We present on the repair of genitourinary tract injuries after emergent hysterectomy. Peripartum hysterectomy is usually performed at the time or within 24 hours of delivery due to hemorrhage and there is a high risk of urinary tract injury. We present the case of a 35-year-old woman with a history of 3 previous cesarean sections. whose cesarean sections resulted in hemorrhage requiring transfusion, bacri balloon placement followed by emergent hysterectomy. This was complicated by a systotomy and urology was consulted who identified multiple systotomies and highly friable tissue. It was decided to perform bilateral percutaneous nephrotomies and the placement of a pelvic drain. The postoperative course was complicated by sepsis and pelvic abscesses. and the patient is transferred to our hospital. A CT scan of the pelvis obtained at that time demonstrated an abscess communicating with the bladder. and a fistulous tract was also observed between the bladder and the vagina. Drainage of the abscess was performed by interventional radiology. We performed an examination under anesthesia, systoscopy, bilateral retrograde pyelograms and again confirmed the vesico-vaginal fistula near the apex of the vagina, probably due to cuff dehiscence. Given the poor clinical improvement and readmissions related to the intraperitoneal bladder injury, Our surgical intervention was planned. Prior to the operating room, we consulted interventional radiology to place antegrade stents that would aid in ureteral identification during dissection. Upon entering the abdomen, careful esiolysis was also performed along the anterior abdominal wall and during this dissection multiple loops of intestine were identified. Note here the upward movement of the anterior abdominal wall to determine the plane of dissection. This part of the dissection was very challenging and lasted over two hours. As the dissection progressed, you can see here that the cephalic portion of the phlegmon was visualized. We begin to see it here, you can see that necrotic tissue. A vaginal retractor was also soon used to determine the correct planes in the abdomen. To determine the correct dissection planes. And we can see it moving there. Here you can see us dissecting around the edges of the phlegmon. Large amounts of necrotic tissue were found and these were suctioned out. And the goal here is to continue sucking the phlegmon which, given the previous imaging, we had already determined that the phlegmon takes you directly to the bladder. Finally, after continually dissecting around the phlegmon, the internal margins of the bladder will be identified. A large part of the dome of the bladder was affected by this phlegmon and was removed. And little by little we are going to see how it is identified that bladder as the phlegmon is eliminated. Ureteral stents were essential and ensured that this did not risk inadvertent and unidentified lessoning of the ureters. Necrotic tissue was removed. And here we can see the foli catheter and the ureteral stents. You can also see the vaginal retractor helping to identify the obese-vaginal plane. During this dissection, we identified the obese-vaginal fistula and proceeded, you can see it here, to continue developing the obese-vaginal plane. For tension-free repair of the systotomy, the anterior bladder wall and retropublic space were mobilized. Here we are in the back space, But we will soon see that the retropublic space will also be dissected in order to have low bladder repair tension. We identified the location of the right ureteral injury. You can see here with our dissection to identify where the right ureter lies. And here the antegrade stents were very useful. Here you can see how we are identifying that right stent and you will be able to see it soon. And here you can identify the stent. We chose not to perform ureteral reimplantation for two reasons. Firstly, due to the loss of global bladder capacity secondary to the systotomy. And secondly, by the continuity of the ureter with itself. Instead, we opted to repair the right ureter over the existing stent. The ureter was repaired with interrupted monocril 4.0. You can see it here. The bladder was debrided until healthy bladder tissue was identified. Due to the expected loss of bladder capacity, 100 units of onobutulinum toxin were injected throughout the detrusor. The systotomy was then repaired in multiple layers. A working bicryl 2.0 was used to make the first layer. The imbricating layer was made by placing stylological sutures. We will see it soon. Here we are at the first layer. And here are the stylological sutures to have an imbricating layer. Then, the first layer was done. A vental flap was then developed to serve as an interposition at the vaginal repair site. You can see it here. He has a good blood supply. Here we can see the peritoneal flap that is going to intervene on the repair of the systotomy. We debride the edges of the layer. We debride the edges of the vaginal fistula and perform a multilayer closure of the fistulized vaginal apex. A 2.0 V-Lock suture was used for the first layer of vaginal apex closure. The peritoneal flap was placed over the systotomy repair. And you can see it here, that interposition. The much larger omental flap was then placed over the fistula closure and ureteral repair. After the operation, the patient progressed well. Three weeks postoperatively, they underwent a cystogram and cystoscopy with removal of the ureteral stents. The findings were notable for a small bladder capacity of 250 milliliters, but no evidence of vesico-vaginal fistula, and retrograde pyelograms were normal. At five weeks, we removed their nephrotomies and a normal renal coography was obtained in the central unit. Normal renal coography at week 6. Currently, the patient reported feeling well and was emptying her bladder normally without incontinence or urgency. The main learning points from our video are One, early identification of unnecessary injuries is essential. Imaging and examination under anesthesia prepare you for intraoperative success. While many surgeons advocate late repair of such injuries, sometimes after three months or more, The patient's clinical picture will sometimes require earlier intervention. Conversion to open surgery should be planned, but surgeons experienced in the modality can definitely consider a minimally invasive approach. And lastly, but definitely most importantly, Collaboration and teamwork are essential. Thank you.

genitourinary tract injuries

emergent hysterectomy

sepsis

vesico-vaginal fistula

ureteral stents