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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