DR EMAMI UROLOGIST

In female Anatomic relationship between REPRODUCTIVE SYSTEM & GUT predispose the GUT to involment by gynecologic disorders and places it at risk

Injury to the bladder or ureter occur Appproximately %1 -%2 of all major gynecologic procedure  Between 50% ad 90 of all lower urinary truct injury occure during gynecologyic surgery.  Some of these injures can not be avoided. but the majority are avoidable.

Review of the surgical literature reveal two fact: Most injury occur during benign procedure Most injury are not recognized During procedure

 Preoprative assessment: patient history,physical examination and preoperative laboratory evaluation may sugest abnormal function of GUT. If any abnormality is revealed Further evaluation shoud be performed

Bladder Continous drainage almost allways Foley catheter(triple lumen)

Ureteral stent dose not reduce incidence of surgical injury to ureter. Ureteral stent predispose the ureter to damage As a result of immobility it imparts to the ureter

During all surgical procedure : Sharp dissection blunt dissection Small pedicles large pedicles (Many ureters are damaged by application Of clamp in a frantic effort to control pelvic hemorrhage)

Complicated case Abdominal _vaginal _perineal _preparaition Foley _catheter_three_way continous drainage

Identify the ureter Abdominal ureter Pelvic ureter

If the surgeon decided to identified the ureter Identification without dissection Follow ureter under posterior peritoneum Over hydrate /lasix injection(peristaltism) Identification with dissection Open retro peritoneom/preserve vascular sheat

Pelvic ureter biforcation common iliac arterie Posterior boundary of ovarian fossae Beneath the uterine arteries Ant and lat cervix and vagina

Pelvic cavity &ureter truma Oblitration of cul_de_sac Plication of utero sacral ligament

Suspentation of vaginal apex

Complete truma /non viablePatial truma/viable tissue

Uretero neocystostomy End to end anastomsis

Don’t try to identified the ureter Good plan between uterine &bladder (vesicoperitoneal fold)

The surgeon should be aware: The bladder may be pull up beneath the anterior abdominal wall :  Incomplate emptying  Previous surgery(cesarean)

Bladder trauma

Good drainage Tissue hydrodistention

Intra operative repair of bladder injur Extra peritoneal laceration Closed with one or two layers of NO3/o Absorbable suture

Trans peritoneal laceration of bladder& Base of bladder Repaired in two layer usingNO3/o Absorbable suture Covered with omental or peritoneal flap

For better healing Continous drainage for at least 7days Anti spasmodic drug Antibiotic therapy

Urinary tract injury occur in %1- %2 of patients undergoing major laparoscopic surgery. Bladder injury result from dissection with or without cautery. For prevention of ureteral injury ureteral catheter is recommended.

Intera operative Seeing the cath through an incision Repaired over a trans urethral cath in layers using NO 3 /o or 4/o Absorbable suture (bulbocavernous fat pab may be requried)

THANKS FOR ATTENTION