Fistulas, bladder and ureteral damage: postoperative incontinence? Check for injuries.(Gynecology)

BALTIMORE -- Have a high index of suspicion when it comes to injuries during pelvic surgery, Dr. Jerry Blaivas said at a urogynecology meeting sponsored by Johns Hopkins University.

Bladder injuries, fistulas, and ureteral injuries are among the common complications of urologic surgery that can result in incontinence.

"If you even think about the fact that you might have injured the bladder, rule it out, either by looking at it or by testing it," said Dr. Blaivas of Cornell University, New York.

If a patient is incontinent after an operation, have a high index of suspicion and check not only for fistulas, but also for prolapse. Dr. Blaivas said that he finds a bilateral retrograde pyelogram worthwhile even if it identifies one ureteral injury in 100 noninjured patients. Be positive that the ureters have not been injured because if they are, they must be repaired, he added.

For vesical injuries identified during surgery. Dr. Blaivas said he closes the bladder with a single running inverted layer of absorbable sutures. Make sure bladder drainage is adequate, and conduct a cystogram approximately 1 week after surgery, he said. He prefers the Connell stitch: sewing from the outside of the bladder to the inside of the bladder, then out, then over to the other side, and then from the outside to the inside again. This technique inverts the entire bladder in a single layer.

Urinary fistulas may be vesicovaginal, ureterovaginal, urethrovaginal, vesicouterine, or colovesical. Most fistulas stem from abdominal hysterectomies. Dr. Blaivas said he finds that a cystoscopy is the best way to diagnose a fistula. Associated pathology includes sphincteric abnormalities, secondary fistulas, urethral defects, and ureteral fistulas or obstructions.

As to the timing of surgery for a fistula, there is usually no need to wait longer than it takes for the site to be free of active inflammation or infection. If the fistula is small, however, postponing surgery for a month may allow it to heal on its own.