A vesicovaginal fistula can be confirmed by filling the bladder with methylene blue and then detecting dye on a tampon previously placed in the vagina. With a ureterovaginal fistula, the methylene blue will not pass into the vagina, but it can be detected with the intravenous injection of indigo carmine.
Knowledge of the course of the ureter through the pelvis is a prerequisite to reducing the risk of injury. The ureter can usually be seen through the peritoneum of the pelvic sidewall between the pelvic brim and the attachment of the broad ligament. Because of variation from one patient to another or the presence of disease, the location of the ureter can become obscured, making it necessary to enter the retroperitoneal space. The techniques used for retroperitoneal dissection are important factors in reducing the risk of ureteric injury. Blunt and sharp dissection with scissors is preferred, although hydrodissection can be used (137). The selective placement of ureteral stents may be helpful in preventing injury.
Ureteral injury can be treated immediately if it is diagnosed intraoperatively. Although limited damage may heal over a ureteral stent left in place for 10 to 21 days, repair is indicated in most patients. Laparoscopic repair of ureteric lacerations and transections is performed, but most injuries require laparotomy (132,138).
Incomplete or small obstructions and lacerations may be treated successfully with either a retrograde or anterograde ureteral stent. Urinomas may be drained percutaneously. If a stent cannot be placed successfully, a percutaneous nephrostomy should be performed before operative repair is undertaken. Repair may be accomplished by excision and reanastamosis, or, more commonly, ureteric reimplantation with or without facilitating procedures such as a psoas hitch or a Boarie ﬂap.
Neurologic Injury Peripheral nerve injury is usually related either to poor positioning of the patient or to excessive pressure exerted by the surgeons. Placing the patient in the modified lithotomy position while she is awake may decrease this risk because the patient can determine whether any undue pressure or discomfort is felt (139). Nerve injury may also occur as a result of the surgical dissection.
In the extremities, the trauma may be direct, such as when the common peroneal nerve is compressed against a stirrup. The femoral nerve or the sciatic nerve or its branches may be overstretched and damaged by excessive ﬂexion or external rotation of the hips. The peroneal nerve may be injured by compression if the lateral head of the fibula rests against the stirrup (139–141). Brachial plexus injuries may occur secondary to the surgeon or assistants leaning against an abducted arm during the procedure. If the patient is placed in a steep Trendelenburg position, the brachial plexus may be damaged because of the pressure exerted on the shoulder joint. In most cases, sensory or motor deficits are found as the patient emerges from anesthesia. The likelihood of brachial plexus injury can be reduced with adequate padding and support of the arms and shoulders or by placing the patient’s arms in an adducted position.
Most injuries to peripheral nerves resolve spontaneously. The time to recovery depends on the site and severity of the lesion. For most peripheral injuries, full sensory nerve recovery occurs in 3 to 6 months. Recovery may be hastened by the use of physical therapy, appropriate braces, and electrical stimulation of the affected muscles. Open microsurgery should be performed for transection of major intrapelvic nerves.