Bladder and Ureteral Injury

Few complications of gynecologic surgery create more anxiety and medicolegal concerns than lower urinary tract injuries. Improved understanding of female urinary incontinence and pelvic floor defects enables the gynecologic surgeon to treat these problems effectively. The advent of advanced laparoscopic techniques allows performing complex operations. Initially, these procedures were concentrated among a few select centers, but, as more surgeons adopt these approaches, training and experience are variable. New techniques are accompanied by a learning curve and an increased number of complications can be expected.1-3 Pelvic surgery demands proficiency in all aspects of endoscopy. Prevention, identification, and treatment of complications are predicated on liberal use of cystoscopy.4 It is essential for all gynecologic surgeons to learn and have privileges in diagnostic cystoscopy. The increasing repertoire of gynecologic surgical procedures emphasizes the importance of understanding anatomy to prevent and manage lower urinary tract misadventures. When complications occur, it is paramount to recognize and treat them appropriately. Gynecologists should manage their own complications. Unusual or complex complications may require a colleague to help manage the problem, but this does not exonerate the primary surgeon from responsibility when problems develop. Urinary tract injuries are still regularly described in case reports.5-7 Surgical training of residents must emphasize the prevention and identification of urinary tract injury. Despite this, emphasis injury rates have remained constant for decades.8-10 The advent of newer, minimally invasive techniques, more aggressive urinary incontinence procedures, and pelvic floor reconstructive procedures may be associated with increased lower urinary tract injuries.11,12 Previous authors have placed emphasis on prevention and early injury recognition. This can only be achieved with diligent study, superior training, and constant vigilance.