The anatomy of the female pelvis is very complex. In addition to the extensive support structures for the uterus and vagina, closely neighboring and somewhat delicate organs are susceptible to injury during childbirth and gynecologic surgery. The ureters (the tubes that deliver urine from the kidneys to the bladder) pass very close to the blood vessels that must be cut in order to remove the uterus. A small amount of tension, heat, or mere distortion can lead to leakage or narrowing of this delicate tube. The bladder (a balloon-shaped organ in the pelvic area that stores urine) lies on top of the uterus and vagina, and is also susceptible to similar harm, even when not directly manipulated by the surgeon. Considering that female pelvic anatomy often becomes very distorted during childbirth and when there is a need for gynecologic surgery, it is surprising that these injuries are not more common.
Injuries to the urinary tract can be difficult to detect during the initial surgery, particularly since these injuries may take time to develop. Urinary leakage can be suspected post-operatively with unexpected abdominal pain or bloating, a decrease in urine production, fever, watery discharge from the vagina or other incision, and changes in certain blood tests. With time, a leaking ureter or bladder can form an abnormal connection (fistula) with the nearby vagina (ureterovaginal or vesicovaginal fistula, respectively). If a ureter becomes obstructed, flank (side) pain and fever are the most common symptoms. Damage to the support structures of the vagina often does not become apparent for months to years following childbirth or pelvic surgery. As a result, prolapse (falling out) of the small intestine, rectum, bladder, and urethra (the tube that empties the bladder) can occur, thereby affecting the function of these organs.
Of course if an injury to a urinary structure is recognized during childbirth or gynecologic surgery, repair should be performed at that time. If the initial procedure is laparoscopic (through small “button-hole” incisions), the urinary injury should be repaired laparoscopically (laparoscopic ureteral re-implantation and laparoscopic bladder repair). Unfortunately, this usually requires the expertise of a highly experienced urologic laparoscopist. This service is not universally available, particularly on short notice. Northside Hospital, Scott D. Miller, MD’s primary site for providing laparoscopic care, has the advantage of commonly being able to provide these services when the need arises. This availability is particularly fortunate since Northside Hospital is one of the largest providers of obstetric and gynecologic care in the United States.
If an injury to a urinary structure is discovered subsequent to the initial surgery, it should still be repaired laparoscopically, regardless of whether the first procedure was laparoscopic. Ureteral injuries are usually best corrected with laparoscopic ureteral re-implantation. A vesicovaginal fistula can be repaired through the vagina or through a large abdominal incision. On the other hand, laparoscopic vesicovaginal fistula repair combines the superior access of the abdominal approach with the minimally invasive nature of the vaginal approach.
In the event of vaginal prolapse, some support structures should be restored with a laparoscopic technique (laparoscopic vaginal prolapse repair). However, some prolapse problems are best repaired vaginally by an expert vaginal surgeon. At times, two surgeons with different areas of expertise will work together.
Q: What information should I bring to my first office visit with Dr. Scott Miller? A: Please bring relevant x-ray films (or computer disks) and any pertinent laboratory, radiology, and pathology reports. Completing our patient information forms (available on our website) prior to your arrival will help inform Dr. Scott Miller regarding your medical history, medications and allergies.
Q: What tests do I need prior to making a treatment choice? A: Dr. Scott Miller may order tests to fully assess the anatomy and function of your bladder or kidneys. On occasion, he will perform a telescopic examination of the bladder (cystoscopy) prior to making a final recommendation.
Q: Once repaired, how will a urinary tract injury affect kidney or bladder function? A: Kidney and bladder function are not typically affected following successful repair. Some temporary symptoms may exist during the recovery period. Dr. Scott Miller will recommend any necessary long-term monitoring.
Facing a second surgery while still recovering from the first can be disheartening. Often, a laparoscopic repair minimally disrupts the recovery period. In addition, the increased precision and decreased trauma associated with laparoscopy lead to a higher success rate and fewer complications than surgery performed through a large open incision. Dr. Scott Miller has one of the largest experiences in the world managing urinary injuries with a laparoscopic approach. Seeing the importance of this service to patients, he actively educates other surgeons on a national level.