should any injury occur , long - term complications are less frequent nowadays . the risk of damage increases when the normal anatomy is altered by primary pathologic factors or when it is insufficiently identified during intraoperative complications , such as severe bleeding or pelvic adhesions .
urinary tract injury complicates an estimated 0.2 to 1% of all gynecologic procedures and pelvic operations .
however , if cases of indeterminate origin are included , it can be estimated that many more cases of urinary tract injury occur during pelvic surgery .
the true incidence is difficult to ascertain from the literature because most studies review only patients who became symptomatic and required urologic intervention .
eighty - two percent of ureter injuries occur during pelvic surgery , and 75% of urinary tract injuries are due to gynecologic surgery .
urinary tract injuries due to obstetric and gynecologic surgery are normally divided into two categories : acute complications such as bladder laceration or ureter laceration that can be identified immediately during the operation , and chronic complications such as vesicovaginal fistula , ureterovaginal fistula , and ureter stricture , which can occur later on . to avoid injury to the urinary tract
, the gynecologist must have an accurate understanding of pelvic anatomy , use a meticulous and methodical surgical technique , and maintain a constant high degree of vigilance . in the case of ureter injury ,
early detection and treatment can prevent the deterioration of renal function and bring about a satisfactory prognosis , but nonsurgical treatment is the recommended first - line method in iatrogenic ureteral injuries with delayed diagnosis .
increasingly , complex , minimally invasive endoscopic procedures are being carried out by urologists to treat pyelo - ureteric disorders .
this study was performed to investigate the clinical features of urologic complications such as iatrogenic ureter , bladder , and kidney injuries following obstetric and gynecologic surgery and to help to prevent future occurrences of urinary tract injury .
all patients who underwent obstetric and gynecologic surgeries in the pelvic cavity from 2007 through 2011 at cheil general hospital were analyzed .
ninety - seven of these patients developed urological complications and were enrolled in this study ( table 1 ) .
all patients had a detailed history taken and a clinical examination performed . through retrospective review
, we researched the site of injury , etiologic characteristics of the injury , etiologic disease of obstetric and gynecologic surgery , and therapeutic success rate with respect to time of diagnosis and treatment of complications .
urological complications were defined as laceration , transection , rupture , or ligation of the genitourinary tract found during surgery or as hydronephrosis and leakage of contrast media out of the urinary tract found after surgery that required interventional or surgical treatment .
patients were followed up in the outpatient clinic at 1 , 3 , and 6 months with complete urinalyses and urine cultures at each visit .
the most common type of urinary tract injury was bladder injury , including bladder laceration and vesicovaginal fistula .
of the 97 patients , 69 ( 71.8% ) had bladder injury , 23 ( 23.9% ) had ureteral injury , 2 ( 2.1% ) had vesico - vaginal fistula , 2 ( 2.1% ) had uretero - vaginal fistula , and 1 ( 1.0% ) had renal injury ( table 1 ) .
of the 23 cases with ureteral injury , 10 had lacerations , 7 had transections , and 6 had ligation .
the right and left ureters were injured with similar frequency , and no patients had bilateral injury .
laparoscopic - assisted radical vaginal hysterectomy had the highest rate of injury , with 3 ( 3.06% ) of 98 cases .
the incidence of urinary tract injury in relation to the type of surgery was 2.78% for radical abdominal hysterectomy , 0.47% for laparoscopic - assisted vaginal hysterectomy , 0.41% for vaginal hysterectomy , 0.38% for total abdominal hysterectomy , and 0.08% for cesarean section ( table 1 ) .
the indications for pelvic surgery in the bladder injury patients were uterine myoma ( 35 cases ) , cesarean section ( 15 cases ) , adenomyosis ( 7 cases ) , and cervical cancer ( 3 cases ) .
the gynecological and obstetric diseases requiring surgery that were responsible for ureteral injuries were cervical cancer ( 8 cases ) , uterine myoma ( 6 cases ) , endometrial cancer ( 3 cases ) , and endometriosis , uterine myoma , and ovarian cancer ( 2 cases each ) .
vesicovaginal fistula resulted from treatment of ovarian cancer and uterine myoma in one patient each .
ureterovaginal fistula resulted from treatment of one case each of uterine myoma and uterine prolapse .
one case of renal injury resulted from treatment of endometrial cancer ( table 2 ) .
all 69 cases of bladder injury underwent combined transabdominal and transvaginal primary repair during surgery with a 100% success rate .
every patient received a urethral catheter , which was left indwelling for at least 10 to 14 days .
seven of these had a ureteral catheter inserted , five underwent ureteroureterostomy , and two cases had ureteroneocystostomy performed with no major complications .
of the remaining nine cases with delayed diagnosis of ureteral injury , ureteral catheter insertion was carried out in three cases , ureteroureterostomy in four cases , and ureteroneocystostomy in two cases .
the success rate of ureteroureterostomy in the delayed diagnosis group was 50% ( two of four cases ) .
however , in the two cases with a failed initial ureteroureterostomy , one underwent ureteroneocystostomy and the other underwent ureteral balloon dilatation and the ureteral injury was successfully repaired in both . in the two cases in which ureteroneocystostomy was performed as a primary intervention , the success rate was 100% .
all four cases of vesicovaginal fistula and ureterovaginal fistula were cured after trans - vaginal primary suturing and ureteroureterostomy following percutaneous nephrostomy ( table 3 ) . in the case of ureterovaginal fistula
, ureteral catheter insertion and percutaneous nephrostomy were initially performed , followed by ureteroureterostomy after a set period to complete the repair .
its incidence is reported to be from 0.5 to 1.5% , and bladder injury is more common than ureter injury .
most bladder injuries , but only one third of all ureter injuries , are identified during surgery . it has been reported that intraoperative cystoscopy reduces the occult ureter injury rate .
the detection rate of ureter injury is 1.6 in 1,000 without cystoscopy , and 6.2 in 1,000 with cystoscopy , which implies that occult injury occurs more often than expected . in our study ,
if it were possible to follow up all patients for an extended period of time , the actual incidence of urinary tract injury would certainly be higher .
of the observed urinary tract injuries , 80% involved bladder laceration , and 74% of all cases of fistula involved vesicovaginal fistula .
this suggests that the bladder is the most common site of urinary tract injury during pelvic surgery .
the observed high incidence of bladder injury may be due to the fact that such injuries are easier to detect than injuries occurring at other sites . the most common indication for pelvic surgery was leiomyoma of the uterus , and the most common type of surgery was transabdominal hysterectomy .
although urinary tract injury was most commonly associated with transabdominal hysterectomy , its rate of complication was 0.28% , which is not much higher than the rate for other pelvic procedures . radical hysterectomy was associated with a 0.74% incidence of fistula formation , which was the highest among all types of pelvic surgery
. this may be due not only to the fact that wide dissection was performed during surgery , but also that its main indication was gynecologic cancer , which can cause pelvic adhesion and changes in normal pelvic configuration .
this can be explained by the fact that it is hard to dissect the bladder with adhesions .
the incidence of urinary tract injury during obstetric and gynecologic surgery could depend on the experience of the surgeon .
surprisingly , we found that experience of the surgeon , or lack thereof , did not correlate with the rate of urinary tract complications .
intravenous pyelography prior to the operation was used to reduce the risk of urologic complications . however , performing intravenous pyelography in all patients is not cost - effective . in selected cases ,
preoperative stent insertion was recommended when patients had a history of previous pelvic surgery or there was a strong suspicion of pelvic adhesion .
this makes the identification of the ureter easier and makes it less prone to injury .
the most common sites of ureteral injury during hysterectomy are along the pelvic wall lateral to the uterine artery , the area of ureterovesical junction , and the base of infundibulopelvic ligament .
this procedure requires special attention during dissection . in cases of gynecologic surgery with severe pelvic adhesion , methylene blue injection or intraoperative cystoscopy
when there is any suspicion of urinary tract injury , this procedure is very useful for preventing and identifying it .
the timing of repair of ureteric injuries is somewhat controversial , with some urologists advocating immediate repair whereas others favor delayed repair .
it has been argued that recognition and repair of injury at the time of urinary tract injury or within a week of the injury allows for better results with fewer complications .
intraoperatively recognized injuries are usually more easily repaired at the time without the need for a second surgical intervention .
however , we found that postoperative diagnosis of ureteral injury and delayed repair had its own merits .
in this situation , surgeons were able to find the borders of viable tissues more readily and were able to avoid unnecessary excision . as a result ,
the urinary tract - vaginal fistula , which was the most common complication detected after pelvic surgery , originates as the result of urine leakage from the vagina and was sometimes accompanied by fever , flank pain , and chills .
our findings in this study were similar to those of others who reported that the duration from operation to appearance of symptoms was from 3 to 33 days .
in the cases of fistula that we treated , repair was performed and stent insertion was also included when the fistula was accompanied by ureter stricture .
the variety of injured states , difficulty of diagnosis , and time to complete cure were much greater among patients with ureteral injury .
when a urologic complication develops , early diagnosis and early urologic intervention are necessary to prevent the occurrence of delayed urologic complications .
 purposeurologic injuries occur frequently during surgery in the pelvic cavity . 
 inadequate diagnosis and treatment may lead to severe complications and side effects . 
 this investigation examined the clinical features of urologic complications following obstetric and gynecologic surgery.materials and methodswe accumulated 47,318 obstetric and gynecologic surgery cases from 2007 to 2011 . 
 ninety - seven patients with urological complications were enrolled . 
 this study assessed the causative disease and surgical approach , type , and treatment method of the urologic injury.resultsof these 97 patients , 69 had bladder injury , 23 had ureteral injury , 2 had vesicovaginal fistula , 2 had ureterovaginal fistula , and 1 had renal injury . 
 with respect to injury rate by specific surgery , laparoscopic - assisted radical vaginal hysterectomy was the highest with 3 of 98 cases , followed by radical abdominal hysterectomy with 15 of 539 cases . 
 all 69 cases of bladder injury underwent primary suturing during surgery without complications . 
 of 14 cases with an early diagnosis of ureteral injury , 7 had a ureteral catheter inserted , 5 underwent ureteroureterostomy , and 2 underwent ureteroneocystostomy . of nine cases with a delayed diagnosis of ureteral injury , ureteral catheter insertion 
 was carried out in three cases , four cases underwent ureteroureterostomy , and two cases underwent ureteroneocystostomy.conclusionsbladder injury was the most common urological injury during obstetric and gynecologic surgery , followed by ureteral injury . 
 the variety of injured states , difficulty of diagnosis , and time to complete cure were much greater among patients with ureteral injuries . 
 early diagnosis and urologic intervention is important for better outcomes . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS