Injury-free vaginal surgery: Case-based protective tactics

These injuries can occur during vaginal hysterectomy or dissection of the anterior vaginal wall (eg, anterior colporrhaphy, paravaginal defect repair). Avoid injuries by dissecting the vaginal mucosa (and lower uterine segment) carefully off the underlying endopelvic tissues.

Signs of an injury

Injury is often heralded by a gush of urine into the vaginal operative field, as in the opening case. When it occurs, determine the extent of injury from the vaginal side, and use a small Allis clamp to temporarily close the injury so that cystourethroscopy is effective. During cystoscopy, take steps to ascertain the extent of the injury and its proximity to the ureteral orifices.

Vaginal approach to intraoperative repair

Lacerations 2 cm or less in size are usually amenable to vaginal repair. In general, if the full extent of the laceration can be visually appreciated and accessed using the vaginal route, the repair can be safely attempted from the vaginal approach.

If the perforation is well away (>1 cm) from the ureteral orifices and there is free efflux from both orifices, close the defect from the vaginal side in 3 imbricating layers, being careful to keep the suture knots out of the bladder lumen.

Start by dissecting the overlying vaginal mucosa off the endopelvic fascia for 1 cm around the defect. This exposes the bladder adventitia, which can be used to reapproximate the laceration as follows:

Test the repair

Backfill the bladder transurethrally with 100 cc of sterile infant formula, and observe the result on the vaginal side. Closure should be watertight. Sterile formula does not stain the tissues and is therefore preferable to indigo carmine or methylene blue.

Reapproximate the vaginal mucosa using 2-0 Monocryl suture in a running, “nonlocked” fashion. Repeat cystoscopy after the closure to ensure prompt, free efflux from both ureteral orifices.

In nonradiated, well-perfused tissues, an interposing fat pad (eg, Martius or omental) is usually not required.

Foley catheter drainage is recommended to allow about 3 weeks of healing time for the closure.

If the laceration is less than 1 cm from a ureteral orifice

Assess the integrity of the affected ureter using a retrograde ureterogram performed under fluoroscopy. If ureteral integrity is confirmed, the affected ureter may be stented prior to repair of the laceration (as discussed above). Any stents may be left in place until the repair is judged to be sufficiently healed.

If the laceration is not fully visible or accessible vaginally

Use an abdominal approach—either open or laparoscopic—after assessing ureteral integrity. Focus on developing a suitable plane between the bladder and vaginal walls around the defect, followed by reapproximation of the bladder in 3 imbricating running layers of absorbable monofilament suture, as described above.

If the injury occurs during vaginal hysterectomy

In this situation, bladder closure can be deferred until the uterus and ovaries (if planned) have been removed.

For other procedures, such as anterior colporrhaphy, finish the procedure after the bladder is successfully closed. If the perforation is near or involves either ureteral orifice, it should be addressed in the manner of a ureteral injury (see below).

After fistula repairs

My patients undergo fluoroscopic evaluation of bladder filling and emptying at the 3-week mark, prior to Foley removal, to document functional closure. Then the Foley catheter and any indwelling stents are removed.

I counsel patients about the need to empty the bladder frequently, and how to recognize and avoid urinary retention.

Injuries to the ureters

The pelvic aspect of the ureters is also of interest to the gynecologic surgeon because these structures are at risk for obstruction or transection.

Vaginal procedures that can put the ureters at risk include vaginal vault (apical) suspensions and paravaginal defect repairs. Always include cystourethroscopy at the end of these procedures to document prompt and free efflux from both ureteral orifices.

3 “risky” regions

Because of its proximity to the vagina and uterus, the bladder is sometimes injured during vaginal surgery. Three areas are vulnerable: the dome and bladder neck/urethra, at risk during sling procedures, and the posterior bladder wall, vulnerable during dissection of the anterior vaginal wall.

If cystoscopy fails to confirm definitive bilateral efflux

Infuse intravenous indigo carmine and inspect the ureteral orifices again, in this situation. If bilateral efflux is not forthcoming, consider removing any intrapelvic packing, and take the patient out of the Trendelenburg position so that she can be observed for 20 minutes.

If there is still no efflux after that interval, a ureter may be obstructed.

If you suspect ureteral kinking or obstruction

Consider removing any suspensory sutures near the obstructed (noneffluxing) ureter. This maneuver usually results in vigorous efflux from the affected orifice.¹⁰ In the case of apical suspension sutures, remove the most lateral suture first and perform cystoscopy after each (more medial) suture is removed.^4,9