Despite these precautions, ureteral injuries may occur. Prompt consultation is necessary if the surgeon is not trained in ureteral repair. If a ureteral obstruction is suspected, confirmation may be obtained by intravenous injection of 1 ampule of indigo carmine dye and performance of
Figure 24.10 Incision of the rectouterine peritoneum and mobilization of the rectum from the posterior cervix. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.11 Ligation of the cardinal ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.12 Removal of the uterus by transection of the vagina. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996.)
Figure 24.13 Vaginal cuff closure incorporating the uterosacral and cardinal ligaments. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.14 A: Vaginal cuff left open with a running suture along the cuff. B: Peritoneum closed. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.) a cystoscopic evaluation. The integrity of the ureters should be confirmed by the presence or absence of bilateral spill of tinted urine.
Because of the close anatomic relationship of the bladder, uterus, and upper vagina, the bladder is the segment of the lower urinary tract that is most vulnerable to injury. Bladder injury may occur on opening the peritoneum or, more frequently, during the dissection of the bladder off the cervix and upper vagina. Unless there is involvement of the bladder trigone, a bladder laceration is easily repaired. In the nonirradiated bladder, a one-or two-layer closure with a small-caliber braided absorbable suture such as a 3-0 polyglycolic acid is adequate. The bladder should be drained postoperatively. The length of time that drainage is required is controversial. If the bladder is not compromised, drainage should be continued at least until gross hematuria clears, which may occur as soon as 48 hours postoperatively. A more conservative practice is to continue drainage for 3 to 14 days depending on the type of injury (50). Elective incision into the dome of the bladder is performed in the same manner. If the trigone is involved, a surgeon trained in complicated urologic repair should be consulted, because reimplantation of the ureter may be necessary.