370 Obstetrics and Gynecology Board Review •••
❍ What is the major cause of urethral injuries?
Urethral injury is rare. Formerly, obstructed labor or instrumented deliveries were the major causes of urethral
injury resulting in fistula in the United States and are still in the developing countries. In the United States, most
urethral injury resulting in fistula results from complications after excision of a diverticulum, including failed
repair, hematoma, or infection. Urethral injury may occur during anterior colporrhaphies, pubovaginal sling
procedures for urinary incontinence or related to traumatic catheterization, especially if a rigid catheter is used.
❍ What is the leading cause of bladder injury resulting in vesicovaginal fistula?
Hysterectomy.
❍ What is the most frequently damaged organ during routine hysterectomy?
The bladder is the most frequently damaged organ during routine hysterectomy, abdominal route being more
often than during vaginal approach.
❍ Can you describe the proper steps of bladder dissection during hysterectomy?
Blunt dissection into the vesicocervical space, and more specifically surgical entry into the vesicovaginal space during
caudal mobilization of the bladder, increases the risk of injury and can also damage the autonomic innervation
to the detrusor muscle. Although there is variation in the supravaginal septum that separates the vesicocervical
space from the vesicovaginal space, it is more appropriate to surgically transverse the septum with careful sharp
dissection rather than blunt maneuvers. In addition, failure to adequately mobilize the bladder will create the risk of
incorporation of the bladder serosa, and potentially the muscularis as well, into the vaginal cuff closure.
❍ True or False: An abdominal hysterectomy has a lower risk of ureteral injury than a vaginal hysterectomy.
False. Seventy-five percent of ureteral injuries occur during abdominal hysterectomy, and 25% during vaginal
hysterectomy. The rate of ureteral injury during abdominal hysterectomy is 0.5% to 1%, and during vaginal
hysterectomy is 0.1%.
❍ What is the leading cause of ureteral injury?
Abdominal hysterectomy for benign causes. Gynecologic surgery accounts for 75% of ureteral injuries.
❍ What is the ureteral injury incident during hysterectomies?
The overall incidence is somewhere between 0.4% and 2.5% and the rate of injury is higher during laparoscopic
hysterectomies (13.9 per 1000) versus vaginal hysterectomies (0.2 per 1000).
❍ How often are ureteral injuries recognized at the time of hysterectomies?
Only one-third of the injuries are recognized at the time of the surgery. It is not a sin to injure the ureter. However, it
is a great sin not to recognize the injury.
❍ Mention six signs that make you suspect a LUTI.
- A defect that can be seen grossly after a laceration or transection of a ureter or a cystotomy.
- Bladder catheter is seen in the operative field or the bladder mucosa is visualized.
- Ureter is noted in close proximity to a clamp, suture, or staple.
- The appearance of urine in the operative.
- The appearance of blood in the urine output from the bladder catheter.
- In laparoscopic surgery, gas may be visible in the bladder catheter output.