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UROLOGICAL INJURIES DR.LALITHA UROLOGIST & UROGYNECOLOGIST YASHODA HOSPITALS


INTRODUCTION • URINARY TRACT INJURIES ARE NOT UNCOMMON • INCREASED INCIDENCE WITH LAPAROSCOPIC SURGERIES • DEVASTATING TO THE PATIENT


UROLOGICAL INJURIES • BLADDER INJURY • URETERIC INJURIES • EITHER DURING CAESAREAN OR HYSTERECTOMY


CLINICAL PRESENTATION • DEPENDS ON THE TIME OF DETECTION • EARLY POST-OP • BLADDER – HEMATURIA • URETER – LOIN PAIN, FEVER, ABDOMINAL DISTENSION • ANURIA – RARE- BILATERAL URETERS


URINARY FISTULAE • MOST DEVASTATING CONSEQUENCE • INJURY UNDETECTED INTRAOP OR EARLY POSTOP • OR • FAILED PRIMARY REPAIR • OR CO-EXISTING INJURY MISSED INTRAOP


TYPES OF URINARY FISTULAE • POST HYSTERECTOMY • VVF • URETERO-VAGINAL FISTULA • POST CAESAREAN • VESICO-UTERINE FISTULA • URETERO-UTERINE FISTULA


VESICO-VAGINAL FISTULA • MOST COMMONLY SEEN FISTULA • CONTINUOUS LEAKAGE OF URINE WITHOUT NORMAL VOIDING • PARADOXICAL INCONTINENCE WITH SMALL VVF


URETERO-VAGINAL FISTULA • 0.5% FOLLOWING VAGINAL HYST. • 1% FOLLOWING OPEN ABDOMINAL HYST. • 2-3% WITH LAP HYSTERECTOMY


URETERO-VAGINAL FISTULA • PRESENTS WITH PARADOXICAL INCONTINENCE • URINE LEAK PER VAGINA WITH NORMAL VOIDING • 1 WEEK – 10 DAYS POST-OP


VESICO-UTERINE FISTULA • UNDETECTED BLADDER INJURY DURING A CAESAREAN SECTION • PRESENTS WITH URINE LEAK THRU CERVIX • CYCLICAL HEMATURIA WITHOUT ANY URINARY LEAK--


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MRI PELVIS—POST CAESAREAN FISTULA BETWEEN BLADDER DOME AND UTERUS


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MR

MRI UROGRAM SHOWING NORMAL UPPER TRACTS WITH VESICO-UTERINE FISTULA


VESICO-UTERINE FISTULA • TREATMENT • TRANSPERITONEAL REPAIR WITH OMENTAL INTERPOSITION • HYSTERECTOMY REQUIRED IN SOME CASES


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RGP SHOWING URETERO-UTERINE FISTULA


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IVP TOTAL URETERIC OBST. FOLLOWING LSCS


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IVP – LEFT URETERO-UTERINE FISTULA


URETERO-UTERINE FISTULA • RAREST FORM OF URINARY FISTULA • 0.02% FOLLOWING CAESAREAN • MORE COMMON ON LEFT SIDE • DUE TO DEXTRO-ROTATION • BLIND ATTEMPT AT HEMOSTASIS


URETERO-UTERINE FISTULA • CLINICAL PRESENTATION • LOIN PAIN, FEVER • URINE LEAK THRU CERVIX • NORMAL VOIDING


PREVENTION OF BLADDER INJURIES • FOCUS ON 3 AREAS • OPENING THE PERITONEUM • FULL BLADDER • PREVIOUS SURGERY • MOBILIZING THE BLADDER OFF THE UTERUS • CLOSURE OF UTERUS OR VAULT


PREVENTION OF URETERIC INJURIES • IDENTIFY HIGH RISK CASES • PID,ENDOMETRIOSIS, OVARIAN TUMORS,BROAD LIG. OR CERVICAL FIBROID • PREOP-IVP • INTRAOP STENTING • AVOID SKELETONIZING THE URETERS


DIAGNOSIS • BEST TIME TO DETECT IS DURING SURGERY • HIGH INDEX OF SUSPICION • WHEN IN DOUBT – CALL A UROLOGIST


BLADDER INJURIES • CHECK FOR INTEGRITY BY FILLING SALINE • ANY BLADDER REPAIR – POST OP INDWELLING CATHETERIZATION • DON’T HESITATE TO PUT AN SPC WHEN INJURY IS EXTENSIVE


URETERIC INJURIES • HIGH INDEX OF SUSPICION ANY DIFFICULT DISSECTION CYSTOSCOPY AND RGP UNDER FLOROSCOPY WHEN IN DOUBT, SAFER TO STENT


POST-OP URINE LEAK • WHAT NEXT? • DIAGNOSIS – TYPE OF FISTULA • HISTORY – TOTAL / PARADOXICAL • EXAM.- LEAK P/V OR PER URETHRA


DIAGNOSIS OF TYPE OF FISTULA USG • VVF / VESICO-UTERINE FISTULA NORMAL KIDNEYS BLADDER MAY BE EMPTY •

UVF / URETERO-UTERINE FISTULA HYDRONEPHROSIS


DIAGNOSIS • IVP URETERIC FISTULAE HYDRONEPHROSIS & HYDRO-URETER VVF- CYSTOGRAM PHASE URINE LEAK INTO VAGINA


DIAGNOSIS [ contd] • CYSTOSCOPY AND RGP • V V F SITE SIZE NUMBER PROXIMITY TO ORIFICES ANY INFLAMMATION RGP- EXACT SITE OF URETERIC INJURY


DIAGNOSIS CT UROGRAM / MRI •

FOR POST CAESAREAN LEAKS VESICO-UTERINE FISTULA URETERO-UTERINE FISTULA


TREATMENT • VVF - CONSERVATIVE • SURGICAL OPTIONS VAGINAL ABDOMINAL – TRANSVESICAL TRANSPERITONEAL LAPAROSCOPIC


TREATMENT VESICO-UTERINE FISTULA TRANSPERITONEAL REPAIR OMENTAL INTERPOSITION MAY NEED HYSTERECTOMY


URETERIC INJURIES • TREATMENT OPTIONS BASED ON • TIME OF DETECTION • SITE OF INJURY • NATURE OF INJURY • UNILATERAL / BILAT.


URETERIC INJURIES TREATMENT OPTIONS URETEROSCOPIC STENTING END-TO-END ANAST. RE-IMPLANTATION DIRECT PSOAS-HITCH BOARI’S FLAP

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