Safeguarding the Urinary Tract in Laparoscopic Surgery: Techniques and Case Studies – ARC Summit

Urinary tract injuries, particularly those involving the bladder and ureters, are a significant concern during gynecological surgeries such as hysterectomies. Howard Chir conducted a study revealing that 73% of urinary tract injuries involved the bladder, while ureter injuries accounted for 2 to 4%. It has been humorously noted that the ureter’s “natural predator” is often the gynecologist, underscoring the need for careful surgical practice.

For example, in an old video from a hysterectomy, we inadvertently found ourselves looking into the Foley catheter through a bladder injury. Such injuries can be repaired laparoscopically, which we did directly without needing to consult a urologist. However, the ureter, likened to a “snake in the grass,” requires precise identification and tracking from the pelvic brim down into the pelvis to understand its relation to the uterine artery and the lateral ligament.

In every hysterectomy, we perform postoperative cystoscopy using a three-way Foley to backfill the bladder and a 5 mm 30° scope for internal visualization. This process helps us confirm the integrity of the urinary jets from the ureters. If a jet is absent, indicating a possible ureteral obstruction from a suture, we immediately address this by removing the suture. In one case, after failing to observe the jet post-suture removal and completing endometriosis resection, we traced the ureter down to the bladder, found no injuries, and then had a urologist place a stent, which resolved the issue.

Moreover, there’s a risk of bladder injury if the medial trocar is placed too low. This happened once when I had to return to the operating room after being called from my office. Cystoscopy revealed a through-and-through injury to the bladder, which I repaired by closing both the internal and external holes. The patient recovered well from this procedure.

These experiences highlight the importance of surgical precision, thorough anatomical knowledge, and immediate corrective action in the event of urinary tract injuries during gynecological surgeries.