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In the name of God

This article discusses the prevention, recognition, and management of gynecologic injuries to the ureter, bladder, and urethra, including surgical techniques and post-operative care.

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In the name of God

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  1. In the name of God

  2. Gynecologic injury tothe ureter /bladder/urethra prevention ,recognition and management DR EMAMI UROLOGIST

  3. Gynecologic injury to ureter&bladder In female Anatomic relationship between REPRODUCTIVE SYSTEM & GUT predispose the GUT to involment by gynecologic disorders and places it at risk

  4. Gynecologic injury to ureter&bladder Injury to the bladder or ureter occur Appproximately %1 -%2 of all major gynecologic procedure • Between 50% ad 90 of all lower urinary truct injury occure during gynecologyic surgery. • Some of these injures can not be avoided. but the majority are avoidable.

  5. TWO FACT Review of the surgical literature reveal two fact: Most injury occur during benign procedure Most injury are not recognized During procedure

  6. PREVENTION • Preoprative assessment: patient history,physical examination and preoperative laboratory evaluation may sugest abnormal function of GUT. If any abnormality is revealed Further evaluation shoud be performed

  7. PREVENTION Bladder Continous drainage almost allways Foley catheter(triple lumen)

  8. PREVENTION Ureteral stent dose not reduce incidence of surgical injury to ureter. Ureteral stent predispose the ureter to damage As a result of immobility it imparts to the ureter

  9. Intra operative care During all surgical procedure : Sharp dissection blunt dissection Small pedicles large pedicles (Many ureters are damaged by application Of clamp in a frantic effort to control pelvic hemorrhage)

  10. pre operative care Complicated case Abdominal _vaginal _perineal _preparaition Foley _catheter_three_waycontinous drainage

  11. Intra operative care(abdominal approach) Identify the ureter Abdominal ureter Pelvic ureter

  12. Ureter & gynecologictruma If the surgeon decided to identified the ureter Identification without dissection Follow ureter under posterior peritoneum Over hydrate /lasix injection(peristaltism) Identification with dissection Open retro peritoneom/preserve vascular sheat

  13. Pelvic ureter biforcation common iliac arterie Posterior boundary of ovarian fossae Beneath the uterine arteries Ant and lat cervix and vagina

  14. Pelvic cavity &ureter truma Oblitration of cul_de_sac Plication of utero sacral ligament

  15. Suspentation of vaginal apex

  16. Ureter/truma Patialtruma/viable tissue Complete truma /non viable

  17. Ureteral injury (recognition&management) End to end anastomsis Ureteroneocystostomy

  18. Vaginal surgery and ureter truma Don’t try to identified the ureter Good plan between uterine &bladder (vesicoperitoneal fold)

  19. Intra operative care(abdominal approach) The surgeon should be aware: The bladder may be pull up beneath the anterior abdominal wall : • Incomplate emptying • Previous surgery(cesarean)

  20. Intra operative care(abdominal approach) Bladder trauma

  21. Intra operative care(vaginal approach) Bladder trauma Good drainage Tissue hydrodistention

  22. Management of bladder injury Intra operative repair of bladder injur Extra peritoneal laceration Closed with one or two layers of NO3/o Absorbable suture

  23. Management of bladder injury Trans peritoneal laceration of bladder& Base of bladder Repaired in two layer usingNO3/o Absorbable suture Covered with omental or peritoneal flap

  24. Management of bladder injury For better healing Continous drainage for at least 7days Anti spasmodic drug Antibiotic therapy

  25. Laparoscopic approach(intera operative care) Urinary tract injury occur in %1- %2 of patients undergoing major laparoscopic surgery. Bladder injury result from dissection with or without cautery. For prevention of ureteral injury ureteral catheter is recommended.

  26. Urethral injury(recognition &management) Intera operative Seeing the cath through an incision Repaired over a trans urethral cath in layers using NO 3 /o or 4/o Absorbable suture (bulbocavernous fat pab may be requried)

  27. THANKS FOR ATTENTION

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