Complications after Hysterectomy: How Would you Handle this Patient?

Question 1

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A patient is seen on the second postoperative day after a difficult abdominal hysterectomy complicated by hemorrhage from the left uterine artery pedicle. Multiple sutures were placed into this area to control bleeding. The patient now has fever, left back pain, left costovertebral angle tenderness, and hematuria. An ultrasound examination shows that fluid has accumulated in the left flank. A ureteral injury is diagnosed. If the injury had been recognized at the time of surgery, which of the following procedures could have been recommended?

Percutaneous nephrostomy

Placement of a ureteral stent without anastomosis

Intraperitoneal drainage without anastomosis

Ureteroureteral anastomosis

Ureteral reimplantation into the bladder

The answer is

Ureteral reimplantation into the bladder

Implanting a severed ureter into the bladder is the procedure of choice, especially when the ureteral transection is near the bladder, as would be expected in this case. Following an injury to the ureter during surgery, a drain should be placed extraperitoneally, not intraperitoneally. If a polyethylene catheter is inserted, it should be placed above the site of injury so that urine is drained before arrival at the site of injury. Ureteroureteral anastomosis should be done only if reimplantation into the bladder is not feasible.

Question 2

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A 44-year-old woman complains of urinary incontinence. She loses urine when she laughs, coughs, and plays tennis. Urodynamic studies are performed in the office with a mutiple-channel machine. If this patient has genuine stress urinary incontinence, which of the following do you expect to see on the cystometric study?

An abnormally short urethra

Multiple unihibited detrusor contractions

Total bladder capacity of 1000 cc

Normal urethral pressure profile

First urge to void at 50 cc

The answer is

Normal urethral pressure profile

As a catheter is introduced for performing a cystometrogram, measurement of residual urine is obtained. During the cystometrogram, a normal first sensation is of fullness felt at 100 mL. Urge is felt at approximately 350 mL, with maximum capacity at 450 mL. The primary reason to perform a cystometrogram is to rule out uninhibited detrusor contractions. The urethral pressure profile is normal in women with genuine stress urinary incontinence.

Question 3

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A 59-year-old G4P4 presents to your office complaining of losing urine when she coughs, sneezes, or engages in certain types of strenuous physical activity. The problem has gotten increasingly worse over the past few years, to the point where the patient finds her activities of daily living compromised secondary to fear of embarrassment. She denies any other urinary symptoms such as urgency, frequency, or hematuria. In addition, she denies any problems with her bowel movements. Her prior surgeries include tonsillectomy and appendectomy. She has adult-onset diabetes and her blood sugars are well controlled with oral glucophage. The patient has no history of any gynecologic problems in the past. She has four children who were all delivered vaginally. Their weights ranged from 8 to 9 lb. Her last delivery was forceps-assisted. She had a third-degree laceration with that birth. She is currently sexually active with her partner of 25 years. She has been menopausal for 4 years and has never taken any hormone replacement therapy. Her height is 5 ft 6 in., and she weighs 190 lb. Her blood pressure is 130/80. Based on the patient’s history, which of the following is the most likely diagnosis?

Overflow incontinence

Stress incontinence[3-4]

Urinary tract infection

Detrusor instability

Vesicovaginal fistula

The answer is

Stress incontinence

This patient’s history is most consistent with a diagnosis of urinary stress incontinence. Genuine stress incontinence is a condition of immediate involuntary loss of urine when intravesical pressure exceeds the maximum urethral pressure in the absence of detrusor activity. Patients with this condition complain of bursts of urine loss with physical activity or a cough, laugh, or sneeze. The cause of stress incontinence is structural, due to a cystocele or urethrocele. In cases of overflow incontinence, patients experience a continuous loss of a small amount of urine and associated symptoms of fullness and pressure. Overflow incontinence is usually due to obstruction or loss of neurologic control. Women with detrusor instability/dyssynergia have a loss of bladder inhibition and complain of urgency, frequency, and nocturia. Vesicovaginal fistulas are uncommon and usually occur as a complication of benign gynecologic procedures. Women with this complication usually present with a painless and continuous loss of urine from the vagina. Sometimes the uncontrolled loss of urine is not continuous but related to a change in position or posture. In the case of urinary tract infections, women usually present with symptoms of frequency, urgency, nocturia, dysuria, and hematuria.

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