Ureteral Injury In patients who develop ﬂank pain soon after hysterectomy, ureteral obstruction should be suspected. The incidence of ureteral injury is lower with vaginal hysterectomy than with abdominal hysterectomy and higher with laparoscopic hysterectomy (41,44). One risk factor for its occurrence is total uterine prolapse, in which the ureters are drawn outside the bony pelvis.
In a patient with ﬂank pain in whom ureteral obstruction is suspected, a CT urogram and a urinalysis should be performed. If obstruction is noted on CT scan, it is usually present near the ureterovesical junction. The immediate step is attempted passage of a catheter through the ureter under cystoscopic guidance. If a catheter can be passed through the ureter, it should be left in place for at least 4 to 6 weeks, allowing sutures to absorb and the obstruction or kinking to release. If the catheter cannot be passed through the ureter, the best course is to perform abdominal exploratory surgery and repair the ureter at the site of obstruction.
Vesicovaginal Fistula Vesicovaginal fistulas occur most often after total abdominal hysterectomy for benign gynecologic disease (50). Intraoperative steps to avoid the formation of a vesicovaginal fistula include correct identification of the proper plane between the bladder and cervix, sharp rather than blunt dissection of the bladder, and care in clamping and suturing the vaginal cuff. The development of a postoperative vesicovaginal fistula after hysterectomy is rare; the incidence is as low as 0.2%.
Patients who have a postoperative vesicovaginal fistula develop a watery vaginal discharge 10 to 14 days after surgery. Some fistulas resulting from surgery are noted as early as the first 48 to 72 hours after surgery. After vaginal examination with a speculum, the diagnosis can usually be confirmed with the insertion of a cotton tampon into the vagina followed by the instillation of methylene blue or indigo carmine dye through a transurethral catheter. If the tampon stains blue, a vesicovaginal fistula is present. If no staining occurs, the presence of a ureterovaginal fistula must be ruled out by the intravenous injection of 5 mL of indigo carmine dye. Within 20 minutes, the tampon should stain blue if a ureterovaginal fistula is present. A CT urogram should be performed to rule out ureteral obstruction.
If a vesicovaginal fistula is diagnosed, a Foley catheter should be inserted for prolonged drainage. Up to 15% of fistulas close spontaneously with 4 to 6 weeks of continuous bladder drainage. If closure has not occurred by 6 weeks, operative correction is necessary. Waiting 3 to 4 months from the time of diagnosis before operative repair is recommended to allow reduction of inﬂammation and to improve vascular supply. After vaginal hysterectomy, the fistula site is above the bladder trigone and away from the ureters. Vaginal repair can be anticipated in most patients. The surgical correction is undertaken in a four-layered closure: the bladder mucosa, the seromuscular layer, the endopelvic fascia, and the vaginal epithelium.
Incidental cystotomy at the time of hysterectomy is more common than vesicovaginal fistula. When identified and repaired correctly, cystotomy rarely results in the development of a fistula.
Prolapse of the Fallopian Tube