Okay, thank you so much for that very thorough introduction. I'm really excited to be, you know, able to have the chance to kind of talk through the way I evaluate and manage lower urinary tract injuries. So I know we're starting just a shy little bit off of the schedule, so I'd like to get right down to the meat of everything. Today I'm going to be focusing on advanced evaluation of the lower urinary tract, and I'm going to try to focus on both the conservative as well as surgical management of delayed and intraoperatively identified bladder injuries and ureteral injuries. In terms of learning objectives, I'd like to have you be able to illustrate prompt and appropriate diagnosis of intraoperative and delayed lower urinary tract injury, differentiate delayed versus immediate injuries and their management, identify helpful radiologic studies in evaluating lower urinary tract and their specific indications, demonstrate appropriate use of diagnostic procedures in the evaluation of lower urinary tract injury, identify conservative management options for managing LUTI, and then illustrate minimally invasive surgical procedures and describe the necessary surveillance in women treated with lower urinary tract injury. So to start things off, I'm going to focus on the lower urinary tract evaluation for injury. So it comes as no surprise to all of us. Unfortunately, iatrogenic ureteral injury, they're associated with urologic and gynecologic procedures are among kind of the top causes of iatrogenic ureteral injury. The reported rates of ureteral injury kind of range in the literature on the low end 0.3% and probably on the high end a little bit under 2%, and certainly the risk is definitely associated with the route of hysterectomy with your abdominal and laparoscopic routes having a slightly higher incidence than the vaginal route. In terms of where the ureteral injuries occur, this is you know probably also not coming into a surprise to anyone, but it does come into play with the way that we evaluate and manage injuries, but there's really three common areas in which the ureter can be injured at the time of a hysterectomy, and that's specifically at the level of the IP ligament ovarian vessels, uterine artery, and vaginal cuff. So one of the most important things I like for everybody to be able to take home is that ureteral injuries are often not recognized at the time of surgery, indicating that these are typically delayed diagnoses. There is a fairly large systematic review that included 157 ureteral injuries associated with laparoscopic hysterectomy, and unfortunately only 14% of those injuries were identified at the time of surgery. This is not the only study that illustrates this, and it will come up several times throughout our discussion, and I hope that I'm able to illustrate why we would like to avoid delayed injuries for women. So intraoperative cystoscopy, certainly this improves the detection of lower urinary tract injury. There are several studies that continue to illustrate this in the literature. Some of the earlier studies took a little under a thousand hysterectomies. There was a four, about a four percent risk of lower, or incidence of lower urinary tract injury, around 2.4% for bladder, 1.8% for ureterals. Great news, cystoscopy identified almost all of those cases. And again, there are, so studies that illustrate that injuries of the lower urinary tract are actually not commonly recognized before cystoscopy, indicating that just inspection or visualization of the lower urinary tract is probably not adequate at preventing our injuries or identifying. You know, if we talk about primary prevention, secondary prevention, primary intervention, primary prevention would be not injuring the ureter, which we understand is not possible, but secondary prevention really would be identifying that before you leave the operating room. So just a quick note on indigo carmine. So in about, in 2015, we lost the use of indigo carmine because it was no longer being manufactured. I'm happy to say that indigo is back. So if you have not requested that at your hospital, you can. It's in production. Reasons why you, you know, if you still don't have indigo, there are some other options that you could use. I typically avoid using methylene blue. There's variable metabolism. So sometimes if you're trying to identify ureteral efflux, it might just not be metabolized for quite some time and that might fool you. Also, it's associated with a small risk of methemoglobinemia. Peridium is a very nice, easy strategy to add to any of your preoperative protocols. You can have a woman take this with a sip of water prior to her hysterectomy and it will be filtered through the renal system for the next six hours or so. So it can really aid in the detection of those ureteral efflux or ureteral jets at the time of cysto. Another great option would be sodium fluorescein. This is pretty easy to come by in the operating rooms because it's typically available for ophthalmologic surgeries. It produces very quickly after it's administered IV, a nice bright green jet once it's filtered. The dosing is 0.25 milliliters of the 10% sodium fluorescein and again it can be really nice if you know you have no other options. In terms of that primary or secondary prevention, what about the role of prophylactic stents? Fortunately, prophylactic stents have actually been studied quite a bit in terms of their ability to prevent and ability to detect injury as well as the cost associated with that. Basically, the punchline is they're probably not going to cause harm. They're not effective at preventing injury, but they can help identify injury, but they are not cost-effective. So if we have no prophylactic stents, what now? I think an even more helpful scenario would be universal cystoscopy at the time of an eye hysterectomy. This has been studied in a few institutions that have implemented a policy and the really nice outcomes of implementation of these processes are the decrease in delayed injury. So these implementing universal cystoscopy has been shown to decrease delayed injury. Again, I'm mentioning injury. I'm going to focus on why you would want to decrease delayed injury. So let's move on to a case. So common case, a gynecologist has a 42 year old that is status post, a total laparoscopic hyst and bilateral self-injection. They notice risk efflux on the right side, but nothing on the left. They have been watching for about 15 minutes. Otherwise, really kind of an uncomplicated procedure and they asked you to come take a look. So on your way, as you start to think about what you might want to be doing, you're going to start to think where could the trouble be and how did it occur? So typically, you know, you're thinking perhaps this is occurring at the vaginal cuff. How can that happen? Certainly, sometimes the bladder is tacked up at the time of the hysterectomy. If it's not taken down completely, there could be, you know, a complex dysthytomy, which is, you know, bringing the injury, causing some complication at the level of the ureter. Oftentimes, when the cuff is re-approximated with the bladder in close proximity, that ureter can be kinked just where it comes into the bladder. Certainly, there can be, you might want to be thinking about injury in the area of the uterine artery or the IP ligament. This can occur typically with a thermal pressure transfection. So what are some of the troubleshooting? So when we think about when there's no efflux from both ureters, you know, first of all, first things first, think of the easy things. Obviously, there can be a patient that has renal insufficiency. Older women, they might have some kidney disease at baseline. Hopefully, people have really moved away from this and gynecologic surgery, but bowel preps have really been known to dehydrate people. There could be a fluid status problem causing decreased perfusion and decreased efflux at the level of the ureters. Some quick and easy maneuvers. If you are operating in an open fashion, one of the, you know, things that you might forget to do is remove the packs. Packs can be putting pressure on the ureter and they can actually be kinking things off. Reverse the Trendelenburg and then think about just giving a little fluid bolus or a touch of IV LASIK. How about when it's one ureter? So you know that something's working. Well, probably the easiest thing to do is think about the operation that is being performed. If it's a uterus sacral, typically we know that the most distal lateral suture is going to be the most likely to cause any kinking at the level of the ureter just because the proximity to the ureter at the level of the most distally placed uterus sacral ligament stitch. The hysterectomy, we've just talked about the three most common sites of injury. Another really important thing is to consider any prior pelvic surgery. So if a woman has a history of, you know, a prolapse repair done at an outside hospital 20 years ago, could it be possible that there was some injury and now she, you know, has a non-functional kidney on that side? Yes, absolutely. And then other history which can kind of, you know, nip you in the butt if you don't remember that. Certainly there's women that have nephrectomies or even are born with a solitary kidney and those can be reasons troubleshooting other outside of the surgical procedure at hand, reasons why you would have only efflux from one ureter. Okay, so what are we going to do when there's no efflux? So as I said, kind of when you're getting that initial call, you're going to start thinking about what you want to do. You're going to want to start to prepare. So typically when there's no efflux on one side or both sides, we're going to start talking about shooting some retrograde pylograms. You're going to want to get the CR, make sure there's fluoroscopy. If you're in a situation or a scenario in which you do not have fluoroscopy capabilities, there is an opportunity to do a one-shot or a single-shot IVP. You would administer IV contrast and then wait 15 minutes and shoot just a plain x-ray. This can be difficult to time. It's not an exact science and it would be kind of a last-resort scenario if you have no fluoroscopic capabilities. Anyhow, so let's say that you do have those capabilities and you're shooting those retrogrades and both kidneys are visualized, great. If the ipsilateral kidney is not visualized with your procedures, you're probably just going to want to get a post-op CT scan. It's likely that there's an old injury. The reasons why fluoroscopy is necessary, if there's any possibility that you might be trying to conservatively manage a ureteral injury, you really need fluoroscopy if you are going to be planning to pass ureteral catheters or stents. This is really just for safety. It's possible that you could perforate a ureter or even kind of skive through the lumen of the ureter. You also want to make sure that you're accurate. If you have a transected ureter and you just kind of get lucky and you place the stents through the ureter and into the abdomen and pelvis and it just happens to be sitting in the right place once it's coiled, it's not going to be very effective because you've just cannulated a blind-ending transected ureter. You're going to want to make sure that you have that capability. How are you going to get ready to do a retrograde pylogram? The first thing that you're going to need is a 30-degree stethoscope. I think that typically, just based on our training, most uro-medicologists feel most comfortable with a 70-degree scope because we're used to using it for surveillance and monitoring of the trigone and the ureteral orifices. But for retrograde pylograms, since we will be focusing on cannulating the ureter, you're really going to be wanting a 30-degree scope. Other things that are helpful, if you're going to be cannulating the ureter with an operative stethoscope, you'll need a sheath that's large enough to accommodate whatever you're going to be passing through there. Usually, that's a five or six French ureteral catheter or sense. You'll need a contrast, renografen or isovue that should be readily available. Then, you'll need a big enough syringe to be able to perfuse that contrast through your catheter. Typically, I like to use the cone tip catheter. The cone tip catheter is the yellow one that's visualized at the top of this picture. It's very nice because it has the hole at the tip that allows the contrast to come out. Then, this larger area is basically the portion that kind of blocks the ureter off so that the fluid has only one direction to go. Certainly, there's other types of ureteral catheters. There's double open-ended catheters that can be used just as easily in a different fashion. But I would suggest, if possible, getting the cone tip catheter. If you think that you might be needing to manipulate the ureter or place a sense, you're going to need a wire. You'll need a double J stent, which we'll focus on. Then, obviously, fluoroscopy. One thing I like to just remind people is a slider bed. You need a bed that's going to be able to admit the passage of the C-arm. Otherwise, you will have to try to maneuver the patient down to the edge of the bed where the C-arm would be able to be located. It can be actually pretty difficult. Everybody knows the portions and the parts of the cystoscope, but just to remind everybody, we've got a lens that can either be 70 or 30 degrees, typically, for your uses. A bridge that's going to connect to the lens or the cystoscope to the actual sheath that's going to allow us to be passing our instruments. Again, I kind of mentioned this. We're used to using the 70-degree scope mainly for surveillance. We were looking in the bladder at the trigone, really, we can see the ureteral efflux very easily with that lens. If you're planning on doing anything operative, it's typically easier to do with a 30-degree lens. That's just the ease at which you can actually manipulate the end of either your stent or your instrument because it's not quite as angled. This can be really helpful in stents, placement catheters, retrogrades, and if you ever want to biopsy the bladder. Just to mention, there's a lot of different kinds of bridges that are going to connect the cystoscope lens to the sheath. One of the nice bridges to kind of keep in mind is the Alboron bridge. This is a bridge that actually has a long portion of it. This tip moves in basically a 30-degree direction so that it can manipulate the stent or the catheter so that you can more easily cannulate the ureter or do whatever you need to do. That can be a really helpful tip if you're having difficulty cannulating a ureter or just visualizing and being able to place your stent. What are some retrograde rules? I think always the most helpful to start on the good side. The good side is going to provide you your quote-unquote control. In our scenario, if the injury was suspected on the left, you're really going to want to start with the right. This is just a picture, a cystoscopic view of what the cone tip catheter looks like when it's starting to cannulate the ureter, the ureteral orifice. Again, that bulged area is going to actually be preventing the backward flow of any fluid, which is the pressure will be pushing and forcing the fluid up through the collecting system. What can the retrogrades do? Well, certainly they're going to help us assess for patency. If the ureter is fully patent, then it can help us assess for constriction. This happens with kinking or in areas of stricture. Stricture can happen with a lot of different reasons. One of the more common reasons in women that are young and having surgery, they could have surgical scar tissue, they could have endometriosis that's caused stricture. If the ureter is not patent, then you're going to want to start to look for extravasation, which can be sometimes a little difficult to appreciate. If there's a blind ending ureter, I'm going to show you some pictures. You're going to be thinking about a transfection and you really want to look to see if there's that flush or blush of contrast. Our portions of the retrograde, it's kind of nice. You can see in this really nice x-ray that during this retrograde, there's basically contrast fluid that's filling the bladder. You can see at the very distal aspect of the ureter, the intramural portion of the ureter that's kind of embedded in the bladder. Retrograde pyelography is actually the best way to evaluate this distal aspect of the ureter compared to CT scan, which as you know is an area in which the ureter definitely can be injured. The ureter then will track all the way up to the renal pelvis and you can evaluate the renal pelvis for the size and location as well, which we'll get into. Again, as I kind of just mentioned, that distal area where the ureter is intramural in the bladder, it's easier to evaluate on retrograde pyelogram than it is on CT scan. What are the steps you're going to set for a retrograde? You're going to assemble the operative cystoscope that we just talked about. Always remember to flush the system, remove any bubbles, cannulate the ureter orifice with a cone tip catheter. We showed you a picture of that. Then, inject that contrast under continuous fluoroscopy. Here are a couple other things that we can see. Certainly, in the first picture, you can see dilation. This renal pelvis is dilated compared to the other side. That's why it's nice to have that control side. You can see a stricture in this area. Certainly, where the red circle is, the narrowed area is strictured. You can see a bunch of things that look like maybe staples. You can see an area of obstruction where there's some dilation and then a definite area of narrowing and obstruction. Then, you can see a blind-ending transfection. In this picture, you see one small aspect of the ureter and then nothing really is happening and then some blush of contrast. That would be a transected ureter. Again, here is just a case presentation of the normal left side. A very normal renal pelvis and ureter and then a blind-ending transected ureter on the right side. Just remember, there's a lot that we can tell from the retrograde pylograms, even when we're talking about the renal pelvis. These are some 2D reconstructions of delayed CT scans that are in the expiratory phase. I'm just going to illustrate a couple things that you can see. You can, number one, tell the location. The renal pelvis, they're really always located in the same area. The left is always higher. It's nice to use the spinal column as a landmark. Always start at the vertebral body where the last rib is coming off. You always know that you're at T12. Then, you can start to count down L1, L2, etc. The left renal pelvis should be lying at the level of L2. The right is a little bit lower at the level of L2 to 3. Then, finally, besides location, you should be able to tell what the normal size of the renal pelvis is. This can be helpful in what we call a dilator or a blown-out system. If you're seeing something that's spanning five vertebral bodies, that's really markedly abnormal because the renal pelvis should really be about three to five vertebral or three to 3.5 vertebral bodies in length. Those are the advanced evaluation techniques for evaluating the lower urinary tract. Now, I'm going to move on to the management of ladder injuries. Again, iatrogenic ladder injuries. These injuries, the majority of these, are identified intraoperatively. Certainly, cystoscopy has been very helpful in identifying these injuries for the surgeon to serve as that secondary prevention. There's a fairly large study that was published in the Green Journal in 2018 that looked at the risk of lower urinary tract injury in benign gynecologic surgery. I'm certainly just going to focus on the hysterectomy aspect. We talk about lower urinary tract injury at the time of hysterectomy. You can see that, as we've discussed before, the incidence of injury does vary by route with this laparoscopic hysterectomy not otherwise specified with the highest incidence of ladder injury. I think the authors described that they're not otherwise specified. They just didn't fit into one of the defined groups, total laparoscopic, supracervical, or LAVH. Anyway, they do range from that 0.1 to about 1.5%. Again, universal cystoscopy is going to help us prevent the delayed injuries, but not all of them. We should be decreasing them using that. Why do they happen? Certainly, bladder injuries and cystotomies can happen with a direct laceration or a missed cystotomy. There are times where there's a lot of cautery used near the bladder, either to take down or develop the bladder flap. When the bladder flap hasn't really been taken down completely, sutures placed at the cuff of the vagina to close or re-approximate the vagina can certainly incorporate the vagina, leading to a cystotomy. What do we do when they are identified, hopefully, intraoperatively? Intraoperatively, immediate identification. This is obviously the best time to successfully manage lower urinary tract injury and bladder injury. Highest efficacy rates, and certainly it will minimize litigation. We'll touch on that. What are the principles of a bladder repair? Intraoperatively, you want to really ensure that the ureteric orifices and intramural ureter are not in proximity to the injury. Use absorbable sutures and a non-cutting-edge needle. We always aim for a double layer, mucosa-to-mucosa tension-free closure, and then it's prudent to consider an omentum or a martius flap if you're able to. Postoperatively, I suggest draining the bladder with a catheter for 7 to 14 days, depending on the size. I say that you can consider a cystogram prior to the removal of the catheter. Certainly, this varies based on surgeon's preference. There was a study that was published in 2016 by Sochenska et al. that looked at the risk or the use of VCUG after bladder repair. In this case series, 2 out of 125 women, or 1.6%, had a persistent leak on post-op VCUG. Both of those were at the time of cesarean section, and both of those were pretty large injuries, so greater than 2 centimeters. Typically, in straightforward, smaller injuries, I do not obtain a cystogram prior to removal of the catheter. What about for delayed identification? This is where we get into trouble. Delayed identification typically results in a GU fistula. GU fistula, really we want to avoid this for the sequelae that it can incur in women, but also this is a large source of litigation. The risk of litigation increases 70 to 90-fold if the lower urinary tract injury is involved. It's a big reason why people are sued. Iatrogenic injury of the lower urinary tract can really result in fistulas at different levels involving vesicovaginal fistulas, ureterovaginal fistulas, urethrovaginal fistulas, and vesicouterine fistulas. Is there a role for conservative management of VVS? I would say there is probably a small role. On occasion, there is a very small pinpoint sothotomy that can be, in my experience, managed with bladder drainage for a certain portion of time, usually 2 to 6 weeks. This has been studied in the literature with reported efficacy of 1 to 11%, so it might be a little bit of a Hail Mary, but can be considered. Fibrin glue has been looked at and there's some small case series and case reports evaluating that, but I haven't had good success and don't utilize this in my practice. So, what are the principles of fistula surgery? Well, first of all, adequate visualization and proper patient positioning is really paramount to this. One of the other huge pearls, we really strive for attention-free closure with really good vascular supply. And then post-operatively, you'll want appropriate bladder drainage. These are some of the things, the considerations that I just want to have you think about. Certainly, the timing, the route, and the use of a graft. So, I'm going to start with timing. I think the old adage was always that you were going to have to wait three months to repair a fistula. And what I say typically is that what we're trying to do in terms of timing is aimed for healthy, non-infected, non-inflammed tissue. The reason why we don't want to wait arbitrarily for three months to pass is that women that have a fistula suffer a lot of psychological distress. And if we can minimize this for them, I think that's really a win-win situation. So, in the late 90s, Slavis kind of published some outcomes related to the timing of repair, early versus late. And certainly, some of the times of repair are, you know, range from like two weeks to three months. And there's not a big difference in between or in a difference with respect to the timing. So, what we typically strive for is when the tissue appears healthy. So, you can evaluate in just an in-office exam, you know, evaluating the vaginal tissue, performing a cystoscopy that can help you. And we try to aim to repair it at the six to eight week mark. And again, that's to avoid really poor wound healing in those first couple weeks after surgery, but to minimize that psychological distress. In terms of the route of repair, the route will really depend on the fistula location. So, is this a fistula that occurred with the placement of a mid-duratorial fling? Is this a fistula that occurred at the time of a cesarean section in a woman who, you know, has no descent of her vagina? It will also depend on previous closure attempts with how many times has this happened? Is there any evidence of pelvic pathology? Has the woman had radiation? Is there cancer? Is this a complex fistula with involvement from other organs? And then what's the patient's preference? You'll need to present the options and some women feel very strongly about the different routes of surgery. So, abdominal versus vaginal repair has been looked at with respect to, you know, adverse outcomes including, you know, operative time, length of stay, morbidity, and mortality. And it has been shown that those adverse outcomes are a little bit higher with an abdominal approach compared to a vaginal approach. But abdominal approaches appear to be slightly more effective at actually, on the first try, surgically correcting the fistula. And what I'd like to point out here, this is a nice study from the SPRN, that an abdominal repair with an omental flap actually had an odds ratio of 3.3 in terms of a successful repair. So, this is probably one of the more successful repair routes for women with a Vespa vaginal fistula. It's just something to keep in mind. For vaginal repair, certainly there's advantages. We think there's less morbidity and it's faster. Typical literature quotes about success rates somewhere around 70 and with higher optimistic results around 98%. I am just going to briefly go through the last repair because I think that everyone's familiar with this repair. It's really one of the more primary repair types for vaginal repair of Vespa vaginal fistula. But in this repair, really, you're going to start by just marking around the fistula, typically circumferentially of one and a half to two centimeters around that fistula. And then the next aspect is just kind of separating that circular ellipse into four quadrants and then dissecting the vaginal epithelium away. And then the first layer is posed with an absorbable suture and then typically followed by a closure of two to three more layers in an invocating fashion and then the vaginal epithelium is re-approximated. I'm going to switch gears and talk a little bit more about minimally invasive abdominal Vespa vaginal fistula repair. So the transvescal approach was one of the first described approaches. This is most people refer to this as the O'Connor technique. This technique, in order to get to the level of the fistula, involves bivalving the bladder. There's another technique that does not involve bivalving a bladder that's referred to as the extravesical approach. This is an approach that's similar to performing a dissection that we all perform when we perform a sacrocopal pexy or taking down the bladder from the vaginal cuff. The bladder is just mobilized distally to the level of the fistula and the defect in the vagina. This allows you to avoid bivalving the bladder in order to identify the fistula site. There's actually a rather large review that looked at around 260 repairs that were all done minimally invasively, but some done with the transvesical approach and others done with the extravesical approach. The good news is that they're both highly effective at curing fistulas. I think that FPMRS surgeons are probably really well suited to the extravesical approach because we're very familiar with this dissection just from hysterectomy and also sacrocopal pexy. What are the operative steps? Certainly a lot of focus is put on counseling, like what should the patient expect? There's going to be a Foley drainage or some sort of catheter drainage. Would they like to have a suprapubic tube or a Foley catheter? All of that goes into the counseling and preoperative planning. Lysis of adhesions is always going to be required. Most of the times, going back on these cases, there's a lot of adhesions at the level and involving the vaginal cuff. Everything's kind of stuck together in that area of injury. We have found it really helpful to use a large lucite stent for vaginal manipulation. This is what allows us to identify the vagina and use this as counter traction when we're dissecting the bladder from the vagina. As I mentioned, you really do develop those two planes, the plane between the vagina and the bladder in order to identify the defects. We strive for a distance of about two centimeters distal to the fistula edges. The bladder and the vagina then need to be re-approximated and it's always advisable to test the bladder closure with bladder filling. I would recommend, based on the literature and experience, performing an interposition graft, which is placing omentum after you've mobilized suturing the omentum to a secure portion of the vagina. If you're doing these procedures robotically, I do typically tend to use the same instruments. I'll use monopolar shears for dissections. I always use a large needle driver and a large suture cut because I find those easier to tie and manipulate with. A pro-graft can be very helpful with elevating the bladder as does a caudiller. Those are kind of my instruments of choice. The patient is a 41-year-old female who underwent total abdominal hysterectomy, complicated by an intraoperative cystotomy. Primary repair was performed at the time of her initial surgery, however the patient subsequently developed urinary drainage through the vagina. A fascicovaginal fistula was confirmed on office exam and cystoscopy. Prior to any fistula repair, we assess for ureteral patency. On this retrograde nephro-ureterogram, we identify surgical clips that are partially obstructing the right ureter. The first step is to identify the location of the fistula. A lucite stent is placed in the vagina for manipulation. The bladder is dissected off of the vagina, starting at the vaginal cuff. The vaginal side of the fistula is identified. We also identify the surgical clips near the right ureter. Here we identify the bladder portion of the fistula. Using this as a guide, the bladder is meticulously dissected off of the vagina. The goal is to mobilize enough tissue to close the bladder in two layers. The surgical plane is developed by applying simultaneous counter-attraction to the bladder and the vagina. The surgical plane becomes easier to identify once we dissect past the fistula. The first layer of the cystotomy is closed using a running monoclonal suture. Be sure to obtain adequate bites of the bladder mucosa in order to re-approximate this layer. For the second layer of the cystotomy closure, we use a vicral suture in an imbricating fashion. Now that the cystotomy is closed in two layers, we turn our direction to the vaginotomy. We use a delayed absorbable suture in a figure of eight stitches to close the vagina. Finally, we create a lamental J-flap. A pedicle of lamentum is mobilized and secured to the vaginal portion of the repair. The patient is a 41-year-old female who underwent total abdominal hysterectomy, complicated by an intraoperative cystotomy. Primary repair was performed at the time of her initial surgery. However, the patient subsequently developed urinary drainage through the vagina. A fascicovaginal fistula was confirmed on office exam and cystoscopy. Prior to any fistula repair, we assess for ureteral patency. On this retrograde nephro-ureterogram, we identify surgical clips that are partially obstructing the right ureter. The first step is to identify the location of the fistula. A lucite stent is placed in the vagina for manipulation. The bladder is dissected off of the vagina, starting at the vaginal cuff. The vaginal side of the fistula is identified. We also identify the surgical clips near the right ureter. Here we identify the bladder portion of the fistula. Using this as a guide, the bladder is meticulously dissected off of the vagina. The goal is to mobilize enough tissue to close the bladder in two layers. The surgical plane is developed by applying simultaneous counter-attraction to the bladder and the vagina. The surgical plane becomes easier to identify once we dissect past the fistula. The first layer of the cystotomy is closed using a running monoclonal suture. Be sure to obtain adequate bites of the bladder mucosa in order to re-approximate this layer. For the second layer of the cystotomy closure, we use a vicral suture in an invocating fashion. Now that the cystotomy is closed in two layers, we turn our direction to the vaginotomy. We use a delayed absorbable suture and figure of eight stitches to close the vagina. We use a delayed absorbable suture and figure of eight stitches to close the vagina. Finally, we create a momental J-flap. A pedicle of momentum is mobilized and secured to the vaginal portion of the repair. Okay, so I think I kind of mentioned all of these tips in the slides before, but one of the things I didn't focus on was the really side docking of the robot. If you're using a robot, it's going to allow for vaginal manipulation with descent as well as cystoscopy, so that would be a nice little tip. Okay, so moving on, I'm going to talk about ureteral injury. Again, you're going to think back to that where's the trouble, how did it occur, when you get called. In terms of intraoperatively identified injuries, so if you have an injury that's identified at the time of injury, I typically think about how did it happen, and certainly one arm would be the unstable patient. In an unstable patient, there's no time to be evaluating, assessing, etc. or managing surgically. Those patients should really be sent to IR and a PERC-NEF tube should be placed. If there is a ligation and you've identified an area of stricture and you've identified the area of ligation, you can remove the suture and stent if you feel that there's damage. More commonly, if there's a crush or a transfection injury, it's probably best to assess for the vascularity. If your ureter seems to be well vascularized, you can stent this and just perform a primary re-anastomosis. If it's devascularized, I would suggest moving towards ureteral re-implant. On the other hand, if there is an injury in the ureter, there is an injury that's not identified in the operating room but identified in a delayed fashion, timing is really paramount. If this is in the first couple of days after surgery, you can actually take these people back to the operating room and perform a ureteral re-implantation or offer them placement of a stent for conservative management. After five days, typically not the best time to go in just due to scar tissue and poor integrity, indurated tissue and poor tissue integrity. In these patients, they would either suggest stent or percutaneous nephrostomy if you don't have stent capabilities. Then if those patients recur or have sequelae from their delayed injury, you would plan for a delayed repair. How do people present? Delayed injuries present either with plank pain, fever, or ascites. This can be evidenced in an obstruction or a urinoma. They can also present with painless vaginal discharge like a ureteral vaginal fistula. Oftentimes, this is a clinical picture that mimics a post-op ILEA so it can be confusing and people can get off to the wrong start very quickly when a patient comes in and you think it's more bowel-related, nausea, vomiting, and distension. Lower urinary tract injury should really always be on the differential. Then creatinine, just as a kind of a point, creatinine in a unilateral ureteral injury or bladder injury is not typically elevated. Why do we care so much about recognized and unrecognized ureteral injury? Well, the morbidity associated with an unrecognized ureteral injury or a delayed ureteral injury is very, very high. These are bad things that can result in fistula, acute renal insufficiency, sepsis, neph tube. The risk of death from these sequelae and readmission is actually higher in the unrecognized group. We really want to avoid this population. Conservative management, this is with stents and percutaneous nephrostomy tube. This is a nice review that actually looked at not only a single site, the Cleveland Clinic, but also some pooled data at the success of these stents placed stents for ureteral injuries. Actually, the success is quite high. Successful stent placement and then resolution of fistulas maintains a pretty high number. This was also reported recently in SPMRS in a case series out of Loyola where there were 19 women with a ureteral vaginal fistula. 12 were chosen to be managed conservatively and of those, almost all had successful stent placement and of those, almost all had complete resolution. So, stents can be very helpful in managing these fistula or ureteral injuries. I'm not going to go through this because I'm running a little low on time, but this is a really nice schema for your conservative management of ureteral vaginal fistula that was also published in that manuscript. So, I would refer to this as a nice way to work up and manage these. So, stent placement, just a couple of pearls. You're always going to be passing a double open-ended catheter over a wire. Wires are causeless damage. They are the safest things to be putting up ureters. So, always put the wire followed by the catheter. Again, I recommend continuous fluoroscopic guidance. This is always accomplished in the renal pelvis with a push-pull technique. The double J stent will be advanced over the wire, so continue to advance the double J using a stent pusher. Once it's coiled in the renal pelvis, you're going to pull the wire carefully under continuous fluoroscopy watching to make sure that the stent remains coiled in the renal pelvis. So, stent basics. So, this is a typical double J stent. They come in different calibers and different lengths. Typically, for women, a caliber of five to six is what you're going to want to use. Just a word to look out for. In the IR suite, they not always stock smaller caliber stents, and they'll only stock an H front, which is probably way too large for a woman and can cause problems with healing. So, just make sure that you request a very small caliber. There is an algorithm or an equation for determining the length, and that's based on the patient's height, as you can see. But you really do have to take into account the renal system. A dilated system might require a larger stent. Again, as I mentioned, always use a 30-degree slope. Angle the light cord to follow the angle of the ureter. That's a really helpful tip. Keep the distance between the cystoscope and the ureter orifice really small. Always keep the ureter orifice in view, and there's different types of wires depending on the situation. And then always watch for the point of no return that I'm going to identify right here. Do not let this pass up past the ureter orifice, because that could cause the stent to get stuck in the ureter. Troubleshooting. Again, I mentioned angled or straight guide wires can be really helpful, but do use them with caution because they are stiff and could perforate the ureter. And then this little torque device can be really helpful if you're having difficulty cannulating the ureter. When all else fails, IR is probably your best friend. They can place either a percutaneous nephrostomy tube or an anterograde stent placement. They have very similar success rates to stents. An anterograde stent is much easier to place than a retrograde, just going to the straight shot that they have from that direction. You'll want to get a post-op KUV, and again that's to identify that the stent is in the right area. Finally, I'm going to talk about ureteral reimplantation. When that conservative management fails, what are we left with? Nowadays, we really focus on minimally invasive repairs, but this is a large study that looked at 96,000 hysterectomies and the injuries that occurred at those times, and then 214 injuries from a minimally invasive hysterectomy that were repaired. Of those that were repaired minimally invasively compared to the open, there were less adverse events, so less length of stay, shorter length of stay, less complications, et cetera. What are the steps? Again, similar to the vestigovaginal fistula repair, appropriate robotic port placement. The ureter needs to be dissected. A retroposy dissection is taken and the bladder is mobilized. The ureter is isolated and ligated with spatulation. It's anastomosed to the bladder. A stent is placed, sometimes a hoist hitch in order to provide attention-free closure, and then make sure that you have a water-tight seal. What are some pearls? I can't say it was enough, but take care to not disturb the adventitia and the blood supply of the ureter, and I have a little diagram that I'll show. The retropubic dissection is paramount to be able to mobilize the bladder. The anastomosis between the ureter and the bladder should be performed in a muposa-to-muposa fashion. A stent should be inserted prior to completing the anastomosis, and then if you're performing a hoist hitch, it's probably wise to identify the genital femoral nerve. Again, this is the blood supply of the ureter in the adventitia, and that's why you want to be really careful when manipulating that. Just to mention a couple of the techniques to decrease tension, you could do a hoist hitch, which is up on top, or even some flaps that just extend the bladder so that it's not pulling on the ureter. And then post-op, we focus on prophylactic antibiotics, a fully-drainage stent for six weeks, and then typically evaluation with either a LASIK renal scan or an ultrasound. One quick question for you, Dr. Mueller. Just in your clinical experience or in the research that you've surveyed, any observations from a patient standpoint, suprapubic versus a transurethral catheter? Yeah, that's a really good question. Sometimes these women, for example, who have had a fistula, have been managed with a catheter for six weeks, and they have PTSD. So they've had a Foley in for six weeks, and they can't tolerate it anymore. Oftentimes, those women will just choose up front to have a suprapubic tube placed. So I typically give women a choice. And then the other consideration is just the location of the fistula repair. So if you are worried, if you have a fistula that's very close to the distal aspect of the trigone where your Foley bulb is going to be sitting, I typically try to go for a suprapubic tube. I'm not aware of any research that helps guide that, but I think probably the biggest player is that patient acceptance. Sure. I think we have one other question. We have a couple of requests for video. Somebody has asked that when you repair the bladder after a fistula or bladder injury, they're asking why you use monocryl for the first layer and vicryl for the second one. Yeah, good question. I mean, monocryl typically would be you don't need something that's going to be sticking around and causing an inflammatory reaction in the mucosa of the bladder. So that's why I choose that for the mucosa. And vicryl, I guess, is just to make myself feel better, that it might actually be sticking around for a long time. And if something were to happen with that, God forbid, the monocryl, then you've got the vicryl on back up. But I guess there's a little bit of voodoo. You could probably go with monocryl and monocryl if you wanted to. In this video, we present the management of delayed iatrogenic ureteral injuries following gynecologic surgery. Iatrogenic ureteral injuries are associated with urologic, gynecologic, and general surgery procedures. Most injuries are a consequence of gynecologic surgery. Reported rates of ureteral injuries following benign gynecologic surgery ranges from 0.3% to 1.5%. Recently, an analysis of a large prospective cohort of women undergoing hysterectomy demonstrated overall lower rates of ureteral injuries. These rates have varied based on route of hysterectomy with laparoscopic and abdominal routes having a rate of 0.3% compared to a rate of 0.04% for the vaginal route. Unfortunately, despite increasing use of cystoscopy, most ureteral injuries are not recognized at the time of surgery. A recent systematic review evaluating urinary tract injuries in laparoscopic hysterectomy identified 157 ureteral injuries. Only 14% of these were diagnosed intraoperatively. There are three common locations for ureteral injuries in gynecologic surgery. These include the level of the infundibulopelvic ligament, the level of the uterine artery, and the level of the vaginal cuff. We illustrate the management of delayed iatrogenic ureteral injuries in a 45-year-old woman who underwent a robotic hysterectomy bilateral salpingo-oophorectomy for the indication of uterine fibroids. Two weeks following her initial surgery, she presented to the outside hospital emergency department with a complaint of severe blank pain. Common signs and symptoms of a delayed ureteral injury include abdominal or flank pain, leukocytosis, and fever. During her initial workup, a CT without contrast was obtained, demonstrating a dilated right renal pelvis as well as right hydronephrosis with an abrupt cutoff in the distal pelvis. In patients with a history and symptoms suggestive of a ureteral injury, we recommend initial evaluation with a CT urogram. CT urography is a diagnostic exam optimized for imaging the kidneys, ureters, and bladder. This test utilizes thin-section imaging and administration of IV contrast and images the renal system during the excretory phase. Based on her symptoms, recent surgery, and CT scan concerning her ureteral injury, a urologist recommended to conservatively manage her obstruction. Consequently, she underwent placement of percutaneous nephrostomy tube. Percutaneous nephrostomy tube placement is a valuable, minimally invasive procedure allowing for spontaneous recovery of an injured ureter. Lask et al. reported the spontaneous recovery of ureteral injuries in 20 patients with delayed ureteral injuries. She ultimately underwent anterograde intraluminal recannulation and stent placement. Minimally invasive anterograde stent placement is another conservative management option where a percutaneous nephrostomy route is created and the injured ureter is recannulated and eventually stented. Several small case series comment on the effectiveness of this procedure, specifically in gynecologic-related ureteral injury with high success rates. She was conservatively managed with a stent for three months. Four weeks following the removal of her stent, she underwent a Lasix renal scan to evaluate her kidney function. Nuclear Renography is a nuclear medicine scan in which a radioisotope is injected to the venous system and a gamma camera tracks its filtration through the renal system. This test provides information on the function and drainage of the kidney. The curves generated in this report are the quantitative representation of the radioisotope tracer movement throughout the kidneys. The administration of Lasix is particularly helpful in differentiating dilation from obstruction. Prompt clearance through the renal system rules out obstruction, whereas delayed clearance is indicative of obstruction. Our patient's left kidney demonstrates prompt clearance of the radioisotope, whereas her right kidney really does not respond to the administration of Lasix, thus indicating a high-grade obstruction. Given her persistent high-grade obstruction, she was referred to our practice. We proceeded with retrograde pylography to determine the location of the ureteral injury. As suspected, her left renal collecting system appeared completely normal. When the retrograde pylogram was performed on the right, dye opacified the ureter approximately one centimeter proximal to the bladder, but with abrupt cutoff at this point, demonstrating a distal obstruction. Given the distal location of the iatrogenic ureteral injury, she was counseled to undergo a robotic ureteroneocystotomy. In the following surgical video, we outline the surgical steps of a robotic ureteroneocystotomy. Briefly, these steps include appropriate robotic port placement, dissection of the ureter, retropubic dissection and bladder mobilization, isolation and ligation of the ureter with spatulation, anastomosis of the ureter to bladder, placement of a double J stent, placement of psoas hitch if necessary, and inspection for a watertight seal. There are several surgical pearls to keep in mind when performing a robotic ureteroneocystotomy. We suggest that to successfully perform this procedure, one must take care not to disturb the adventitian blood supply of the ureter, perform adequate retropubic dissection to mobilize the bladder, anastomose the ureter and bladder in a mucosa-to-mucosa fashion, insert the stent prior to completing the anastomosis, ensure a watertight closure, and if performing a psoas hitch, identify the genitofemoral nerve. We use a W port arrangement with a camera at the umbilicus, two robotic ports on the patient's left side, one on the patient's right side, with an additional assistant port on this side. It is helpful if there are at least 10 cm between each port. If the obstruction is suspected to be more proximal, the ports might have to be shifted upwards. We find it helpful to place a large acrylic dilator in the vagina to help develop the planes between the bladder and the vagina in aiding in dissection. Despite the location of injury, it is always easiest to identify the ureter at the bifurcation of the common iliac vessels. An adequate retropubic dissection is necessary to provide mobilization of the bladder for a tension-free anastomosis. It is important to be mindful of the location of the obturator nerve when performing this dissection. Once the ureter is isolated, it is helpful to place a vessel loop around it for manipulation. We place a single stay suture at the apex of the spatulated ureter to maintain orientation. Due to the high rates of congenital absence of the psoas tendon minor, we advocate direct visualization of the genitofemoral nerve by incising the peritoneum to avoid nerve injury. We place the most posterior anastomotic sutures first to allow for optimal visualization when completing the anastomosis. We place the most posterior anastomotic sutures first to allow for optimal visualization when completing the anastomosis. We place the most posterior anastomotic sutures first to allow for optimal visualization when completing the anastomosis. We place the most posterior anastomotic sutures first to allow for optimal visualization when completing the anastomosis. We place the most posterior anastomotic sutures first to allow for optimal visualization when completing the anastomosis. We place the most posterior anastomotic sutures first to allow for optimal visualization when completing the anastomosis. We place the most posterior anastomotic sutures first to allow for optimal visualization when completing the anastomosis. We place the most posterior anastomotic sutures first to allow for optimal visualization when completing the anastomosis. Postoperatively, we obtained a KUB to document appropriate stent placement. Correct stent placement is confirmed using bony landmarks. The vertebrae can be easily identified by locating T12. As highlighted in blue, the proximal coil of the double J stent is located at L2, the anatomic location of the right renal pelvis. Our patient was discharged home on postoperative day number one. Her transurethral catheter and right ureteral stent were removed in the office two and six weeks respectively following surgery. A Lasix renal scan demonstrated resolution of her obstruction. Thank you for joining us for this webinar, everyone. Have a good night. Thank you.

lower urinary tract injuries

bladder injuries

ureteral injuries

gynecologic surgery

evaluation

diagnosis

treatment options

conservative management

surgical options

post-operative management