Bladder and injuries

Urinary Bladder

Location & relations

• Located in the ant pelvis

• Rests on anterior part of pelvic floor, behind the symphysis pubis and below the peritoneum

Bladder anatomy Size & shape varies with amount of urine

Hollow muscular organ, urine reservoir

PARTS OF BLADDER Body with a fundus or base Bladder neck Apex A superior surface Two inferolateral sufaces

Superior surface

Related to Peritoneum of utero-vesical pouch, uterus and bowel

Base of the bladder

Related with thesupravaginal cervix &the anterior fornix.

Inferolateral surface

Related with the space of Retzius.

Bladder neck

Rests on superior layer of the urogenital diaphragm

Bladder bed

Angles of the Bladder

• Apex - continuous with the obliterated urachus

• Neck - most inferior part, related to the superior pelvic fascia

• 2 Lateral angles where the ureters enter the bladder

Trigone of the Bladder

Triangular area marked by three openings

Two ureteral orifices Urethral opening

uterus

cervix

vagin

a

vagina

Bladder trigone

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

Histology of bladder

Blood Supply

Superior VA Arises from the proximal part of ant div of Int I A Divides into numerous br & supply dome of bladder

Middle VA Br of SVA Supplies the base of bladder

Inferior VA Arises from middle rectal or vaginal artery Base & the Trigone

Vesical arteries

Venous drainage of bladder

Vesical venous plexus

Internal Iliac veins

Internal vertebral venous plexus

Lymphatic supply

• Superior part - external iliac lymph nodes

• Inferior part - internal iliac lymph nodes

• Bladder neck - sacral or common iliac lymph nodes

MicturitionResults from a complex interplay of sympathetic , parasympathetis & higher centre

Micturition reflex

Filling of urinary bladder → stretch receptors → sensory impulse via pelvic nerve to S2 – S4 → Parasympathetic impulse via pelvic nerve → Contraction of detrusor muscle & relaxation of internal sphincter → urine in urethra stimulates stretch receptors → sensory impulse via pelvic nerve to S2 – S4 → inhibition of somatic fibers in pudendal nerve → relaxation of external sphincter → results in urination

Micturition reflex

Sympathetic (through hypogastric nerve) stimulation of beta receptors on detrusor muscle causes relaxation & of alpha receptors on internal sphincter causes constriction of sphincter, hence sympathetic stimulation causes filling & referred to as nerve of filling.

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.

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

BLADDER INJURIES

Risk factors

Distorted pelvic anatomyPrevious Cesarean sectionsPrevious gynecologic surgeriesExtensive pelvic adhesion ( Severe endometriosis, PID etc)Large myomas Pelvic malignanciesExtensive surgical dissection (e.g, RH, Retropubic procedure)

BLADDER INJURY

More frequent than Ureteral Injuries

Rate - 1-1.8%

BLADDER INJURIES

Mechanism of Bladder injury

Perforation of bladder dome during Veress needle/trocar insertion

Incidental cystotomy during development of bladder flap & VVS in routine/radical Hysterectomy Adhesiolysis or dissection with endoscopic scissors with or without electrosurgery

Bladder injury in a case with previous C-section

Bladder injury during TLH for Big fibroid (20 weeks)

Diagnosis of bladder injuries

Unlike ureteral injuries, almost all the bladder injuries are diagnosed intra-operatively

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

Intraoperative bladder injury identification by Methylene blue test

Post-operative identification of Bladder injury

Bladder injury is suspected in the presence of: • Haematuria

• Leakage of urine per vagina ( fistula)

• Fever, flank pain, ileus, abdominal distension

• Sepsis

CystoscopyCystogramPad testIVPDiagnostic laparoscopy

POST-OPERATIVE

Post-operative Diagnosis

VVF

Cystogram showing VVF

Sequelae of Undiagnosed Injuries

• Voiding dysfunction

• Detrusor instability

• Bladder stone formation with recurrent UTI

• Uro-genital fistula formation

• Renal damage

Management

Depends on : Size & location

• Small cystotomy (<10 mm) - Closure followed by drainage for 5-7 days

• Larger injuries - Laparoscopic or open repair

Intra-operative bladder injury

Laparoscopic Bladder injury repair

Cystoscopy - Exclude injury to trigone - Check proximity of the defect to the ureter

Remove necrotic tissue, adhesions or areas ofendometriosis before actual repair

Laparoscopic repair of small intraoperative bladder injury

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

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 damage Retrograde cystogram to confirm healing

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

Incidence 0.3-2%

Abdominal hysterectomy- 83%

Vaginal-8%

Urological surgeries-6.9%

Radiation-4%

Obstetric- 6.5%

Demographic variation

Obstetric injuries are most common cause ofVVF in developing countries whereas in developedcountries, gynecological surgical injuries are the commonest cause of VVF.

What causes fistula ?

• Direct trauma • Tissue devacularisation during dissection• Inadvertent suture placement• Infection- > tissue necrosis• Overdistention of bladder post operatively

Risk factors

• Previous surgery• h/o sepsis• Endometriosis• Malignancy• Adhesions with bladder and uterus or cervix• Anatomical distortion within pelvis• Radiation

Clinical features

Depend 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

Type of fistula

Simple - Tissue healthy, good vaginal access

Complicated – large (> 5cms) scarring Impaired access Involvement of ureteric orifices

classification of urogenital fistulas

• Urethral• Bladder neck• Sub symphysial• Midvaginal• Juxtacervical/vault• Vesicouterine• Vesicocervical

Presentation

• Continuous urinary incontinence• Limited sensation of bladder fullness• Infrequent voiding

Timings of presentation

5-14 days post-operatively

Investigations

• Dye test• Cysto urethroscopy• IVP• Retrograde pyelogram• Vaginal fluid collection to see conc. of urea• Urine analysis and culture

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

Techniques of repair

• Conservative• Abdominal approach• Vaginal approach• Laparoscopic • Combined • Electrocautery• Fibrin glue• Using interposition flaps or grafts

Various approaches Vaginal Flap splitting Latzko’s procedure Abdominal O’conor technique Modified O’Conor Laparoscopic transperitoneal repair

Vaginal vs abdominal approach

Vaginal

• In simple fistula• When easy access to

anterior vaginal wall e.g, trigonal fistula• Less morbiditiy• Shorter operative time• Minimal blood loss• Quicker recovery

Abdominal

• Inadequate vaginal exposure• For complicated fistula• Recurrent fistula• Failure of vaginal repair• Multiple fistula• Larger fistula• Associated pelvic pathology• In close proximity to ureter

Timings of repair

• If diagnosed within 48 hrs post operatively – immediate repair

Early repair 1-3 months Late repair 2-4 months

Pre operative care

• Urinary or vaginal infection- treated• Early attempts to divert urinary stream• Catheter drainage( spontaneous healing in 7 %)• Care for perineal skin

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.

Flap splitting technique

Flap splitting technique

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

Latzko’s repairPrerequisites - Adequate preoperative vaginal vault length - Fistula located at vaginal apex

Success rate - 89% at first attempt

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

Latzko’s repair

Abdominal repair

Operative technique • Cystoscopy• Ureteral stenting• Vesicovaginal fistula catheterisation• Transperitoneal laparoscopic approach

O’conor technique

Abdominal repair video

Post operative care

• Supra pubic drain for distal fistula• Urethral catheterization• Adequate hydration

Interposition grafting

• Brings in new blood supply to the area• Supports fistula repair site• Creates additional layer• Fill the dead space

Tissues used..

• Martius graft- ( bulbocavernous muscle used)• Gracilis muscle• Omental pedicle graft• Peritoneal flap graft (paravesical area)

Complications of Fistula Repair

• Post Operative Failure• Recurrent Fistula Formation• Injury to Ureter, Bowel, or Intestines• Vaginal Shortening

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

Thank You