Objective: To analyze the management of urological complications of gynecologic and obstetric surgeries. Material and Methods: We retrospectively studied 39 patients hospitalized in the Department of Urology of the Conakry Teaching Hospital for urological complications of gynecological surgery, during 9 years. The epidemiological, diagnostic, surgical and outcome parameters have been analyzed. Results: The urological complications of gynecologic surgery represent 0.29% of admissions in the Department of Urology. The mean age was 31 years with extremes of 18 and 47 years. Etiological factors were dominated by caesarean section with 74.36% of cases. The main lesions observed were vesico-vaginal and uretero-vaginal fistulas respectively 43.6% and 41.2% of cases. The mean delay of diagnosis was 5 months (extreme: 7 days to 3 years). Urine leakage from the vagina was the main symptom. The surgical treatment consisted in 17 surgeries for vesico-vaginal fistulas, 16 surgeries for uretero-vesical reimplantation, 2 surgeries for termino terminal ureterorraphia, 2 surgeries for vesico-uterine fistulas and 1 surgery for hysterectomy. Healing was obtained in all ureteral injuries and we noted two cases of failure in vesico-vaginal fistula. Conclusion: urological complications of gynecologic surgery remain frequent. They are dominated by the vesico-vaginal and uretero-vaginal fistulas and the main etiology is caesarean section. The treatment is surgical in our context.
Lesions of the ureter and bladder following gynecological or obstetric surgeries are commonly found in women because of the close anatomical relationship between the urinary and female genital tracts. These urological complications result not only from large surgical resections required for the management of pelvic genital cancer [
This is a retrospective study carried out from January 2005 to December 2013 in the Urology-Andrology Department at the University Hospital of Conakry. It focused on the records of 39 patients hospitalized for urologic complications following gynecological and obstetrical surgeries. The subject of the study constituted the clinical and operative data of the first surgery at the origin of the complication, treatment of complications, and imaging data. The age and origin of the patients, the time of diagnosis, clinical data, intravenous urography and ultrasound, renal function, types of surgery involved, topography of injury, and reparative surgery outcome after an average period of three months were also analyzed in the study. The therapeutic results were judged based on the following criteria:
・ Satisfactory: When the patient was found to be dry in cases of vesicovaginal fistulas (VVF) or at the lack of urinary leakage with a restoration of the anatomical and functional integrity of the ureter to intravenous urography in the ureteral injuries.
・ Failed: When the anatomical and functional integrity of the ureter was not restored, or fistula was not closed with persistent urinary leakage.
During the study period, 13,248 patients were hospitalized in the department of Urology and Andrology, including 39 patients (0.29%) with urinary complication following gynecological and obstetrical surgeries. The average age of the 39 patients was 31 years (range, 18 and 47 years). The diagnosis delay was five months on an average (range, 7 days to 3 years); this period was more than one year in 41% of patients. Of the patients included in the study, 19 (48.72%) came from the community hospital, 11 (28.21%) from a major surgical department in Conakry University Hospital, and 9 (23.07%) from a regional hospital. Clinically, urine leakage through the vagina with or without the need of intact voiding was recorded as the main symptom (
The various urological complications observed following gynecological and obstetrical surgeries were dominated by VVF and ureteral-vaginal fistulas with 43.60% (n = 17) and 41.02% (n = 16) of cases, respectively (
Etiologic factors | Number of cases | Percentage |
---|---|---|
Cesarean section for acute fetal distress | 17 | 43.57 |
Cesarean section for uterus scar | 6 | 15.38 |
Cesarean section for pre-uterine rupture | 4 | 10.25 |
Cesarean section for narrow pelvis | 2 | 5.13 |
Hysterectomy for uterine fibroma | 4 | 10.26 |
Hysterectomy for uterin prolapsus | 3 | 7.69 |
Extended colpo-hysterectomy | 2 | 5.13 |
Myomectomy | 1 | 2.56 |
Types of lesion | Number of cases | Percentage |
---|---|---|
Vesico-vaginal fistulas | 17 | 43.60 |
Uretero-vaginal fistulas | 16 | 41.02 |
Vesico-uterine fistulas | 3 | 7.69 |
Uretero-uterine fistulas | 1 | 2.56 |
Ureteral ligation | 1 | 2.56 |
Vesico-vaginal fistula + uretero-vaginal fistula | 1 | 2.56 |
done in all patients that demonstrated a unilateral ureterohydronephrosis in 16 patients who had ureteral injuries. The intravenous urography detected silent kidney with ureterohydronephrosis in one of the patients. Therapeutically, different surgical methods of management of urological complications following gynecological and obstetrical surgeries are listed in
Therapeutic results considered after a mean follow-up of five months were found to be satisfactory in 94.87% (n = 37) of cases. Thus, all ureteral injuries were healed except in two that underwent vesicovaginal fistulorra- phy. In three patients, a parietal suppuration was noted and subsequently treated with antibiotics along with local wound care. Vesico-cutaneous fistula observed in a patient was treated by the maintenance of the bladder catheter for a few more days.
Surgical treatment | Number of cases | Percentage |
---|---|---|
Vesico-vaginale fistulorraphy | 17 | 43.59 |
Uretero-vésicale reimplantation (UVR) | 16 | 41.03 |
Vesico-uterine fistulorraphie | 2 | 5.12 |
Hystérectomy + cystorraphy | 1 | 2.56 |
Termino-terminale ureterorraphy | 2 | 5.12 |
UVR + vesico-vaginal fistulorraphy | 1 | 2.56 |
Total | 39 | 100 |
The incidence of lesions of the ureter and bladder consecutive to gynecological and obstetrical surgeries show a higher incidence in Guinea. In our study, we noted 39 cases with ureter and bladder lesions in 9 years. Diallo et al. [
The consultation delay was longer in our study, which exposed the patients to serious complications including ureteral injuries, especially that none of them were diagnosed during the surgery. The lack of specificity of clinical pictures could explain this long consultation delay in our study. The consultation period was shorter in the study by Odzebé et al. [
In the present study, hysterectomy is considered as the second type of surgery responsible for urological complications. As per the studies conducted by Diallo et al. [
The lesions observed in our study were dominated by the VVF; this is in accordance with Bouya et al. [
In the present study, surgery was considered as the definite treatment for the vesico-uterine fistulae that involved the closure of the fistula in two cases, and hysterectomy was associated with the closure of the bladder opening. Hysterectomy was indicated in a patient of 47 years, who was multiparous with a major fibrous scarring making the vesicouterine dissection difficult. Few studies advocated a hormonal treatment suppressing the menstrual flow for a variable period from three to six months or holding the bladder catheter to allow healing of the vesico-uterine fistula [
The ureter lesions observed in our study were in the form of uretero-vaginal and uretero-uterine fistulas or ureteral ligation. In the gynecological surgery, the incidence of iatrogenic ureteral wounds was in the range of 0.013% to 1.8%. This surgical discipline alone accounted for 47% - 55% of all postoperative ureteral wounds identified in the literature [
The management of ureteral injury is based on its topography, extent, the delay between the occurrence and time of diagnosis (intraoperative, early or late), mechanism, and patient comorbidities. There are multiple therapeutic options that exist. Apart from the endoscopic methods (J stent or percutaneous nephrostomy), one can perform a direct approach for surgery of the lesion to realize an ureterovesical reimplantation. The reimplanta- tion can be done with or without the psoic bladder, uretero-ureteral end-to-end anastomosis or end-to-side between the injured ureter and healthy urethra or even urétéroiléoplasty when there is any serious defect [
In our series, all patients underwent open surgery because of the antiquity of the lesions. Ureterovesical reim- plantation was performed in 16 cases, including 4 on-flap Boari Küss and 3 on the psoic bladder. This reimplan- tation was preferred when the lesion was less than 2 cm and distally positioned (<3 - 5 cm above the ureterove- sical junction) [
The resection anastomosis uretero-ureteral performed in two of our patients was used for short lesions located at a distance from the ureterovesical junction. Technically, the resection should switch to healthy tissue, and the anastomosis should be broad, sloping, and without traction on a JJ stent.
In our study, 94.87% of satisfactory results were obtained. All ureteral lesions were healed, but two failures were noted after vesicovaginal fistulorraphy. In the previous study by Bouya et al. [
Urological complications resulting from gynecological and obstetrical surgeries are disabling conditions that are still found to be relevant. The causes are dominated by caesarean section and major VVF and ureteral injuries that remain unrecognized. In the present context, the late diagnosis has led to the need for surgical treatment. The best treatment for urological complications of gynecological and obstetrical surgeries is prevention, which requires a thorough knowledge of the anatomy and compliance with good surgical practices.
Abdoulaye BoboDiallo,TellySy,Thierno MamadouOury Diallo,Alpha BoubacarBah,AboubacarTouré,Mamadou DiawoBah,Mamadou BoboDiallo, (2015) Surgical Treatment of Urological Complications of Gynecological and Obstetric Surgeries at the University Hospital of Conakry Guinea. Open Journal of Urology,05,231-237. doi: 10.4236/oju.2015.512037