2. DR EMAMI UROLOGIST

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

4. 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.

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

6.  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

7. Bladder Continous drainage almost allways Foley catheter(triple lumen)

8. 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

9. 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)

10. Complicated case Abdominal _vaginal _perineal _preparaition Foley _catheter_three_way continous drainage

11. Identify the ureter Abdominal ureter Pelvic ureter

12. 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

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

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

15. Suspentation of vaginal apex

16. Complete truma /non viablePatial truma/viable tissue

17. Uretero neocystostomy End to end anastomsis

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

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

20. Bladder trauma

21. Good drainage Tissue hydrodistention

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

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

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

25. 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.

26. 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)

27. THANKS FOR ATTENTION