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Infections are common in women of all ages starting from young girls to newly married [HONEYMOON CYSTITIS] to elderly postmenopausal women. In each group the cause may be different and requires thorough examination. Some women also suffer from TUBERCULOSIS of urinary tract.
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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• V V F• 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--
MRI PELVIS—POST CAESAREANFISTULA BETWEEN BLADDER DOME AND UTERUS
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
RGP SHOWING URETERO-UTERINE FISTULA
IVP TOTAL URETERIC OBST. FOLLOWING LSCS
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