Bladder and injuries


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  • In O’Connors technique, bladder is bi-valved but in modified approach, bi-valving is avoided and and repair is done by making a small incision on the posterior aspect to reachupto the fistula.
  • Bladder and injuries

    1. 1. Urinary Bladder
    2. 2. Location & relations• Located in the ant pelvis• Rests on anterior part ofpelvic floor, behind thesymphysis pubis and belowthe peritoneum
    3. 3. Bladder anatomySize & shape varies with amount of urineHollow muscular organ, urine reservoir
    4. 4. PARTS OF BLADDERBody with a fundus or baseBladder neckApexA superior surfaceTwo inferolateral sufaces
    5. 5. Superior surfaceRelated to Peritoneum of utero-vesical pouch, uterus and bowel
    6. 6. Base of the bladderRelated with thesupravaginal cervix &the anterior fornix.
    7. 7. Inferolateral surfaceRelated with thespace of Retzius.
    8. 8. Bladder neckRests on superior layerof the urogenitaldiaphragm
    9. 9. Bladder bed
    10. 10. Angles of the Bladder• Apex - continuous with • 2 Lateral angles where the obliterated urachus the ureters enter the bladder• Neck - most inferior part, related to the superior pelvic fascia
    11. 11. Trigone of the BladderTriangular area marked bythree openings Two ureteral orifices Urethral opening
    12. 12. Bladder trigone cervix uterus
    13. 13. Female Urethra • 3 to 4 cm long • External urethral orifice – between vaginal orifice and clitoris • Internal urethral sphincter – detrussor muscle, thickened smooth muscle, involuntary control • External urethral sphincter – skeletal muscle, voluntary control
    14. 14. Histology of bladder
    15. 15. Blood Supply Vesical arteriesSuperior VA Arises from the proximal part of ant div of Int I A Divides into numerous br & supply dome of bladderMiddle VA Br of SVA Supplies the base of bladderInferior VA Arises from middle rectal or vaginal artery Base & the Trigone
    16. 16. Venous drainage of bladder Vesical venous plexus Internal Iliac veinsInternal vertebral venous plexus
    17. 17. Lymphatic supply• Superior part - external iliac lymph nodes• Inferior part - internal iliac lymph nodes• Bladder neck - sacral or common iliac lymph nodes
    18. 18. MicturitionResults from a complex interplay of sympathetic , parasympathetis & higher centre
    19. 19. Micturition reflexFilling of urinary bladder → stretch receptors → sensoryimpulse via pelvic nerve to S2 – S4 → Parasympatheticimpulse via pelvic nerve → Contraction of detrusor muscle &relaxation of internal sphincter → urine in urethra stimulatesstretch receptors → sensory impulse via pelvic nerve to S2 –S4 → inhibition of somatic fibers in pudendal nerve →relaxation of external sphincter → results in urination
    20. 20. Micturition reflexSympathetic (through hypogastric nerve)stimulation of beta receptors on detrusor musclecauses relaxation & of alpha receptors on internalsphincter causes constriction of sphincter, hencesympathetic stimulation causes filling & referred toas nerve of filling.
    21. 21. Higher brain centers of Micturition• Facilitatory & inhibitory centers in brain stem especially pons• Centers located in cerebral cortex is normally inhibitory but can become excitatory• For voluntary urination, cortical centers can facilitate the sacral micturition centers to help initiate a micturition reflex & at the same time inhibit the external urinary sphincter.
    22. 22. Voluntary Control of Micturition• Micturition center in pons receives stretch signals and integrates cortical input (voluntary control)• Sends signal for stimulation of detrussor and relaxes internal urethral sphincter• To delay urination impulses sent through pudendal nerve to external urethral sphincter keep it contracted until you wish to urinate• Valsalva maneuver – aids in expulsion of urine by pressure on bladder – can also activate micturition reflex voluntarily
    23. 23. BLADDER INJURIES Risk factorsDistorted pelvic anatomyPrevious Cesarean sectionsPrevious gynecologic surgeriesExtensive pelvic adhesion( Severe endometriosis, PID etc)Large myomasPelvic malignanciesExtensive surgical dissection(e.g, RH, Retropubic procedure)
    24. 24. BLADDER INJURIESINJURY BLADDERMore frequent thanUreteral InjuriesRate - 1-1.8%
    25. 25. Mechanism of Bladder injuryPerforation of bladder dome duringVeress needle/trocar insertionIncidental cystotomy duringdevelopment of bladder flap & VVS in routine/radical HysterectomyAdhesiolysis or dissection withendoscopic scissors with orwithout electrosurgery
    26. 26. Bladder injury in a case with previous C-section
    27. 27. Bladder injury during TLH for Big fibroid (20 weeks)
    28. 28. Diagnosis of bladder injuriesUnlike ureteral injuries,almost all the bladderinjuries are diagnosedintra-operatively
    29. 29. Signs of intra-operative bladder injuries• Visualization of the Foley catheter bulb• Distention of urine collection bag with CO2 (Pneumaturia)• Urine drainage from accessory trocar site• Intraperitoneal leakage of Methylene Blue• Haematuria• Suprapubic bruising• Abdominal wall or pelvic mass• Cystoscopy – size & location
    30. 30. Intraoperative bladder injuryidentification by Methylene blue test
    31. 31. Post-operative identification of Bladder injuryBladder injury is suspected in the presence of:• Haematuria• Leakage of urine per vagina ( fistula)• Fever, flank pain, ileus, abdominal distension• Sepsis
    32. 32. Post-operative DiagnosisCystoscopy POST-OPERATIVE VVFCystogramPad testIVPDiagnostic laparoscopy Cystogram showing VVF
    33. 33. Sequelae of Undiagnosed Injuries• Voiding dysfunction• Detrusor instability• Bladder stone formation with recurrent UTI• Uro-genital fistula formation• Renal damage
    34. 34. Management Intra-operative bladder injuryDepends on :Size & location• Small cystotomy (<10 mm) - Closure followed by drainage for 5-7 days• Larger injuries - Laparoscopic or open repair
    35. 35. Laparoscopic Bladder injury repairCystoscopy - Exclude injury to trigone - Check proximity of the defect to the ureterRemove necrotic tissue, adhesions or areas ofendometriosis before actual repair
    36. 36. Laparoscopic repair of smallintraoperative bladder injury
    37. 37. Laparoscopic Bladder suturing• Interrupted or continuous absorbable sutures through full thickness of bladder wall• Polyglactin or Polydioxanone , no 3-0• Single layer closure is sufficient• Repair should include mucosa, muscularis & serosa• Peritoneal imbrication or omental graft placement between suture lines may decrease risk of fistula formation
    38. 38. Post-operative PeriodBladder drainage with large caliber urethral orsuprapubic catheter 5-7 days - simple fundal laceration 14 days - closer to trigone or vaginal vault - significant thermal damageRetrograde cystogram to confirm healing
    39. 39. Vesico-vaginal fistula• Delayed bladder injury presents as a VVF• Abnormal connection b/w bladder and vagina• Seen in first 7-10 days post operatively
    40. 40. Incidence 0.3-2% Abdominalhysterectomy- 83% Vaginal-8%Urological surgeries- 6.9% Radiation-4% Obstetric- 6.5%
    41. 41. Demographic variationObstetric injuries are most common cause ofVVF in developing countries whereas in developedcountries, gynecological surgical injuries are thecommonest cause of VVF.
    42. 42. What causes fistula ?• Direct trauma• Tissue devacularisation during dissection• Inadvertent suture placement• Infection- > tissue necrosis• Overdistention of bladder post operatively
    43. 43. Risk factors• Previous surgery• h/o sepsis• Endometriosis• Malignancy• Adhesions with bladder and uterus or cervix• Anatomical distortion within pelvis• Radiation
    44. 44. Clinical featuresDepend on site and size of fistula• Vaginal leakage• Recurrent cystitis• Pyelonephritis• Unexplained pyrexia• Hematuria• Pain: flank, vaginal or supra pubic• Abnormal urinary stream• Irritation of vagina and perineum• Foul odour
    45. 45. Type of fistulaSimple - Tissue healthy, good vaginal accessComplicated – large (> 5cms) scarring Impaired access Involvement of ureteric orifices
    46. 46. classification of urogenital fistulas• Urethral• Bladder neck• Sub symphysial• Midvaginal• Juxtacervical/vault• Vesicouterine• Vesicocervical
    47. 47. Presentation• Continuous urinary incontinence• Limited sensation of bladder fullness• Infrequent voiding
    48. 48. Timings of presentation 5-14 days post-operatively
    49. 49. Investigations• Dye test• Cysto urethroscopy• IVP• Retrograde pyelogram• Vaginal fluid collection to see conc. of urea• Urine analysis and culture
    50. 50. Basic principles for fistulae repair• Ensure that there is no cellulitis, edema, or infection at the fistula site prior to closing the fistula• Excision of avascular scar tissue• Wide mobilisation of bladder• Tension free layer closure of bladder and vagina• Good hemostasis with bladder drainage• Using transplanted blood supply
    51. 51. Techniques of repair• Conservative• Abdominal approach• Vaginal approach• Laparoscopic• Combined• Electrocautery• Fibrin glue• Using interposition flaps or grafts
    52. 52. Various approachesVaginal Flap splitting Latzko’s procedureAbdominal O’conor technique Modified O’Conor Laparoscopic transperitoneal repair
    53. 53. Vaginal vs abdominal approach Vaginal Abdominal• In simple fistula • Inadequate vaginal exposure• When easy access to • For complicated fistula anterior vaginal wall • Recurrent fistula e.g, trigonal fistula • Failure of vaginal repair• Less morbiditiy • Multiple fistula• Shorter operative time • Larger fistula• Minimal blood loss • Associated pelvic pathology• Quicker recovery • In close proximity to ureter
    54. 54. Timings of repair• If diagnosed within 48 hrs post operatively – immediate repairEarly repair 1-3 monthsLate repair 2-4 months
    55. 55. Pre operative care• Urinary or vaginal infection- treated• Early attempts to divert urinary stream• Catheter drainage( spontaneous healing in 7 %)• Care for perineal skin
    56. 56. Flap splitting technique• Adequate exposure made.• Fistula tract excised with a scalpel• The entire tract is dissected• The layers of the bladder wall and vagina adequately delineated and mobilized• The bladder mucosa closed with interrupted 4-0 synthetic absorbable suture• A second layer, the bladder muscle, is closed with 2-0 synthetic absorbable suture.
    57. 57. Flap splitting technique
    58. 58. Flap splitting technique
    59. 59. Flap splitting technique• Vaginal incision closed separately• The bulbocavernosus muscle transplant ±• The bladder filled with 200 mL of methylene blue to ascertain fistula closure.• Catheter for 3 wks
    60. 60. Latzko’s repairPrerequisites - Adequate preoperative vaginal vault length - Fistula located at vaginal apexSuccess rate - 89% at first attempt
    61. 61. Latzko’s repair• Obliterates upper vagina for 2-3 cm around the fistula ( partial colpocleisis)• An elliptical portion of vaginal epithelium is stripped in all directions around fistula tract• Pubovesical fascia closed in two layers• Vaginal epithelium closed in interrupted sutures• Posterior vaginal wall becomes the posterior bladder wall
    62. 62. Latzko’s repair
    63. 63. Abdominal repair Operative technique• Cystoscopy• Ureteral stenting• Vesicovaginal fistula catheterisation• Transperitoneal laparoscopic approach
    64. 64. O’conor technique
    65. 65. Abdominal repair video
    66. 66. Post operative care• Supra pubic drain for distal fistula• Urethral catheterization• Adequate hydration
    67. 67. Interposition grafting• Brings in new blood supply to the area• Supports fistula repair site• Creates additional layer• Fill the dead space
    68. 68. Tissues used..• Martius graft- ( bulbocavernous muscle used)• Gracilis muscle• Omental pedicle graft• Peritoneal flap graft (paravesical area)
    69. 69. Complications of Fistula Repair• Post Operative Failure• Recurrent Fistula Formation• Injury to Ureter, Bowel, or Intestines• Vaginal Shortening
    70. 70. Prevention of bladder injuries• Routine drainage of bladder prior to trocar insertion• Identify the boundaries of the bladder (fill with 200-300 ml NS)• Meticulous & careful sharp dissection in the presence of• adhesion, endometriosis or previous LSCS• Be careful with the use of cautery & while suturing the vault• Be intrafascial in approach CYSTOSCOPY at the end
    71. 71. Thank You
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