Injury to the bladder or urethra (Lower urinary tract) complicating a gynecologic procedure has long been recognized. Accidental injury to the bladder during a gynecologic surgical procedure is usually inconsequential if recognized and repaired at the time of the surgical operation. A simple closure in layers followed by continuous drainage for a period of time has no long term consequences for the patient. Gynecologists should be skilled in the prevention and early detection of accidental bladder injuries during gynecologic surgery. It is essential that injury to the bladder should be identified before the operation is concluded and immediately repaired. If the gynecologist does not posses the required training in repairing a bladder injury, an intraoperative consultation with a urologist to perform the bladder repair is mandatory.
The close anatomical association between the urinary bladder and the female reproductive organs is well known to any surgeon operating in the abdomen and pelvis of a woman. Working knowledge of the proximity of the bladder at all times during a surgical procedure is essential to prevent its injury. It is a well know and accepted fact that injury to the bladder at the time of a gynecologic operation performed through the abdomen can be almost completely avoided by the simple preliminary measure of routine identification of the pelvic tissue planes.
The principles that contribute to the safety of the bladder in all pelvic procedures include: adequate exposure of the surgical field; appropriate dissection of the retrovesical and paravesical spaces; clamping and suturing under direct vision. In patients who had undergone prior pelvic surgery (cesarean section, urinary incontinence repair) anatomical distortion is to be expected. Failure to properly identify the bladder perimeter and the pelvic tissue planes increase the risk of bladder injury during a gynecologic procedure.
The most common causes of Injuries to the bladder are:
o Prolonged labor o Midforceps procedures o Cesarean section o Cesarean hysterectomy
o Abdominal hysterectomy o Vaginal hysterectomy o Radical oncologic surgery o Anterior colporrhaphy o Urinary incontinence surgical repair o Untrained surgeon
Cancer (cervix, bladder, urethra)
Quite often, bladder injuries at the time of gynecologic surgery escape the recognition by the surgeon until postoperative complications present itself. Unrecognized bladder injury following a cesarean section or a hysterectomy may result in the formation of a vesicovaginal fistula. Vesicovaginal fistulas are the most common complication resulting from undiagnosed and unrepaired injuries to the bladder. They are classified according to the organs they connect and include:
Vesicovaginal fistula (between bladder and vagina)
Vesicocervical fistula (between bladder and cervix)
Vesicouterine fistula (between bladder and uterus)
The uncontrolled leakage of urine into the vagina is the hallmark sign and symptom described by a woman suffering from a vesicovaginal fistula following a gynecologic pelvic surgical procedure. The drainage of urine may be constant or intermittent if the fistula is very small. Bladder injuries can present themselves by extravasation (spillage) of urine intraperitoneally into the peritoneal cavity, extraperitoneally into a close space (urinoma) or by spontaneous healing and formation of a fistula. A fistula is defined as the communication between two organ sites that is lined with epithelium. In the case of the bladder, they are named in accordance with the adjacent affected organ. Although bladder injuries secondary to obstetrical complications will manifest themselves within the first 24 hours after delivery, the majority of vesicovaginal fistulas associated with pelvic surgery will present symptoms between one week and one month following the surgical operation.
Most bladder injuries are preventable, identifiable and treatable at the time of the abdominal or pelvic surgical procedure if the surgeon and/or surgical assistant performs the proper and required dissection and identification of the bladder before cutting and suturing the tissues. Eventhough an injury to the bladder at the time of abdominal hysterectomy can occur regardless of the experience of the surgeon, proper identification of the bladder disruption at the time of the surgical procedure allows:
the prevention of an bladder injury
immediate recognition the bladder injury
immediate repair to obviate further complications or the need for a subsequent operative procedure or in the alternative can lead to the formation of a genitourinary fistula.
Some indications for the surgical procedure (large uterine fibroid(s)) as well as prior surgical history should alert the operating surgeon that an enlarged uterus is associated with a distortion of the normal pelvic anatomy. As such, it became mandatory for the operating surgeon and his assistant to identify the tissue planes surrounding the bladder before any tissues are cut and/or sutured as part of the abdominal or pelvic surgical procedure. Failure to do so is a clear deviation of the acceptable standard of care for a gynecologist performing and/or assisting in the performance of an abdominal and/or pelvic surgical procedure and increases the chances for injury to the bladder to occur.
The failure of a surgeon (or assistant) to timely identify that the bladder or urethra had sustained an injury before completing the abdominal or pelvic surgical procedure and closure of the abdominal cavity or vaginal surgical layers is a clear deviation from the acceptable standard of care expected from an obstetrician- gynecologist performing an abdominal or pelvic surgical operation. Early detection and repair of intraoperative injuries to the bladder or urethra usually can restore normal function, prevent postoperative complications and possibly subsequent surgery..
If you believe that you or your loved one have been injured as a result of an obstetrical or gynecologic error that was diagnosable, avoidable and/or preventable, you may have a valid cause of action. The injury may be the result of a medical provider's mistake in handling your gynecologic condition and the result of medical negligence. Dr. Borten has over 35 years of experience as an obstetrician and gynecologic surgeon to fully evaluate the merits of your potential case. Allow the Boston area medical malpractice attorneys at Gorovitz & Borten help you assert your rights and get the compensation you deserve.
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