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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
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 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
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.
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
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
Bladder injury in a case with previous C-section
Bladder injury during TLH for Big fibroid (20 weeks)
Diagnosis of bladder injuriesUnlike ureteral injuries,almost all the bladderinjuries are diagnosedintra-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 injuryidentification by Methylene blue test
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
Sequelae of Undiagnosed Injuries• Voiding dysfunction• Detrusor instability• Bladder stone formation with recurrent UTI• Uro-genital fistula formation• Renal damage
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
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
Laparoscopic repair of smallintraoperative 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 damageRetrograde 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
Demographic variationObstetric injuries are most common cause ofVVF in developing countries whereas in developedcountries, gynecological surgical injuries are thecommonest 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 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
Type of fistulaSimple - Tissue healthy, good vaginal accessComplicated – large (> 5cms) scarring Impaired access Involvement of ureteric orifices
classification of urogenital fistulas• Urethral• Bladder neck• Sub symphysial• Midvaginal• Juxtacervical/vault• Vesicouterine• Vesicocervical
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
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
Timings of repair• If diagnosed within 48 hrs post operatively – immediate repairEarly repair 1-3 monthsLate 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• 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 apexSuccess 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
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