Urethral and

Bladder Injury
 Injuries to the urinary tract, even if they occur relatively
infrequently, can cause significant morbidity. The effects of the
injury, its management, and its sequelae may result in temporary
or permanent loss of employment, pain, anxiety, depression, and
adverse effects on interpersonal relationships and quality of life.
 Gynecologic surgery can have major perioperative morbidity,
including urinary tract and bowel injuries, infection, hemorrhage,
thromboembolism, and death.

Review AS, Gilmour D, Flowerdew G. Urinary Tract Injury at Benign Gynecologic

Surgery and the Role of Cystoscopy. 2015;126(6):1161–9
Anatomy of Female
Pelvic Organ
  Ureters:
 Originate at renal hilum at L2
 Path initially medial to vertebrae and at
pelvic brim take infero-posterior path
 Oblique entry into bladder avoids
urinary reflux
 Crossed by gonadal artery in pelvis
 Posterior to it are psoas and
genitofemoral nerve
 Under it are uterine artery and vas
deferens
 Arterial supply via gonadal, renal,
Renal Tract vesical, vaginal and aortic branches
 Autonomic innervation
 Bladder:
 Trigonal structure.
 Wall has 3 layers of smooth muscles:
inner circular and middle/outer
longitudinal layers
 Arterial supply from superior and
inferior vesicalnerves: sympathetic
closes bladder neck whilst
parasympathetic relaxes detrusor
muscle to allow for miturition
  Rectum
 Superior 1/3 covered by peritoneum
anteriorly and laterally, middle 1/3
anterior peritoneum only and
inferior 1/3 bare
 Arteries: superior rectal from
inferior mesenteric and middle
rectal from internal iliac +inferior
Rectum and rectal from pudendal artery
 Venous drainage from internal
anus venous plexus which drains to:
 superior rectal which then drains to
inferior mesenteric vein, middle
rectal which drains to internal iliac
vein and inferior rectal vein which
drains into pudendal vein

 Anus:
 Starts at anorectal junction (dentate
line)
  Uterus:
 Held at lateral walls by double fold of peritoneum
aka broad ligament
 Uterine artery
 Sympathetic and parasympathetic innervation
from pelvic plexus
 Venous plexus drain to rectal and vesical veins
 Ovaries:
 Attached to posterior aspect of broad ligament
 Ovarian artery
 Right ovarian vein drains to IVC whilst left to left
renal vein
 Sympathetics from aortic plexus and
parasympathetics from pelvic plexus
Reproductive  Fallopian tubes:
Organs  Run in free edge of broad ligament
 Ovarian and uterine arteries
 Vagina:
 Opens into vaginal vestibule
 Vaginal artery
 Sympathetic supply from pelvic plexus and
somatic sensory innervation from ilioinguinal and
pudendal nerves
 Venous drainage from pelvic floor plexus to
internal iliac
 Clitoris:
 Female equivalent of penis
 Nerve supply via pudendal
Blood Supply
of Pelvic

INFERIOR VESICAL
vaginal artery in female
  Lateral pelvic drain
everything EXCEPT:
 Para aortic drain: gonad +
fallopian tube + uterus + ureter
Lymphatics  Inferior mesenteric drain: upper
rectum
 All ultimately drain into
lymphatic duct and cisterna
chyli
  Dermatomes: T12 (suprapubic), L1
(groin), L2 (upper thigh), S1, 2, 3, 4,
5 (buttocks, perineal and perianal).
S1, 2 (genitals).
 Sympathetic: from lumbo-sacral
trunk (L1-S5).
 Parasympathetic: S2-4
 Lumbar plexus: L1-5 roots lie on
Psoas M. Branches:
Nerves  3 lateral to Psoas (lateral cutaneous
nerve, iliohypogastric, ilioinguinal)
 1 anterior to Psoas: genitofemoral
 2 medial to psoas: femoral,
obturator
 Sacral Plexus: S1-4
 Pudendal: S2-4. mixed
sensory/autonomic
 Coccygeal
Dermatomes
 Sympathetic
 Hypogastric nerves:
preganglionic fibres travel to
hypogastric plexus and
synapse there then travel to
Autonomic viscera as hypogastric nerves.
 Sacral splanchnic nerves:
fibres synapse at
sympathetic chain and
postganglionic fibres travel
to hypogastric plexus as a
splanchnic nerve.
Parasympathetic
 Pudendal nerve: mixed
autonomic and sensory. S2-4
 Pelvic splanchnic nerves:
preganglionic fibres from S2-
4 travel to hypogastric plexus
ad from there nerves travel
to and synapse at viscera.
 Cause erection and sphincter
relaxation for
micturition/defaecation
 Lateral cutaneous nerve: sensory to
lateral thigh
Iliohypogastric: motor to
transversus and internal oblique,
sensory to mon pubis
Ilioinguinal: motor to internal
oblique, transversus and conjoint
tendon. Sensory to upper medial
thigh, labia majora, scrotum and
Divisions of root of penis
Lumbar plexus Genitofemoral: motor to
cremaster. Sensory to scrotum,
anterior thigh, spermatic fascia
and tunica vaginalis.
Femoral (L2,3,4): motor to iliacus,
pectineus and quadriceps
femoris. Sensory to anterior
thigh.
Obturator
  Formed by L4, 5, S1-5
 Lies on piriformis
 Branches:
 6 nerves from sacral roots
 Nerve to piriformis
 Posterior femoral
 Perforating cutaneous
 Perineal branch to levator ani
 Pelvic splanchnic
 Pudendal
Sacral Plexus
 Anterior division:
 Nerve to Quadratus femoris
 Nerve to Obturator internus
 Tibial branch of sciatic nerve

 Posterior division:
 Superior gluteal
 Inferior gluteal
 Common peroneal branch of
sciatic nerve
  Somatic and autonomic
 Origins S2-4
 Exits through greater sciatic
foramen and re-enters pelvis
via lesser sciatic foramen
 Travels with pudendal vessels
Pudendal along ischiorectal fossa in
Alcock’s canal
Nerve
 Supplies sphincters and
genitalia via perineal, dorsal
root of penis/clitoris and
inferior anal nerves
 Promotes ejaculation, sexual
arousal, anal and bladder
sphincter control.
  31st spinal nerve
 Forms coccygeal plexus with
Coccygeal S5

Nerve  Coccygeal plexus gives rise to

annococcygeal nerve which
supplies sacroccygeal joint
and skin over coccyx.
Urological injuries during obstetric
and gynaecological procedures
Urological injuries which involve damage to the urinary bladder
and ureter are not uncommon in obstetric and gynaecological
surgeries.
In a retrospective study, incidence of bladder injury and ureteric
injuries in gynaecologic surgeries was 0.48% and 0.08%
respectively, whereas in obstetric procedures the incidence of
bladder and ureteric injuries was 0.1% and 0% respectively.
Most of the ureteric injuries occurred while performing
laparoscopic hysterectomies.

[Desai RS, K SK. Urological injuries during obstetric and gynaecological procedures : a retrospective
analysis over a period of eleven years. 2016;5(6):1916–20.]
Prevention of urological trauma
 Clear understanding of anatomy, particularly if
there is suspicion of an anomaly
 Identify risk factor
 Cystoscopy

[Sharp HT, Adelman MR. Prevention , Recognition , and Management of Urologic

Injuries During Gynecologic Surgery. 2016;127(6):1085–96.]
Ureteric Injury
  Ureteral injury is one of the most serious
complications of gynecologic surgery, although
it’s less common than injuries to the bladder or
Background rectum, especially when not recognized until
postoperatively.
 The distal third of ureter is the most common
site of iatrogrenic injury
  The ureter is a narrow muscular tube,
about 25 cm in length.
 It runs retroperitoneally from the
kidney to the urinary bladder.

Anatomy  At the pelvic inlet: The ureter enters

the pelvis above the bifurcation of the
common iliac artery anterior to the
sacroiliac joint.
 In the pelvis: It runs downwards lying
in front of the internal iliac artery.
 At the base of the broad ligament
it runs medially and forwards
through the parameterium till it
reaches about 1 cm lateral to the
supravaginal cervix where it
passes below and at right angle to
the uterine artery.
 The ureter then passes forwards
through the ureteric canal in the
upper part of the cardinal
ligament, closely related to the
lateral vaginal fornix, to enter the
trigone of the urinary bladder.
  A systematic review of 79 studies of gynecologic surgery for
benign conditions found an adjusted ureteric injury rate of
0.3%.Postoperative ureteric injury detection rates per 1,000
surgeries were estimated at 1.6 without routine cystoscopy
and 0.7 with routine cystoscopy.
[Review AS, Gilmour D, Flowerdew G. Urinary Tract Injury at Benign Gynecologic
Surgery and the Role of Cystoscopy. 2015;126(6):1161–9.]

 A systematic review of 37 studies by Adelman et al found that

Epidemiology laparoscopic hysterectomy had an overall urinary tract injury
rate of 0.73% and a ureteral injury rate that ranged from 0.2%
to 0.4%, depending on procedure type. These investigators
concluded that contrary to earlier published findings citing
unacceptably high urinary tract injury rates, laparoscopic
hysterectomy was a safe procedure in terms of the bladder
and ureter.
[Manoucheri E, Cohen SL, Sandberg EM, Kibel AS, Einarsson J. Ureteral Injury in
Laparoscopic Gynecologic Surgery. 2012;5(2):106–11.]
 6 most common mechanism of operative ureteral injury:
 Crushing from misapplication of a clamp
 Ligation with a suture
Etiology  Transsection
 Angulation of the ureter with secondary obstruction
 Ischemia from ureteral stripping or electrocoagulation
 Resection of a segment of ureter
  Ureteral injury may have different outcome, depends on many
factors, such as type of injury ad when the injury being identified
 It may :
 Resolve spontaneously,
 Forming ureteral stricture, or
 Ureteral necrosis
 Later, it may effect the kidney, causing hydronephrosis
Pathophysiology
 If the injury is minor, easily reversible, and noticed immediately,
the ureter may heal completely and without consequences.
 In complete unrecognized ligation of the ureter, a section of the
ureter wall necroses because of pressure-induced ischemia. The
ischemic segment eventually weakens, leading to urine
extravasation into periureteral tissue and to peritoneum. This may
causing ascites
  NO specific medical therapy, but if there’s potential concomitant
conditions of ureteral injury (eg, infection, renal failure), these
condition should be treated medically.
 Surgical intervention :
 Simple removal of a ligature
 Ureteral stenting with or without ureterotomy  If tissue ischemia or a
partial transection of the ureteral wall is suspected
 Ureteral resection and ureteroureterostomy  If extensive ischemia or
necrosis is present
Treatment  Transureteroureterostomy  If ureteroureterostomy cannot be performed
technically and the defect is too proximal in the ureter for ureteroneocystostomy.
Contraindication:
 Urothelial cancer
 Contralateral reflux
 Prior pelvic irradiation
 Retroperitoneal fibrosis
 Chronic pyelonephritis
 Ureteroneocystostomy  If the ureteral injury occurred below the pelvic
brim
Surgical
Treatment
Bladder Injury
 Interior of the Urinary Bladder
• Mucous membrane thrown into folds
except in the triangular region in the
base of bladder, between the
openings of the two ureters and the
urethra. This region is called the
‘trigone’. Here The mucous
membrane is always smooth even
when the bladder is empty
• Uvula vesicae, a small elevation
located just behind the urethral
orifice, It is produced by the median
lobe of prostate.
 Blood & Nerve Supply
• Arterial supply: from internal iliac artery
• Venous drainage: into internal iliac vein
• Lymphatics: into internal iliac lymph nodes
 The nerves form the vesical nerve plexus that
contains:
 Sympathetic fibers derived mainly from L1,2

 Parasympathetic fibers derived from pelvic

splanchnic nerves S2,3,4

 Sensory fibers from the bladder are visceral

and transmit pain sensation resulting from

overdistention
• The normal capacity of
bladder is about 300-
500ml.
• As bladder fills, the
superior surface bulges
upward into abdominal
cavity.
• The peritoneal lining is
peeled off the lower part of
anterior abdominal wall
and the bladder comes into
direct contact with the
anterior abdominal wall
  Frequency of bladder rupture varies according to the mechanism
of injury, as follows:
 External trauma (82%)
 Iatrogenic (14%)
 Intoxication (2.9%)
 Spontaneous (< 1%)
Epidemiology  Approximately 60%-85% of bladder injuries result from blunt
trauma, while 15%-40% are from penetrating injury. [5] The most
common mechanisms of blunt trauma are motor vehicle collision
(87%), fall (7%), and assault (6%). In penetrating trauma, the most
frequent culprit is gunshot wound (85%), followed by stabbing
(15%).
 Approximately 10%-25% of patients with pelvic fracture also have
urethral trauma. Conversely, 10%-29% of patients with posterior
urethral disruption have an associated bladder rupture.
  Blunt Trauma : impact, accident, or physical attack
 Penetrating Trauma : Gunshot and stabbing
 Obstetric Trauma
During prolonged labor or a difficult forceps delivery, persistent pressure from the fetal head
against the mother's pubis can lead to bladder necrosis. Direct laceration of the urinary
bladder is reported in 0.3% of women undergoing a cesarean delivery. Previous cesarean
deliveries with resultant adhesions are a risk factor for injury. Unrecognized bladder injuries
may lead to vesicouterine fistulas and other problems.

Etiology  Gynecologic Trauma

Bladder injury may occur during vaginal or abdominal hysterectomy. Blind dissection in the
incorrect tissue plane between the base of the bladder and the cervical fascia is generally the
maneuver implicated in such cases.
 Urologic Trauma : During bladder biopsy, cystolitholapaxy, transurethral resection of the
prostate (TURP), or transurethral resection of bladder tumor (TURBT).
 Orthopedic Trauma : during internal fixation of pelvic fractures and arthroplasty
prosthetics, which thermal injuries to the bladder may occur.
 Idiopathic Bladder Trauma : Patients with alcoholism, previous bladder surgery (areas of
scarring are weakened and prone to rupture).
  Most extraperitoneal bladder leaks can be effectively managed
with maximal bladder drainage per urethral or suprapubic
catheter.

Treatment  Depending on the presumed size of the bladder defect, the

bladder should be drained for 10 to 14 days and then assessed for
healing via cystogram. Approximately 85% of such injuries will
heal within 7 to 10 days, at which point the catheter can be
removed and a trial of voiding completed.
Surgical Therapy
 Intraperitoneal Bladder Rupture
 Essentially every intraperitoneal bladder rupture requires surgical
management. Such an injury will not usually heal with prolonged bladder
drainage alone, as urine will continue to leak into the abdominal cavity
despite the presence of a functional catheter. This results in metabolic
derangements and can produce urinary ascites, abdominal distention, and
even ileus.
 Extraperitoneal Extravasation
 Bladders with extensive extraperitoneal extravasation are often repaired
surgically. This facilitates more rapid healing and decreases the potential
for complications, as well as the necessary duration of indwelling catheter
use in many cases.
 Surgical Principles
 In the trauma setting, closure of bladder defects is usually performed in a
two-layer fashion. With iatrogenic injury, some surgeons routinely close
the bladder in one layer with success. In either manner, a running suture is
placed to obtain a water-tight closure. Only absorbable suture should be
used on the bladder, as permanent sutures serve as a nidus for later stone
formation and infection. Similar to nonoperative management of bladder
leaks, an indwelling catheter is left for at least 10 to 14 days to facilitate
healing of the defect. A cystogram is done prior to catheter removal