Short summary

Iatrogenic bladder and ureteral injury are known complications to abdominal and pelvic surgery, where gynecologic and obstetric surgeries accounts for a high number. Length of catheterization following iatrogenic urinary tract injury has sparsely been investigated. Therefore, the primary aim of the present study is to evaluate the management and outcome of these injuries following gynecologic and obstetric surgery, including length of catheterization, follow-up, and impact on quality of life.

Rationale

Iatrogenic bladder injury is a known complication to abdominal and pelvic surgery, where gynecologic and obstetric surgeries accounts for a high number. Despite it is well-known complication, most previous studies report a prevalence lower than 1 %. The incidence of bladder injuries varies among gynecologic and obstetric procedures with hysterectomy and caesarean delivery as those with highest rates ranging from 0,9% to 3,6 % after hysterectomy. Other procedures, where bladder injuries are reported are prolapse surgery, urogynecology surgery, salpingectomy, and endometriosis surgery. Besides injury to the bladder, also the ureter and urethra or in combination is associated with surgery related injuries. Additionally, the rate of injury varies by surgical approach such as vaginal vs laparoscopic.

Most frequently, bladder injury has been descripted as a full thickness laceration of the bladder wall. Bladder injuries can be divided into three subgroups: intraperitoneal, extraperitoneal or combined, depending on the location of the injury. In intraperitoneal injuries the lesion is located above the peritoneal reflection, whereas the lesion in the extraperitoneal injuries is located below the peritoneal reflection. Most iatrogenic injuries are intraperitoneal.

Most lesions are recognized intraoperatively by direct visualization. For those which are not recognized perioperative, postoperative CT-urography or cystoscopy are the gold standards for diagnosing bladder injuries.

Lesions recognized postoperatively are characterized by urosepsis, microscopic or macroscopic hematuria, abdominal extension because of urine leakage into the peritoneal cavity, problematic voiding, peritonitis, infection etc.

Several studies have demonstrated a correlation between prior abdominal or pelvic surgery and the risk of iatrogenic bladder injury. Other well documented associations with a higher risk of urinary tracts injuries are adhesions, inflammation, malignity, and a bladder, which is not fully emptied before surgery.

In most reports a bladder injury includes a repair by a 2-layered suture if the injury has been classified as intraperitoneal. The prompt surgical repair is necessary to avoid sepsis and to ensure the wellbeing of the patients. Furthermore, the injury is managed by Foley catheter drainage. There is no exact agreement in time until removal of the catheter, but to ensure the integrity of the bladder the drainage should be maintained for about seven days. Others reports that the Foley catheters can be removed after five to seven days, while others suggest removal after ten to fourteen days (8). Another study reports that the catheter is removed after ten to fourteen days and only after conformation that there is no extravasation by cystogram. In rare cases, some have suggested to use a suprapubic catheter if there is indication for long term catherization.

Extraperitoneal injuries do not require surgical repair, but most often they are managed conservatively with a Foley catheter and observation. The catheter is supposed to decompress the bladder.

To our knowledge, there is a lack of a study that investigate the length of time catheterization ought to be. The catherization period has sparsely been investigated.

Furthermore, little is reported about length of hospitalization and complications following urinary tract injuries and bladder function following removal of the catheter.

The primary aim of the study is to evaluate the length (days) of catheter use needed following urinary tract injuries following gynecologic and obstetric surgery to ensure sufficient healing.

This will be evaluated by the number of patients demonstrating any urine leakage or recurrent bladder surgery after the catheter has been removed in relation to the postoperative days having a catheter.

Furthermore, to evaluate the need of postoperative control regarding voiding function and residual urine volume and impact on quality of life. This will be evaluated by the number of patients resubmitted after removal of the catheter due to urinary retention or residual urine > 300 ml.

Finally, to evaluate quality of life, recurrent urinary infection or urinary retention, incontinence and other complications following iatrogenic urinary tract injury. This will among other be evaluated by a questionnaire sent to the patients.

Description of the cohort

Women > 18 years with an iatrogenic bladder or ureter injury at the Department of Obstetrics and Gynecology, Odense University Hospital, Region of Southern Denmark. ICD-10 codes were utilized to identify patients. Following ICD-10 codes were used: KKCH, KKCW, KKCW96, KKCH00, KKCH01, KKCH02, KKCH96, DT812U, DT812UD, DT812UC, DT812UE, KKBH40, KKBV00, KKBA10, KKBV10, KKBV01, KKBV02, KKBV02A, and KKBV02B. Patients included must have an injury in the period from January 2015 to May 2021.

Data and biological material

Data in the project are obtained from the patients' medical records. Demographics included are date of surgery, age at the time of primary surgery, body mass index, smoking history, alcohol consumption, prior surgery to the abdomen, vaginal births, and comorbidities. Other information from the medical records is information regarding surgery and the postoperative period. This includes surgical procedure, indication of surgery, management of injury, type and size of suture, complications and reoperation, catheterization time, length of follow-up and length of hospitalization. Furthermore, the project contains data from a questionnaire sent to the patients through e-Boks. The questionnaire seeks to investigate urinary tract symptoms and quality of life and included International Consultation in Incontinence Questionnaire - Urinary Incontinence Short form.