Management, and we'll be presented by Dr. Maggie Mueller. Dr. Mueller's presentation is going to run for 45 minutes, and then the last 15 minutes of the webinar will be dedicated to question and answer. So before we get started, I just want to say a few words about Dr. Mueller for those of you who don't know her. She joined the faculty of the Division of Female Pelvic Medicine and Reconstructive Surgery as an assistant professor in obstetrics and gynecology after completing her fellowship in female pelvic medicine and reconstructive surgery at Northwestern University. She completed her residency at the University of Chicago. She's a board-certified OBGYN and urogynecologist. Her clinical interests include treatment of urinary incontinence, pelvic organ prolapse, genital incontinence, complex urinary and rectal fistulas, and mesh complications. She's also worked with expert pediatric surgeons to develop a nationally-recognized program called the Collaborative Advanced Reconstructive Evaluation Clinic, or the CARE Clinic for Women with Congenital Anomalies, to care for young women with complex congenital anomalies in a transdisciplinary fashion. Increasing numbers of women who underwent complex surgery for cloacal and bladder exstrophy surgeries are transitioning to adulthood with unique needs, and so this clinic was really designed to meet the needs of these women. Dr. Mueller's CV is long and really, really impressive. She recently earned her ABAG-focused practice designation in pediatric and adolescent gynecology and is on staff at the Anna Roberts Lurie Children's Hospital, as well as Northwestern Medicine. She's actively involved in women's health research, and she's received several national grants to study complex pelvic floor disorders. She's also currently a principal investigator in a national multicenter innovative research network studying the effects of the urinary microbiome on sacral neuromodulation in women with urinary incontinence. Dr. Mueller is enthusiastic about surgical education, and she's also currently a member of the Robotics Education Curriculum Committee, as well. So I can keep going on, but we do have to get started. But before we get started, I want to go over a few housekeeping items. This webinar is being recorded and is livestreamed. Please use the Q&A feature on the Zoom webinar to ask any questions when the Q&A portion of the program has started. And also use the chat feature if you have any tech issues, because we're going to be monitoring the chat as well. Again, after the presentation, we will have 15 minutes for question and answer. So without much ado, I'm going to get started on Dr. Mueller's presentation. Of note, she is stuck in the operating room, and so her session is recorded, but she'll be joining us live for the last 15 minutes for question and answers. There are some things that you can do to make it easier on yourself. When the panic mode begins, and that's what I'm going to focus on today. So just an overview, I'm going to be presenting an advanced evaluation of the lower urinary tract, covering bladder injury, as well as ureteral obstruction and injury. Okay, thank you very much for that wonderful introduction. In the interest of time, I'm going to go ahead and get started here. I'm just going to share my screen. Okay. So this is called Navigating the Nightmare, Tips and Tricks to Evaluate the Lower Urinary Tract Injury, because none of us want to find ourselves in this position. So there are some things that you can do to make it easier on yourself when the panic mode begins, and that's what I'm going to focus on today. So just an overview, I'm going to be presenting an advanced evaluation of the lower urinary tract, covering bladder injury, as well as ureteral obstruction and injury. Today at the conclusion of the lecture, you'll be able to illustrate prompt and appropriate diagnosis of an intraoperative and delayed lower urinary tract injury. You're going to be able to differentiate delayed versus immediate lower urinary tract injury management evaluation and management, and identify conservative management options for managing lower urinary tract injury, and finally illustrate minimally invasive surgical procedures to help manage lower urinary tract injury. So to get started with, we're going to focus on the evaluation of lower urinary tract injury, both immediate and delayed. So I think we all know that iatrogenic ureteral injury is associated with urologic, gynecologic, and general surgery procedures. Actually about 50% to 80% are associated with gynecologic surgery. So certainly we, you know, within our field, we're one of the leading reasons why there can be an iatrogenic ureteral injury. But even though we're the leading field, those rates are pretty low overall, so reported rates of ureteral injury following benign GYN surgery, they hover around 0.3% to 1.8%. So with historectomy, it has been shown here on the slide, abdominal and laparoscopic appear to be equal, but there is more data to demonstrate that rate of ureteral injury is even decreasing with laparoscopic procedures, so historectomy compared to abdominal, and so that's for reasons you might think about the reason why an abdominal rut is chosen, pathology, et cetera, but certainly by far, vaginal historectomy is associated with the lowest risk of ureteral injury. The problem with ureteral injuries is oftentimes they're not recognized at the time of surgery. There was a systematic review that looked at 157 ureteral injuries that were associated with laparoscopic historectomy. Only 14% of those were identified at the time of surgery, so certainly everyone's looking to identify ways that we might be able to increase that identification to avoid a delayed ureteral injury and some of the consequences associated with that, which I'll touch on later. So ureteral injuries, where do they occur? Typically there's three places where we think that ureteral injuries are likely to occur if they do occur, and those would be at the… …specifically at hysterectomy. There was a study a while back with 839 benign hysterectomies. There was 39, or 4%, that had a lower urinary tract injury. You can see here 2.4% had a bladder injury, 1.8% had a ureteral injury. Cystoscopy identified nearly all of the cases, so 38 out of 39 cases, and another series Again, in 2007, … …there were 4%… …recognized for improving the use of cystoscopy. So certainly I think we all know the guidance for universal cystoscopy at the time of pelvic reconstructive surgeries, this really is suggested, and a quality guideline coming from Oggs. But I think that the jury's still open on hysterectomy. There's a lot to consider regarding the cost-effectiveness, training, etc., but certainly I think these data can be extrapolated, and it is our only modality to actually reduce a lower urinary tract injury at the time of hysterectomy. So I know there are folks that advocate for universal cystoscopy, and I am one of those folks. So how do we, as for ureteral patency, I think everyone is very clear with this given, you know, everybody's in FPMRS. There were a couple hiccups for a while. … …to see anything come out, and certainly the risk of methenoglobinemia. Prunium can be a really good choice if you're at a hospital that just runs out of either indigo or the sodium fluorescein. This can be given orally prior to surgery and can be included in some of your ARIS protocols, or in the moment, if you didn't give prunium and you've run out of options, you can crush this and put this down the OG tube. … … … … Hey, Melissa, is it sharing the video? No, not right now, it's not. I think your internet connection, I think, might have dropped because you dropped off completely. Okay, we apologize. Let's do this. I'll re-share the video. When you share it, there's a setting that says to clip to allow sound so that you can also mute. Okay, we'll do that. So I'm going to share this again. Okay. So let me get back to where we left off. Share this. Okay. By far our best option at this point in time. The dosage here is 0.25 milliliters of 10% sodium fluorescein. It helps to tell your anesthesiology colleague that they might want to use a TB syringe to draw this up just because it is a really small volume. But this works quite quickly, within minutes, and colors the urine a nice fluorescent green. So this has been one of the best options to utilize. What about prophylactic stents? There have been a lot of studies that looked at this, that looked at the evaluation, or that evaluated the use of prophylactic stents. I'm not going to get into the detail of that right now, but the punchline is prophylactic stents probably don't cause harm in the setting of GYN surgery. The setting of GYN surgery, they are not effective at preventing injury, but they are effective at identifying injury, and they are not cost effective at this point in time. So if there's no prophylactic stents I mentioned, what now? Well, certainly universal cystoscopy at the time of hysterectomy, this has been kind of a hot button issue. There's a lovely study out of the University of Michigan that looked at a universal cystoscopy protocol after it was implemented, and they compared the risk of delayed lower urinary tract injury prior to their intervention, which is universal cystoscopy, and they demonstrated a decrease in delayed lower urinary tract injury from 0.7% to 0.1%. So again, it's not going to prevent all of delayed injuries, but it certainly will decrease them, and you'll see later reasons why we might want to decrease a delayed lower urinary tract injury. So we're going to get into the meat of things, so intraoperative identification. So let's say you have a 42-year-old, status post TLHBS in the room next to you. There's risk efflux on the right side, nothing on the left. Observe for 15 minutes, otherwise uncomplicated. Can you come take a look? I think we get that call frequently. So what I always remind everybody is, first of all, think about where's the trouble? How did it occur? So if we're thinking that this was a, you know, your colleague was doing an endo case, and they were up by the IP ligaments, or they were wearing vessels, this could have occurred here. What kind of injury? Could it be a thermal injury, a crush, a transection? Same thing goes for the location of the uterine artery. Those are typically the types of injuries that we see there, thermal, crush, or transection. And then the vaginal cuff, oftentimes this can just be kinking, or there could be a complex histotomy that's involving the ureter at that level. So both ureters, I think if both ureters aren't going, you've systoed, and you're not seeing efflux from either ureter. Some of those just troubleshooting things, or just remember. When there's panic ensuing, there certainly can be, you know, renal insufficiency. There could be a fluid status. I think that this is less likely now in the age of ARIS. But just some common sense maneuvers. If you're open or in a vaginal surgery, remove the packing, because that certainly can compress the ureters. Reverse the Trendelenburg. This seems silly, but honestly, I have been in a scenario where I didn't see any efflux, and just reverse the Trendelenburg a little bit, and this improved. And then consider a fluid bolus with even some IV Lasix. And start with IV Lasix with a normal dose of 20 milligrams. Anything less than that, you're going to be continuing to ask for more Lasix. Okay, so one ureter. I think we're all used to this scenario. You know, with, you've got lack of efflux at one ureter. So first of all, just back to basics. Think about your surgery. Did you do a uterus sacral? If so, remove the most lateral suture, because this is the distal lateral, the distal suture is in the highest proximity to the ureter. If it's just a hysterectomy that your colleagues have called you for, just think about the three common sites of injury. Always remember prior pelvic surgery, and then don't forget those one-offs. You can have a patient that donated a kidney. There can be an infrected situation. There could be a solitary kidney. And you're always going to want to be able to dive into that to prevent yourself from, you know, getting too worried about nothing. Okay, so we're gonna go with the no efflux from one side. So when this occurs, you've been there, you've done all your maneuvers, nothing's happening. You're gonna first call for your C-arm and start to prepare to do a retrograde pylogram. I have on this algorithm, the one-shot IVP with some information there. I present this really for more historical background purposes. It is hard for any hospital to time a one-shot IVP even with a radiologist. If you've asked for it, you've probably run into difficulty. And if you're gonna try to do this on your own in the operating room, it's probably gonna be difficult and low yield for you because you would be the one trying to time it and take a KUV. So I do not suggest that. The much easier path here is a retrograde pylogram. So let's say you perform both, excuse me, your retrograde pylogram on both sides and you visualize both kidneys. The other option is you visualize the ipsilateral kidney or you see one, the kidney that you're not concerned about or the kidney that you are concerned about. You could have a post-op CT, which is demonstrating an old injury. So how do you do this? Getting ready to do a retrograde pylogram. Well, first of all, I'm gonna present just the basic equipment that you need. You need a 30-degree cystoscope. We're used to using 70-degree cystoscopes, so make sure you call for the right one. You need some contrast, renografen, or isovu. You need a large operative sheath because you're gonna be trying to put something through that. So you're used to using a 17 or a 19 French sheath. You're gonna need a 21 French sheath. You need a large syringe that you can push a good amount of volume through your catheter. Which brings me to the catheter. There's two types of catheters. Typically for a retrograde pylogram, you're gonna use a cone-tip catheter, which is a nice way to occlude the ureteral orifice while you're pushing in contrast. You can certainly use a double open-ended catheter and do a pull-down technique, which I can mention a little bit later. You'll need a wire. If you plan to do a stent, you're gonna need a double J stent, a stent pusher. Certainly you'll want fluoroscopy, and then you will make this much easier if you have a slider bed. Otherwise, there will be a significant amount of maneuvering to try to get the patient in a position where they can fit the C-arm underneath the bed. So everybody knows this. You've got your lens, your bridge, your sheath, but this does come into play when we're talking about more operative-type procedures. And just as a way of background, you know, your operative 30-degree scope is great for ureters. It's really nice to use for stent manipulation to shoot retrogrades and then to biopsy. We're all really comfortable using the 70-degree scope, but this is much better at evaluating the bladder and the urethelium. So retrograde rules, some good things to remember, again, in a high-stress situation when there's a little bit of panic mode ensuing, just, you know, trying to remember back to those basics. I'm going to give you some rules that you can rely on. So you're always going to want to start with the good side. This is going to show you what your control is. So this will be what the perfect scenario is. So when you are placing your cone-tip catheter, cystoscopically, this is what you're going to see. You're going to want your cone-tip catheter really close to the edge of your scope so that you can manipulate it effectively. If it's way out in front, it's going to be almost impossible for you to do it. So it's going to be really close to the tip of your lens and your scope. And you'll be right close to that ureteral orifice to help cannulate that. So what are we doing with our retrogrades? Well, we're going to first assess for patency. If it's patent, then we're going to assess for constriction or stricture. The ureter certainly can be deviated medially and kinked. And we see this a lot with uterus sacrals, and then we can look for areas of stricture. If it's not patent, that's when we're going to start to look for extravasation or a blind ending pouch or transection. So here's an example here where we started on the good side. At the top, you can see the renal pelvis with the contrast filling the renal pelvis, the ureter, the path of the ureter, and then down in the bladder, we filled the bladder with contrast. It's nice to notice here that the distal ureter, as it goes into the kidney, this can be a really difficult area to assess via CT scan. So lots of times we advocate that a retrograde might actually give you better information than a CT scan in this certain area. So the steps of the retrograde we mentioned, assemble your operative cystoscope, flush the system, take out all the bubbles, and cannulate your ureteral orifice with a cone tip catheter. Always remember, start on your good side, that's going to be your control. And then under continuous fluoroscopy, you're going to inject a good amount of your contrast, usually 50% diluted with saline, about 15 cc's to help get the entire renal pelvis and ureter opacified with contrast. So I'm going to show you here, at the top left-hand of your screen, we're looking at patency, but you can notice that there is some dilation. At the bottom left-hand of the screen, there's certainly an obstruction. You can see a narrowed structure and then a dilated proximal ureter. And at the right-hand, top right-hand, you can see a structure. And then while there's a lot of evidence of staples and lots of stuff, lots of trail of evidence with the staples. And then at the bottom right, you can see basically a blind ending transaction versus obstruction. So you see the contrast going into the very distal ureter and then nothing above. And again, here's a scenario in which we started with our good side. On the left, you can see the normal path of the ureter all the way up to the renal pelvis. And then sadly, on the right, you see a very distal either transaction or obstruction. Okay, so that's when you're in the operating room, certainly the best time to identify it. But what about when you've gone, you've left the operating room or a patient's presenting to the operating room? We always talk about labs, but there's a couple of scenarios in which you can get a little tricked up. So bilateral ureteral injury, that's easy. It's always gonna increase your BUN, your creatinine and potassium. And a bladder injury, this is the one at the bottom into the abdomen. Well, that's easy too, because you're gonna always have lab abnormalities. It's these two middle ones that can be confusing. So unilateral ureteral injury can increase your labs, your creatinine, your BUN or not, they can be normal. And then a bladder injury into the vagina, your labs are almost always gonna be normal. So labs will never help you in the scenario of a fistula. So delayed in identification on CT scan, I'm gonna present the CT scan where you can kind of see some eager to, we'll chat through the CT scan. You can see we're looking at the renal pelvis with a contrast. It's a very dilated ureter down here and renal pelvis. And again, tracing it down with the contrast on the other side. In a scenario where you're trying to identify a delayed ureteral injury, you're always gonna wanna CT yourogram with contrast. There are different techniques that you can use. You know, for example, if the patient has a really high creatinine and you're really concerned about obstruction, you certainly wouldn't wanna give contrast to kind of stun the kidneys anymore. And in that case, you might wanna just move straight towards a retrograde pylogram. If you were to get a CT non-contrast, you might be able to see some dilation, but it would be very difficult to really identify anything else. So how about etiologies of bladder injuries? I think we all really know this. Most commonly, these are delayed, or excuse me, direct lacerations or a missed astatomy. This can be caused from extensive cautery near the bladder or even sutures placed near the cuff that could incorporate the bladder. So intraoperative identification. Again, your immediate identification is the best time to successfully manage your lower urinary tract injuries, either ureteral or bladder injuries. You get a more efficacious repair, certainly a lower morbidity. And then honestly, this is the best thing to minimize any litigation. Litigation is really increased in the setting of a delayed or missed ureteral or bladder injury. So intra-op, when you've identified a bladder injury, some of the principles, you're gonna always wanna ensure the ureteric orifices and intramural ureter are not in proximity to your injury. And this can be of importance at the level of the trigone. You'll want to always use an absorbable suture and a non-cutting needle. Typically, we perform a delayed, excuse me, a double-layer mucosa-to-mucosa tension-free closure. You can always consider either a nomental graft or a Martius flap to help with healing. And then management post-operatively, drain with a Foley for seven to 14 days, depending on the size. And then consider a cystogram prior to removal of the catheter. We'll talk a little bit about this, but I would really only do that in a scenario of a very complex or large cystotomy. This is just a quick video demonstrating, you know, everything's looking good. You're doing your bladder dissection, and then, boop, you've got a bladder injury. So again, the bladder injuries are certainly easier to identify and less likely to need cystoscopy to identify. But what do you do in this scenario where you're certainly gonna wanna continue to dissect a little bit to increase your mobility so that you can get a good amount of space between the bladder and the vagina, typically about two centimeters. And then you'll start thinking about the closure. Obviously, you've got fluid pouring out here. You probably wanna just go ahead and close this. Again, typically, double-layer closure using, utilizing, you know, a quickly-absorbable suture. Typically, that first layer will use monocryl, and then an imbricating layer of the serosa with a vipral suture so that you can get a watertight closure. I think most people, at the conclusion of a cystotomy repair, would advocate for just a gentle cystoscopy just to make sure that your incision line looks good, you can evaluate the integrity of the ureters, and you don't see any fluid coming into the abdomen. You've got a watertight closure. In the interest of time, I'm gonna keep us moving, but it's very straightforward. That's a small cystotomy. I'm sure you guys have all encountered that and repaired those effectively. I mentioned this, the post-op cystogram. Again, this is certainly not necessary for every cystotomy. There was actually this very nice study done by Kate Pachunska that looked at the use of VCUG, or post-op cystograms, and evaluating lower urinary tract injury repairs. And again, I mean, out of all the patients that they looked at that had cyst, excuse me, a cystotomy repair, only 1.6 of those had a persistent leak that was identified on a post-op VCUG. Both of those were at the time of cesarean, which can be quite complex, and both were greater than the size of two centimeters. So I think I keep those in mind as principles as when to order a cystogram. And typically, in most of the scenarios, GYN-based cystotomy repairs, I'm not ordering cystograms prior to removal. Okay, let's talk more about ureteral injuries. So first of all, in our evaluation, we talked about where is the trouble, how did it occur? Again, those three principles of places where we can find ourselves in trouble. How do we manage? So again, if it's identified at the time of injury, you've got to think about what type of injury occurred, transection, crush, ligation, and then certainly I have a pathway that's unstable patient, so which we would manage differently. In the scenario of either a transection or a crush injury, you can, which you've identified, you can certainly assess that area of the ureter for vascularity. If it looks like it's well vascularized, there hasn't been a lot of damage in that area, stenting, or even primary reanastomosis would be a favorable. And then if that area is devascularized or just doesn't look healthy, at this point in time, the locations in which you're going to be called for ureter injuries can probably most often be managed with a ureteral reimplantation. In the scenario of a ligation, like a suture, this can be very easy to do. You can remove the suture, and if you look and see any damage, you can certainly stent. And then anytime in an unstable patient, you probably want to avoid any of this maneuvering. You can always perk a patient post-operatively, and they actually have pretty good data regarding the conservative management, which we'll get through too. And then how about the management of delayed injuries? So this is a little bit different and very, very time-sensitive. So if the delayed injury is identified within one to four days of the surgery, the initial surgery, you've got a couple options open to you. You can think about stenting the patient or even going back and just reimplanting the ureter. But really after five days, you're going to be looking to do conservative management. You're not going to be wanting to go in and reimplant the ureter in the state post-op healing, and there's going to be a lot of inflammation, poor tissue integrity. This is going to really lead you to increased risk of failure. So in that scenario, you're going to think about conservative management with either a stent or a Parknep tube. Delayed presentation, how do they present? Well, they typically present with flank pain, fever, ascites that can be in the setting of an obstruction or a urinoma. Or as we're all aware, a patient can present with painless vaginal discharge with a fistula. A clinical picture mimicking a post-op ilias like nausea, vomiting, abdominal distension, lower urinary tract injury should always be on your differential, especially a ureteral injury. And then again, important to remember that a creatinine and a unilateral injury doesn't always necessarily need to be elevated. And it won't be elevated with a bladder injury unless the urine is pouring into the abdomen. So why am I talking so much about delayed injuries? Well, in the setting of a ureteral injury, delayed injuries are really going to increase all of your risks. This is a study, a really nice study that compared delayed versus immediate injuries and the complications. So you can see this risk of sepsis is really high in an unrecognized injury, as well as renal insufficiency and needing management with a post-op Parknep tube. So we really want to be evaluating this and managing this expeditiously. So how do we conservatively manage a ureteral injury? I'm going to talk about stents and Parknep tubes. So this seems really counterintuitive, but management with a urinary, excuse me, a ureteral injury, even a transfection can be effective with conservative management with the stent or Parknep tube. So this is a nice little study by Johnny Shaw et al in 2014 that looked at stents for ureteral injury or ureteral vaginal fistula in a delayed setting. And they looked at stent success placement and then resolution of ureteral vaginal fistula. And here, modern day, we've got about 71% efficacy in successfully resolving a ureteral vaginal fistula. And again, this is just a table, excuse me, that's demonstrating the series, again, using ureteral stents for conservative management that looked at different studies. And again, pretty high success rates, you know, nearing 100% if you're able to successfully stent a patient. And then they did mention the other procedures that patients need if they didn't have a successful resolution of their fistula. But actually, you know, these are pretty good numbers for successfully, conservatively managing a fistula. And then Brandon Chen and colleagues looked at, you know, basically a little algorithm and looked at their own cases and then developed an algorithm for managing ureteral vaginal fistula in a small case series that include 19 patients. 12 of those patients with a ureteral vaginal fistula were managed with ureteral stents. 11 had a successful stent placement. Of those 11, 10 had complete resolution with just one ureteral structure requiring a ureteroneal cystotomy. So those are pretty high success rates for conservative management and certainly keeping morbidity down low, you know, exposing a patient to another surgery. So they came up with a kind of nice algorithm of how they manage their patients. Again, they developed this into an algorithm for diagnosis, management, and then follow-up. Typically, I haven't mentioned this yet, but the ways that we follow up a patient, you could first primarily evaluate the patient for any evidence of obstruction, like with a renal ultrasound. And if you were concerned about that, it would be probably the appropriate next step in management to proceed with a LASIK's renal scan. Again, this is the one study that can show you and help determine the difference between dilation and an obstruction. Oftentimes, these systems will continue to be dilated in the post-op period, even once the obstruction is managed. And it's really just the LASIK's renal scan, which will help demonstrate whether or not there's an obstruction. So stent placement, I haven't touched on this. How do you do it? A couple guidelines, again, to be remembering during that high-stress scenario. You're gonna pass a double open-ended catheter over a wire. And just like you might imagine, you're gonna advance the wire, then the catheter, then the wire, then the catheter, kind of push it up sequentially. And then we always recommend doing this under continuous fluoroscopic guidance. Once you're in the renal pelvis, you can pull the catheter, but keep the wire there. So you, again, want to use that pull, a push-pull technique so that you don't actually move the wire. The next step is to take your double J stent and advance that over the wire. You're going to continue to advance the double J using that stent pusher. Once you, you know, once that stent is out of your hand, you got to push it up somehow, and that's with the stent pusher. Once the stent is then effectively coiled in the renal pelvis, you're going to pull the wire carefully under fluoroscopy because you don't want to pull the stent, and then remove your scope. You're always going to look for appropriate coil in the renal pelvis and bladder. So these are the typical stents. You know, in general, there's a little algorithm to help you figure out what size you need. It's a patient's height in inches, minus 42. So for a five-foot, six-inch woman, 66 minus 42, you're going to need a 24-centimeter stent. But a little caveat here at the bottom, you really want to take into account the system. So in a hugely dilated system, you might need a longer stent, and I typically will err on the side of longer rather than shorter, because the one scenario in which I do not want to be finding myself is a stent that's in the renal pelvis and not in bladder. These little strings that come with the stents are supposed to be, you know, for increased ease for pulling. They readily and easily pull the stent out, so I usually take those out just to avoid inadvertent pulling of your stent with your cystoscope once you successfully placed it. These little hash marks are really important because they show you the length of a stent. So you'll see kind of this hash mark here at the bottom, and then these are in five-centimeter increments, all stents are different, but this one would show five, 10, 15, 20, and then this is the end here. I usually say that's the point of no return to the fellows. That's the point I want to always be looking at under cystoscopic guidance. So tips for successful stent placement. Again, always use your 30-degree scope. This will be easy because you've already pulled this for any other scenario where you're doing a retrograde, et cetera. A helpful tip, it can be really helpful to angle your light cord to follow the angle of the ureter. This will just kind of help you more successfully manipulate the stent. You're going to want to maintain, again, I mentioned this close proximity between the cystoscope and the ureteral orifice. If the stent is way out in front of you, or you've got like a really far out picture, it's just going to be really difficult. Always, again, always keep the ureteral orifice in view. You might want to use a different type of wire depending on your situation, but typically the double open catheter is probably the easiest thing to use, as well as a Benson guide wire. And then again, as I mentioned, watch for that point of no return. So you never want to see that black bar at the end going past the ureteral orifice. Otherwise you are at risk for losing a stent in the renal pelvis. And that's the little point of no return that I showed you. Okay. So what happens when that doesn't work? So when all else fails? Well, there's always IR and percutaneous nephrostomy tube placement can always be an option. But the other nice thing that IR might be able to offer you is just anterograde stent placement. So sometimes it can be really hard to stent a distal ureteral injury just with the path of the ureter. It takes a sharp turn there. And they can actually usually have a much easier time stenting someone from above or what we call an anterograde stent just because they have such a long trajectory of normal, normal, normal, and then they can kind of slide past that area of injury, which oftentimes is difficult for us to do from below. So if you're in a scenario where you're trying and you're just not able to, I think it's always good to have a time limit cutoff in mind. You probably don't want to be trying to do that for greater than an hour. And if that happens, I would not feel badly about calling your colleagues in IR who might have an easier time at successfully stenting a patient. And then again, there are some other studies that actually just look at percutaneous nephrostomy tube treatment and the success rates for conservatively managing an injury with a perc neph tube, they're actually quite similar to stents. So this can always be something nice to have in your back pocket. So I do want to take some time to review a ureteral reimplantation because when called for the management of a ureteral injury in the gynecologic setting, this is probably going to be your go-to operation. So when we look at the route of ureteral reimplantation, this was published in Urology in 2016, they looked at a pretty large amount of hysterectomies, almost 100,000. They looked at 300 ureteral injuries at the time of hysterectomy and then identified that 214 of those from a minimally invasive hysterectomy were repaired immediately. And they looked at that immediate versus converted to an open repair. So minimally invasive versus an open repair. And you can see, as you might think, there are some improvements. Obviously operating room time is shorter when you continue with your minimally invasive repair. And then their length of stay, as you might have already identified, is lower with minimally invasive repair as well. So a reimplantation of the ureter is actually not a difficult procedure. It's more just, it's like plumbing. You're going to be taking the ureter and putting it into a new hole into the bladder. That is it. So what are the steps that you need to think about? You want to have an appropriate robotic port placement. I think we're all comfortable with that given everybody's experience with minimally invasive surgery. You'll want to first dissect the ureter, but be very careful to pay close attention to keeping the adventitia with the ureter because this really is where the blood supply is. You'll want to continue with a retro pubic dissection and bladder mobilization because one of the tenets is attention-free repair. You'll want to isolate and ligate the ureter with spatulation, and then anastomose the ureter to the bladder. You'll want to place a double J stent right before you finish that anastomosis. And then you can think about steps and techniques to decrease tension. So a stitch probably being the easiest one and the one you'd probably be the most comfortable with. And then inspection with cystoscopy for a watertight seal. Those surgical pearls that I alluded to, again, you're going to want to take care not to disturb the adventitia and the blood supply. You want to perform an adequate retro pubic dissection to mobilize the bladder. Anastomose the ureter and bladder in a mucosa to mucosa fashion. So, you know, basically always attaching the mucosa to the mucosa and the serosa to the serosa. In stent, you want to insert a stent prior to completing the anastomosis. Ensure a watertight seal. And then if you are performing a sewage stitch, you'll want to just identify some landmarks and you'll want to be making sure to identify any nerves that you put in counter. So a quick case here, you have, again, a 42 year old with a four centimeter cystotomy in the dome. At the time of her total abdominal hysterectomy, which is repaired at the time of surgery, she's sent home with a catheter. Five days later, she develops pain, nausea and vomiting, as well as leaking fluid for the vagina. This is just a little ploy here to always assess the ureter when you're called for a bladder injury. And this is a retrograde here where you can see this area of kind of, you know, some abnormality in the bladder, like that old repaired cystotomy. But what they didn't do is a retrograde at the time of surgery to repair that cystotomy, where you can see a significant abnormality here in the ureter. So whenever there's a cystotomy complex, you're concerned about a complex cystotomy with a complex surgery, you know, you're always going to want to evaluate that ureter. So I think I have some videos here of a re-implant. Again, typically robotic re-implantation would probably be the easiest route. But if the hysterectomy was already performed through a minimally invasive laparoscopic surgery, certainly you can proceed that laparoscopically as well. Again, the first step is really that identification of the ureter, and then that dissection to mobilize it, again, trying to keep the blood supply with it. Once you've isolated that ureter, you can kind of slip a little lasso underneath it. To, again, help with that dissection. And then the retropubic dissection that I think we're all comfortable with from other procedures, like a BIRCWH procedure. You'll really want to perform a nice retropubic dissection to get your mobilization. Then you can have that like flappy bladder that will reach to your ureter. You want to fill the bladders to see where you can make that cystotomy in a location on probably the posterior aspect of the dome that will be in close proximity to your ureter that you're going to be re-implanting, again, to minimize that tension. And then you can have that retropubic dissection to help with the mobilization. And then you can have that retropubic dissection to help with the mobilization. It's always the hardest part for us to do is just come and transect the ureter, which we're always trying to avoid. You can see the, there's probably indigo coming, or not indigo, but iridium coming out of there. Spatulate the ureter just to increase your surface area for your reanastomosis. So that just needs to be done on one side. It's easiest to do that on the anterior side so you can see what you're doing. And then just start your repair. Again, you'll always want to be opposing the mucosa to the mucosa. Start with the posterior sutures first. Once you get about halfway through, that's when you can consider you've completed your posterior anastomosis. That's when you can consider placing your stent. Again, we're always taking care to get the mucosa opposed to the mucosa here. This is a scenario in which if you do have a dual consult, it can be really nice to utilize that dual consult to have another arm active, just because given the complex nature of the surgery, it's really nice to have an active assistant in there helping you robotically. So that's one scenario in which usually we're advocating for the dual consult just from an education standpoint, but for this procedural standpoint, it can be very helpful. So we're going to slide that stent in, so we're going to slide that stent in. It's kind of already loaded with the guide wire just to help decrease steps here. And we pass it in through above just because we're directly looking at it. And then we are going to kind of tuck that part into the bladder. And we'll certainly always assess for the position afterwards. But we can kind of tuck that coil nicely into the bladder. And then once that's done, you can go and finish your anastomosis. Obviously, you might be called to do this from an abdominal approach, either an abdominal hysterectomy or a C-section. The principles are all the same. Again, I think we make this probably harder than it is. Literally, we're just finding a new location for the ureter to be implanted into the bladder. At the end, again, gentle testing to see if you have a watertight closure. You don't need to do anything that's involving aggressive filling of the bladder. I would say probably put no more than 200 cc's in there. And then you can see this is nice. It doesn't look like it's on tension. There's no kinking of the ureter, et cetera. But if there was, certainly a psoas hitch is a nice way for you to easily take off some of the tension. I don't think we have time right now but the next slide is a video that demonstrates a psoas hitch. There are other ways of creating different flaps and incisions on the bladder in order to increase the length or decrease the distance between the bladder and the ureter, such as a biore flap, et cetera. But I think probably your go-to is gonna be a psoas hitch. So again, just in the interest of time, I wanna make sure that I have time for questions. I think you guys have the slide so you can look at this video. It's also probably on the ODS website or on YouTube, just the management of delayed injury. It takes you through all the principles that we talked about, as well as highlights the use of Lasix renal scan and the evaluation and management following the lower urinary tract injury as well. But it's about 10 minutes, so I'm gonna leave that. And I'm gonna go ahead and end here. Again, I hope this kind of helps you feel more comfortable in just your basic evaluation, advanced evaluation of a urinary tract injury, because we are the ones that are gonna get called for it and we are the ones that have the background knowledge in gynecology and neurology to really take care and manage that patient well. So I hope this kind of empowers you to feel comfortable to do that. As I mentioned, we didn't have time for a couple of those videos, but you have all the slides and there's many more videos that I did not cover that are in the slide set. And then at the end of the slide set, there are some cases that demonstrate kind of just workup and evaluation. Most of those are from a delayed standpoint because those are kind of a little bit trickier in nature, but you can work through those and use those as reference. And certainly as always, feel free to reach out to me if you have any questions. Again, it's been a pleasure kind of sharing this information with you. And I look forward to taking any questions you may have. Thank you so much. Thank you, Dr. Mueller. So I know the session went over because of our technical difficulties, but I wanted to leave, we have about five minutes left for questions. And I see there are two questions that I wanna pose. The first is after re-implant, is there any concern for VUR? Do you need any evaluation that's needed in the long-term? Yeah, thanks, Tani. That's definitely a great question. So by far with our re-implantations, I don't think folks are worrying too much about reflux. I think probably the most concerning consequence of a real re-implantation would be stricture. So we typically will evaluate for any presence of obstruction. You can do that pretty simply by just starting with a renal ultrasound if you were not concerned that you had a dilated system. But as I mentioned, if you're going into this knowing that your system's dilated, it's probably best to just get a LASIK renal scan. We typically do that about six weeks after the second call. But reflux isn't something that we worry about too much the adult population. There was a question that came up in the chat that Dr. Mueller did answer. So I just wanna pose it out just so she can talk about it. What has your experience been in implementing universal cystoscopy at your hospital institution, your hospital system? Tani, did you want me to repeat what I wrote in the chat? Yes, please. Oh, okay, sure. So yeah, I think universal cystoscopy is great. I'm a big proponent of it. We were able to successfully implement that at Northwestern, which is a pretty large hospital system with a fairly large number of general gynecologists specialists. So that certainly took some time and effort to implement that to make sure everyone was comfortable. We did a lot of training for our GYN colleagues, and then we're kind of always available in the operating room if they needed a consult on a cystoscopy or a cystoscopy finding. And I think that overall, it's proven to be very, very helpful. And I think we have time for maybe one more. I see one in the chat. It says, a urologist I know says he does not like to use methylene blue because it stains the bladder and it makes it harder to see for repair. I'm assuming this individual is saying, do you agree with this? What are your thoughts on this? You know, methylene blue, it doesn't usually come into my algorithm much just because it's really, it has a variable filtration through the kidneys. So I don't love using it to assess for ureteral patency because it can take a long time. And then I typically wouldn't use that to backfill the bladder either. I haven't found that to be very helpful. So I really can't tell you if it stains the bladder. But I just don't, I don't know if it's a very helpful agent these days when there are other things like fluoroethane that can be pretty helpful. Okay. I think we are right at our time. I just want to, on behalf of AUGS, thank Dr. Mueller and everyone for joining us today. For a full list of upcoming webinars, please visit the AUGS website to sign up. This video, Dr. Mueller's video, will be posted to the AUGS website. So if you know individuals who missed it and would be interested in this, please refer them to the website. Thank you so much again, Dr. Mueller. It was my pleasure. Thank you for moderating, Tenny. And please, if anyone has any further questions or wants to chat further, I'm always happy to chat. Please reach out to me via email. And thanks again, Tenny. I really appreciate this opportunity. All right. And good night, everybody. Thank you.

Dr. Maggie Mueller

obstetrics and gynecology

lower urinary tract injuries

bladder injuries

surgery

evaluation techniques

conservative options

ureteral re-implantation

robotic surgery