Introduction Litigation Indemnity cover: MPS Urologic complications Important to know the normal...

IntroductionLitigationIndemnity cover: MPS

Urologic complicationsImportant to know the normal urinary tract

anatomy and various anomalies (3.3-11.1% of the population) encountered in clinical practice

To prevent injury and complications and medicolegal problems

Causes of oliguriaPrerenal

Decreased volume Dehydration Blood loss Third space

sequestration

Circulatory Septic shock Cardiogenic shock

PostrenalAcute obstructive

uropathy Ureteral obstruction Urethral obstruction

Urinary extravasation

Intrinsic renal disease

Ureteric injuryLow incidence (0.4-2.5%) but serious

implications of morbidity and litigation75% occur during gynaecologic surgeryThought to be higher with laparoscopic

surgeryOnly 1/3 detected during surgeryIntraop recognition is critical for prompt

repair before renal compromise occursPrevented by routine identification and

dissection of the ureter

Risk factors for ureteric injuryEnlarged uterusPrevious pelvic

surgeryOvarian neoplasmsEndometriosisPelvic adhesions

Distorted anatomyMassive bleeding

Types of ureteric injuryLigationAngulationTransectionLacerationCrushIschaemiaResection

Sites of ureteric injury1. Most common site during abdominal

hysterectomy or adnexectomy is the pelvic brim where it lies beneath the IFP ligament

2. Over the iliac arteries3. In the cardinal ligament at the level of the

internal cervical os where the uterine artery crosses the ureter

4. At the anterolateral vaginal fornix as the ureter enters the bladder

Sites of injury5. In vaginal hysterectomy: near the internal

cervical os and vaginal fornices as it enters the trigone of the bladder

6. At laparoscopy near the USL esp. with endometriosis

7. Trying to control bleeding in broad ligament at caesarean hysterectomy

8. Hypogastric artery ligation

Prevention of ureteral injuriesUreteric stenting for difficult cases e.g. Ca

ovaryAdequate exposure during surgery. Identify

the ureterAvoid blind clamping of vesselsCaution when using diathermy (laparoscopy)

Diagnosing ureteric injury70% diagnosed postop in gynaecologic

procedures

Intraoperative diagnosisIf ureters can’t be identified, use of IV

methylthioninium chloride or indigo carmine can demonstrate patency

Intraop transurethral cystoscopy or abdominal telescopy may be used to show ejaculation of dye stained urine from both ureteric orifices

Cystoscopy should be considered for complex cases

Postoperative diagnosisSymptoms are variable: Flank pain, fever,

haematuria, retroperitoneal urinoma (sonar)IVP, CT with IV contrast, retrograde

ureterogram, renal u/s, cystoscopy, contrast dye tests

Treatment of ureteral injuries: principlesTension free anastomosisMinimal use of fine absorbable sutureUse of peritoneum or omentum to surround

the anastomosisDrain site with passive drain to prevent urine

accumulationStent with ureteric catheter

Case Prolonged labourC section donePost-op abd distension? Diagnosis

Bladder injury2 layer repairCatheter for 10 days

Cardiovascular complicationsPerioperative cardiac morbidity is the leading

cause of death after anaesthesia and surgeryIncludes: MI, unstable angina, CCF,

dysrhythmiaRisk factors: Age, previous MI, hypertension,

DiabetesPrevention: good preop care, lab tests, ECG,

CXR, cardiologist review

Haematological complications: risk factorsAlcohol abuseLiver diseaseFamily h/o bleeding

tendencyPrior need for

transfusionSevere menorrhagiaFrequent nosebleedsEasy bruising

Von Willebrand’s disease

Chronic renal disease

SLEAnticoagulant useAntiplatelet drugs

Intraoperative bleeding: risk factorsSurgical technique: blood vessels in

retroperitoneal spaceObesityLarge pelvic massAdhesionsCancerPrior radiotherapy

Blood product replacementRed cell transfusion: whole blood, red blood

cells, leukocyte-poor red cells, washed red cells

Platelet transfusionPlasma derivatives: Cryoprecipitate-rich in

Factor VIII and fibrinogen

GITApproached with trepidation by the

gynaecologistImportant in complicated surgery like Ca

ovaryBowel injury during surgeryPostop complications: Perforation, ileus,

obstruction, reexploration for bowel complications, fistulae

OthersRetained foreign bodiesLymphoedemaSexual dysfunctionDeath