylene blue Role of intra op cystoscopy.

Indigo-Carmine Test

Immediate post-op detection Urine leak per vagina Urine leak in the wound Leukocytosis, azotemia, acidosis Creatinine levels of the drain fluid

Delayed detection Hydroureteronephrosis Nonfunctioning kidney Urinary fistulae

Investigations Ultrasound scan of abdomen I.V.U. X ray CT with contrast Antegrade Nephrostogram Retrograde Ureterogram MCU Cystoscopy & methylene blue test

USG showing hydroureteronephrosis secondary to ureteric stricture

CT urogram

Retrograde ureterogram

Antegrade Nephrostogram

MCU

Cystoscopy

Management D.J.Stenting End to end anastomosis Ureteric reimplantation Psoas hitch/boari flap Ileal ureter V.V.F. Repair

D J Stenting

End to End anastomosis

Ureteric Reimplantation

Psoas hitch

Boari flap Tongue shaped flap from the Urinary Bladder Ureter is anastomosed to the tubularised bladder flap over a DJ stent

V.V.F. repair

Early laparoscopic repair for supratrigonal vesicovaginal fistula International Gynaecology Journal July 2007, Volume 18, Issue 7, pp 759-762 HK Nagaraj , TA Kishore et al Laparoscopic repair undertaken 2-4 wks after initial surgery. – Excellent outcomes

A Simplified Laparoscopic Approach to Repair Vesicovaginal Fistula: The M.S. Ramaiah Technique Tarun Dilip Javali, Amit Katti, and Harohalli K. Nagaraj UROLOGY 85: 544e546, 2015

Prevention Exposure to urinary tract Ureteric catheter insertion Use weck clips Stay close to uterus Prevent lateral tear of uterus during caesarian Put a drain-when in doubt Keep partially full bladder Use large size catheters to drain bladder Do bed side U/s abd

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