Conference Coverage

Don’t neglect urinary tract in gynecologic procedures


 

EXPERT ANALYSIS FROM PAGS 2019

Pay close attention to the urinary system with an eye toward spotting injuries and repairing them – but when the time is appropriate, John B. Gebhart, MD, MS, urged.

You don’t need to stop a procedure to fix a bladder injury. Rather, mark the spot with a suture, finish what you are doing, then come back and fix the bladder injury, he advised.

“We need to be thinking [of the]urinary tract all the time in the procedures that we’re doing,” Dr. Gebhart, a urogynecologist and reconstructive pelvic surgeon from the Mayo Clinic, Rochester, Minn, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“Can you look at the bladder and see that it’s intact, that ureters are functioning like they should? You don’t need to have the skill set to place stents, but you should be able to look in and know you’re okay leaving the operating room,” he said.

According to Dr. Gebhart, urethral injuries can occur in these procedures: anterior repair, cystoscopy, midurethral sling, and treatment of diverticulitis or Skene’s duct abscess.

He offered these tips about urethral injuries:

  • Use catheters, dyes, and urethroscopy to reveal injuries. “Putting in a catheter is great because it helps you identify injury because you can visually see it,” he said. “We can squirt some dye in the urethra and see if it’s leaking out. We can put in a zero-degree scope and do urethroscopy.”
  • Consider linking multiple holes in the urethra. “Don’t make individual repairs,” he said. “Connect the holes, making them into one hole that you can fix in one setting.”
  • Check your repairs for leakage. “I might take a little indigo carmine or methylene blue in a little [angiocatheter], squirt it down the urethra, and see if I’ve got anything leaking out from my repair site,” he said. “If I do, then I want to go back and repair that so that I’ve got a watertight closure.”
  • Consider a catheter after repair. “If you do a repair, you want to place a catheter at the end of the splint in the urethra for 7 to 10 to 14 days to help prevent stricture afterwards.”

Dr. Gebhart also discussed bladder injuries, which he said can occur in anterior repair, cystoscopy, hysterectomy, midurethral slings, sacrocolpopexy, and other procedures.

He offered these tips:

  • Use bladder backfilling to detect injury. “We can backfill the bladder with the little methylene blue stain–normal saline to help identify whether you’ve got a leak or an injury,” he said. “[Cystogram] can also be very helpful as well.”
  • Don’t stop a hysterectomy to fix a bladder injury. “Mark the hole with a suture, finish the hysterectomy and get it out of the way, then come back and fix the hole in the bladder,” Dr. Gebhart said.
  • After repair, drain the bladder with a catheter for 10-14 days. “You’re always better draining through a catheter a little longer than pulling the catheter too soon, putting a stretch on the bladder, and maybe compromising your repair,” he said.

He recommended performing a quick cystogram before pulling the catheter to make sure there’s no leak.

Dr. Gebhart disclosed consultant (Hologic) and advisory board (UroCure) relationships and royalties (UpToDate, Elsevier).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

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