Urologic Injury

The most commonly injured urinary organ is the bladder, and the most common instrument causing injury is the Veress needle (81). Primary trocar injuries of the bladder have also been reported and secondary trocar injury to this structure is rare, with few reported cases.

Although gynecologic pelvic surgery is the most likely type of surgical procedure to produce a laparoscopic bladder injury, an impressive number have been reported from relatively small (by comparison to the gynecologic literature) numbers of laparo-scopic pelvic lymph node dissections for staging prostate cancer (82-85).

The estimated risk of developing a trocar site hernia is about 0.77% to 3.0%.

In addition, laparoscopic herniorrhaphy series have a growing literature of this complication as well. The most common site within the bladder to be injured is in the midline dome. This most commonly occurs when the bladder is overdistended and a suprapubic trocar is being inserted (86). Small bladder stab wounds are capable of closing spontaneously if adequate drainage is maintained. Larger, more irregular injuries require formal closure, usually sutured two or three layered plus adequate drainage with a large Foley catheter and a drain. This has been accomplished laparoscopically by many authors. Fortunately, the diagnosis of bladder injury is made during the laparoscopic procedure. This is noted when the indwelling Foley catheter bag is filled by CO2 gas, if the urine turns bloody, or in high-risk cases by distending the bladder with sterile saline at the conclusion of the case.

Less common injuries have been reported to the ureter, the urachus, and the kidney (87). The urachal report was noted to occur during placement of an access trocar and patency of the normally obliterated connection to the bladder. Ureteral injuries are most common during laparoscopic-assisted vaginal hysterectomy when taking down the vascular ovarian pedicles. Additional injuries have been reported from thermal coagulation with electrocautery and laser ablation of endometriosis. Nezhat and Nezhat (83) has described the laparoscopic correction of ureteral transection with the performance of a laparoscopic ureteroneocystomy (Lych-Gregoir type). Injuries have also been published with laparoscopic colon resections, pelvic lymph node dissections, and laparoscopic radical prostatectomy series. These injuries are always rare, and their incidence appears to be not rising (49,88-94). A final rare reported complication has been noted during a laparoscopic nephrectomy in a patient with an antecedently placed percutaneous nephrostomy catheter. In this case, the kidney was ruptured secondary to the tethering effect of the nephrostomy tube during placement of one of the trocars (87).

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