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Urinary tract injuries during laparoscopically assisted hysterectomy: Causes and prevention
Urinary tract injuries during laparoscopically assisted hysterectomy: Causes and prevention Nicholas
Kadar,
MD,
and Luc Lemmerling,
MD'
Neptune, Piscataway, and Princeton, New Jersey Two patients who had urinary fistulas after laparoscopic hysterectomy are described. In both cases the ureters were dissected free and the uterus was freed laparoscopically. Injury to the urinary tract occurred during transvaginal closure of the vaginal cuff. Preventative strategies are discussed. (AM J OssTET GYNECOL 1994; 170:47-8. )
Key words: Laparoscopic hysterectomy, vesisovaginal fistula, ureteric ligation Ureteric injuries during laparoscopic hysterectomy have been linked to the use of an endoscopic stapler. ' We describe two urinary fistulas that were unrelated to stapler use, and discuss predisposing factors and remedial measures. Case reports Case 1. A 30-year-old white woman underwent laparoscopic hysterectomy and left salpingo-oophorectomy for a borderline of the serous cyst adenocarcinoma perand right oophorectomy ovary after appendectomy formed 2 months earlier at another hospital. Adhesions at laparoscopy were so extensive that the pelvic organs could not be visualized, and initially only one trocar into the peritoneal cavity. The could be introduced adhesions were lysed without incident. During subseboth ureters were dissected free, quent hysterectomy and the entire specimen was freed laparoscopically except for about a centimeter of the vaginal cuff, which and then the cuff closed. was divided transvaginally The patient's postoperative course was unremarkable ileus. An intravenous pyelogram except for prolonged showed what was thought to be a small bladder leak and a urinoma that did not fill with dye. This was managed with a Foley catheter, but the patient leaked urine fourteenth day the and a on postoperative vaginally diagnosis of ureteric fistula was made. Retrograde urewas unsuccessful, but the patient teric catheterization dry by a percutaneous nephrostomy, was rendered in for 3 left months. At ureteric reimplace was which plantation the ureter was noted to have been ligated at the urethrovesical junction.
From the Diaozon of Gynecologic Oncology, Jersey Shore Medical Wood Center, the University of Medicine and Dentistry-Robert Johnson Medical School, ' and the Department of Obstetrics and Gynecology, Medical Center at Princeton. " Received for publication June 22,1993; revised July 9,1993; accepted July 19,1993. Reprint requests: Nicholas Kadar, MD, Jersey Shore Medical Center, 1945 Conies Ave., Neptune, NJ 08512.
Copyright © 1994 by Mosby-}Par Book, Inc. 0002-9378/94 $1.00 + 20 6/1/50178 .
laparo2. A 39-year-old woman underwent and bilateral salpingo-oophorecscopic hysterectomy pelvic pain. Both ureters were tomy for long-standing identified and dissected free during the operation, and and rethe uterus was freed entirely laparoscopically moved through the vagina. The cuff was closely vaginally because endoscopic needle holders were not available. The patient made an uneventful recovery but had A tampon a vaginal urine leak a week postoperatively. test in the office demonstrated a vesicovaginal fistula. It 3 months later and required was closed abdominally because of the proxipsi]atera] ureteric reimplantation Case
imity of the fistula
to the ureteric
orifice.
Comment The features common to these injuries are that both in both occurred spite of meticuunrecognized, were lous anatomic dissection of the ureters, and both inlaparoscopic reseccomplete or almost volved complete tion of the uterus followed by transvaginal closure of the vaginal cuff. We believe that these injuries were caused during closure of the cuff and were predisposed to by extensive laparoscopic dissection of the bladder off the cervix and vagina. During
hysterectomy
the bladder
is
an abdominal dissected caudally off the cervix, and the vaginal cuff during bladder, to the vaginal whereas closed proximal
the bladder is dissected cephalad and the In both situations cuff closed distal to the bladder. dissection of the bladder serves to expose the vaginal cuff and facilitate its closure after removal of the uterus. By contrast, the bladder is dissected caudally and the cuff closed distal to the bladder if bladder dissection hysterectomy
during
laparoscopic
hysterectomy
is followed
by transfar from
vaginal closure of the vaginal cuff. Therefore, facilitating closure of the cuff, laparoscopic dissection of the bladder brings the bladder and distal ureter down into harm's way. Neither ureteric
dissection nor a scent will protect the ureter from transvaginal injury, but a stent will help to identify unrecognized ureteric ligation, and its use is
47
Gaudier et al.
strongly recommended. Similarly, neither strategy nor instillation of indigo carmine into the bladder will identify transvaginal suture placement into the bladder, and some dissection of the vaginal cuff to evert its edges toward the operator may be required to safeguard against this. However, it seems to us more logical to avoid laparoscopic dissection of the bladder altogether if the cardinal and uterosacral ligaments are to be divided vaginally, for this does not facilitate the operation very much. Division of the bladder peritoneum is still worthwhile because in the absence of uterine de-
January 1994 Am J Obstet Gynecol
scent the white line of the anterior cul-de-sac can be high and difficult to reach, particularly if the subpubic arch is narrow. If absence of uterine descent and a very narrow subpubic arch render vaginal access to the cardinal and uterosacral ligaments difficult or impossible, the best approach is to do the entire operation laparoscopically, including closure of the vaginal cuff. REFERENCE 1. Woodland MB. Ureter injury during laparoscopy-assisted vaginal hysterectomy with endoscopic OBSTEI GYNECOL 1992; 167: 756-7.
lineal
stapler.
Ant J
Acid-base status at birth and subsequent neurosensory impairment in surviving 500 to 1000 gm infants Francisco L Gaudier, MD, Robert L. Goldenberg, MD, Kathleen G. Nelson, MD, Myriam Peralta-Carcelen, MD, Susan E. Johnson, RN, Mary B. DuBard, MA, Tracy Y. Roth, MD, and John C. Hauth, MD Birmingham, Alabama OBJECTIVE: The purpose of this study was to assess, in Infants born weighing s 1000 gm, if umbilical cord blood acid-base measures at birth are associated with an additional increase In neurosensory impairment.
STUDY DESIGN: Of 289 surviving Infantswith a birth weight of 500 to 1000 gm born from 1979 to 1989, 219 had umbilical cord acid-base status measured at birth and were followed prospectivelyfor a1 year. Measuresof neurologic impairment used In this study Included mental retardation,cerebral palsy,and major neurosensoryImpairment. RESULTS: Gestational age was Inversely associated with all neurosensory impairments and was a better predictor of subsequent impairment in this population than was birth weight. Very low umbilical cord pH values were also significantly related to adverse outcomes. There was also an Inverse relationship
between cord blood bicarbonate levels and major neurosensoryImpairment.The highly significant relationship between cord blood bicarbonate and pH values and the development of neurosensory impairments persisted in spite of adjustment for gestational age, birth weight, plurality,use of general anesthesia,maternal race, and presence of hypertension. CONCLUSION: An adverse acid-base status at birth Is additive to the effect of gestational age In predicting neurosensory impairment in infants weighing s 1000 gm. (AM J OBs1ETGYNrECOL 1994; 170: 48-53. )
Key words: Acid-base status, neurosensory impairments, cerebral palsy, very low birth weight
From the Pennatal Epidemiology Unit, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Pediatrics, University of Alabama at Birmingham. Supported in part by the Agency for Health Care Policy Research Contract No. 282-92-0035. Presented in part at the Twelfth Annual Meeting of the Society of Pennatal Obstetricians, Orlando, Florida, February 3-8,1992.
48
Receivedfor Publication October 7,1992; revisedApril 30,1993; acceptedJuly 19,1993. Reprint requests:Robert L. Goldenberg,MD, Division of MaternalFetal Medicine, Department of OB/GYN, 620 S. 20th St., Birmingham, AL 35233-7333. Copyright ® 1994 by Mosby--YearBook, Inc. 0002-9378/94 $1.00 + 20 6/1/50151 .
Kadar,
MD,
and Luc Lemmerling,
MD'
Neptune, Piscataway, and Princeton, New Jersey Two patients who had urinary fistulas after laparoscopic hysterectomy are described. In both cases the ureters were dissected free and the uterus was freed laparoscopically. Injury to the urinary tract occurred during transvaginal closure of the vaginal cuff. Preventative strategies are discussed. (AM J OssTET GYNECOL 1994; 170:47-8. )
Key words: Laparoscopic hysterectomy, vesisovaginal fistula, ureteric ligation Ureteric injuries during laparoscopic hysterectomy have been linked to the use of an endoscopic stapler. ' We describe two urinary fistulas that were unrelated to stapler use, and discuss predisposing factors and remedial measures. Case reports Case 1. A 30-year-old white woman underwent laparoscopic hysterectomy and left salpingo-oophorectomy for a borderline of the serous cyst adenocarcinoma perand right oophorectomy ovary after appendectomy formed 2 months earlier at another hospital. Adhesions at laparoscopy were so extensive that the pelvic organs could not be visualized, and initially only one trocar into the peritoneal cavity. The could be introduced adhesions were lysed without incident. During subseboth ureters were dissected free, quent hysterectomy and the entire specimen was freed laparoscopically except for about a centimeter of the vaginal cuff, which and then the cuff closed. was divided transvaginally The patient's postoperative course was unremarkable ileus. An intravenous pyelogram except for prolonged showed what was thought to be a small bladder leak and a urinoma that did not fill with dye. This was managed with a Foley catheter, but the patient leaked urine fourteenth day the and a on postoperative vaginally diagnosis of ureteric fistula was made. Retrograde urewas unsuccessful, but the patient teric catheterization dry by a percutaneous nephrostomy, was rendered in for 3 left months. At ureteric reimplace was which plantation the ureter was noted to have been ligated at the urethrovesical junction.
From the Diaozon of Gynecologic Oncology, Jersey Shore Medical Wood Center, the University of Medicine and Dentistry-Robert Johnson Medical School, ' and the Department of Obstetrics and Gynecology, Medical Center at Princeton. " Received for publication June 22,1993; revised July 9,1993; accepted July 19,1993. Reprint requests: Nicholas Kadar, MD, Jersey Shore Medical Center, 1945 Conies Ave., Neptune, NJ 08512.
Copyright © 1994 by Mosby-}Par Book, Inc. 0002-9378/94 $1.00 + 20 6/1/50178 .
laparo2. A 39-year-old woman underwent and bilateral salpingo-oophorecscopic hysterectomy pelvic pain. Both ureters were tomy for long-standing identified and dissected free during the operation, and and rethe uterus was freed entirely laparoscopically moved through the vagina. The cuff was closely vaginally because endoscopic needle holders were not available. The patient made an uneventful recovery but had A tampon a vaginal urine leak a week postoperatively. test in the office demonstrated a vesicovaginal fistula. It 3 months later and required was closed abdominally because of the proxipsi]atera] ureteric reimplantation Case
imity of the fistula
to the ureteric
orifice.
Comment The features common to these injuries are that both in both occurred spite of meticuunrecognized, were lous anatomic dissection of the ureters, and both inlaparoscopic reseccomplete or almost volved complete tion of the uterus followed by transvaginal closure of the vaginal cuff. We believe that these injuries were caused during closure of the cuff and were predisposed to by extensive laparoscopic dissection of the bladder off the cervix and vagina. During
hysterectomy
the bladder
is
an abdominal dissected caudally off the cervix, and the vaginal cuff during bladder, to the vaginal whereas closed proximal
the bladder is dissected cephalad and the In both situations cuff closed distal to the bladder. dissection of the bladder serves to expose the vaginal cuff and facilitate its closure after removal of the uterus. By contrast, the bladder is dissected caudally and the cuff closed distal to the bladder if bladder dissection hysterectomy
during
laparoscopic
hysterectomy
is followed
by transfar from
vaginal closure of the vaginal cuff. Therefore, facilitating closure of the cuff, laparoscopic dissection of the bladder brings the bladder and distal ureter down into harm's way. Neither ureteric
dissection nor a scent will protect the ureter from transvaginal injury, but a stent will help to identify unrecognized ureteric ligation, and its use is
47
Gaudier et al.
strongly recommended. Similarly, neither strategy nor instillation of indigo carmine into the bladder will identify transvaginal suture placement into the bladder, and some dissection of the vaginal cuff to evert its edges toward the operator may be required to safeguard against this. However, it seems to us more logical to avoid laparoscopic dissection of the bladder altogether if the cardinal and uterosacral ligaments are to be divided vaginally, for this does not facilitate the operation very much. Division of the bladder peritoneum is still worthwhile because in the absence of uterine de-
January 1994 Am J Obstet Gynecol
scent the white line of the anterior cul-de-sac can be high and difficult to reach, particularly if the subpubic arch is narrow. If absence of uterine descent and a very narrow subpubic arch render vaginal access to the cardinal and uterosacral ligaments difficult or impossible, the best approach is to do the entire operation laparoscopically, including closure of the vaginal cuff. REFERENCE 1. Woodland MB. Ureter injury during laparoscopy-assisted vaginal hysterectomy with endoscopic OBSTEI GYNECOL 1992; 167: 756-7.
lineal
stapler.
Ant J
Acid-base status at birth and subsequent neurosensory impairment in surviving 500 to 1000 gm infants Francisco L Gaudier, MD, Robert L. Goldenberg, MD, Kathleen G. Nelson, MD, Myriam Peralta-Carcelen, MD, Susan E. Johnson, RN, Mary B. DuBard, MA, Tracy Y. Roth, MD, and John C. Hauth, MD Birmingham, Alabama OBJECTIVE: The purpose of this study was to assess, in Infants born weighing s 1000 gm, if umbilical cord blood acid-base measures at birth are associated with an additional increase In neurosensory impairment.
STUDY DESIGN: Of 289 surviving Infantswith a birth weight of 500 to 1000 gm born from 1979 to 1989, 219 had umbilical cord acid-base status measured at birth and were followed prospectivelyfor a1 year. Measuresof neurologic impairment used In this study Included mental retardation,cerebral palsy,and major neurosensoryImpairment. RESULTS: Gestational age was Inversely associated with all neurosensory impairments and was a better predictor of subsequent impairment in this population than was birth weight. Very low umbilical cord pH values were also significantly related to adverse outcomes. There was also an Inverse relationship
between cord blood bicarbonate levels and major neurosensoryImpairment.The highly significant relationship between cord blood bicarbonate and pH values and the development of neurosensory impairments persisted in spite of adjustment for gestational age, birth weight, plurality,use of general anesthesia,maternal race, and presence of hypertension. CONCLUSION: An adverse acid-base status at birth Is additive to the effect of gestational age In predicting neurosensory impairment in infants weighing s 1000 gm. (AM J OBs1ETGYNrECOL 1994; 170: 48-53. )
Key words: Acid-base status, neurosensory impairments, cerebral palsy, very low birth weight
From the Pennatal Epidemiology Unit, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Pediatrics, University of Alabama at Birmingham. Supported in part by the Agency for Health Care Policy Research Contract No. 282-92-0035. Presented in part at the Twelfth Annual Meeting of the Society of Pennatal Obstetricians, Orlando, Florida, February 3-8,1992.
48
Receivedfor Publication October 7,1992; revisedApril 30,1993; acceptedJuly 19,1993. Reprint requests:Robert L. Goldenberg,MD, Division of MaternalFetal Medicine, Department of OB/GYN, 620 S. 20th St., Birmingham, AL 35233-7333. Copyright ® 1994 by Mosby--YearBook, Inc. 0002-9378/94 $1.00 + 20 6/1/50151 .