UROLOGICAL COMPLICATIONS FROM OBSTETRICS & GYNAECOLOGICAL PROCEDURES IN ILORIN, NIGERIA – CASE SERIES

Abstract

Background:

Despite the advances and improvement in science and surgical skills, post-surgical operation complications are oftentimes inevitable, although they could be minimized. Generally, complications occur because of several reasons including patient factors, the disease condition, management option, skills and expertise of the managing team as well as technical factors. Analysis of postoperative complications will help to understand their pathogeneses and identify ways of preventing such complications in the future.

Aim & Objectives:

To retrospectively analyse the urological complications arising from obstetrics and gynaecological procedures at the University of Ilorin Teaching Hospital, Ilorin, Nigeria.

Methodology:

Retrospective analysis of available records of patients with urological complications following either obstetrics or gynaecological procedures between the year 2010 – 2012 managed by the urology unit of the University of Ilorin Teaching Hospital, Ilorin, Nigeria. The patients were identified from the unit and theatre records. From the patients’ clinical records, the data retrieved included the biodata, presentation, details of the gynaecological operations (calibre of surgeons, notable events at operations) and the complications that were recorded. The urological interventions and outcomes were also recorded.

Results:

There were 11 patients with urological complications during the three year period. Their ages ranged from 28 and 65years (mean 43.8 +/-0.05 years), about 60% had hysterectomy for uterine fibroids. Various complications such as urinary fistulae (45.5%), ureteric obstructions (36.5%), retained surgical foreign bodies (9%) and ureteric transection (9%) were recorded. Corrective urological interventions were successful in majority (72.7 %) of them.

Conclusion:

Urological complications associated with gynaecological and obstetrics procedures are sometimes inevitable but their occurrence could be reduced when standard practices are observed.

Introduction

Post-operative complication is defined as any undesirable, unintended, and direct result of surgery affecting the patient which would not have occurred had the surgery gone as well as could reasonably be hoped1. The desired postoperative outcome is for the patient to make quick recovery from the effects of anaesthesia, have speedy wound healing, achieve the purpose for which the operation was carried out and have no undesirable outcome. Sometimes, not all the aforementioned expectations are met. Complications could be mild and insignificant, could cause permanent disability or be life threatening. Despite the advances and improvement in science and surgical skills, even in the best of centres, complications are sometimes inevitable. All efforts are needed to reduce the incidence because of the implications to the patients, surgeons and health-care institutions.

Generally, complications may occur for several reasons namely patient factors, the disease condition that is being treated and technical factors2,3. The patient factors include previous surgical operations and other treatments such as radiotherapy4, associated systemic diseases such as diabetes mellitus5 and the presence of obesity. Also, postoperative surgical infections have been found to act as predisposing factor for the urinary tract complications 5, 6. The factors related to the disease condition include whether the disease is benign or malignant, and if malignant, the stage of the disease5, 7. The technical factors include the nature of the procedure to be carried out and how technically demanding it is; the surgeon’s skill and competence; and his understanding of the relevant anatomy.

It is therefore not uncommon to find urological complications following obstetrics and gynaecological procedures. Analysis of these urological complications is important since not all of them are inevitable and hence such a study will help to understand their pathogeneses and identify ways of preventing such complications in future patients. This study therefore aims to retrospectively analyze the urological complications, arising from obstetrics and gynaecological procedures managed at the urology unit of the University of Ilorin Teaching Hospital. The study also plans to identify the factors associated with these complications and to proffer preventive measures in subsequent patients.

Methodology

The records of patients with urological complications following either obstetrics or gynaecological procedures between the years 2010 – 2012 managed at the urology unit of the University of Ilorin Teaching Hospital, Ilorin, Nigeria were identified through the unit records and the operating room database.

The data retrieved included the patients’ bio-data; the preoperative clinical conditions or diagnoses; the obstetrics and gynaecological procedures that were carried out; the highlights or critical relevant points of the procedures and the urological complications recorded; the intervention that were carried out; the outcomes of the interventions and the patients’ disposal. The data were analyzed using Microsoft Excel for mean and frequencies.

Case series

The clinical summary of the 11 patients in this case series is presented in the table below:

Table 1 . Summary of the patients and their outcome .

S/N	Age	Obstetrics/ Gynaecological Procedures	Urological complications	Intervention	Outcome
1	45	Dilatation and curettage for incomplete abortion	Lt Ureterovaginal fistula	Ureteric reimplantation	Satisfactory
2.	48	Hysterectomy for symptomatic uterine fibroid	Enterovesical fistula (EVF), retained abdominal pack in the urinary bladder,Retained intra- abdominal haemostat	Endoscopic retrieval of abdominal pack.Exploratory laparotomy , retrieval of haemostat and repair of EVF	Satisfactory
3.	65	Hysterectomy for symptomatic uterine fibroid	Retained abdominal pack in the urinary bladder + renal failure	Vesicotomy and retrieval of abdominal pack	Died of renal failure
4	38	Excision of? ovarian cyst in pregnancy	Partial excision of urinary bladder and bilateral ureteric obstruction (ligation)	Left Ureterostomy then augmentation cystoplasty & bilateral ureteric implantation	Satisfactory
5	47	Hysterectomy for symptomatic uterine fibroid	Vesicovaginal fistula	Urethral catheterisation& continuous bladder drainage	Satisfactory
6.	38	Hysterectomy for symptomatic uterine tumour (had had previous abdominal operation)	Bilateral ureteral obstruction	Bilateral tube ureterostomy	Recovered from renal failure but later developeda pelvic tumour. Lost to followup
7.	39	Hysterectomy for symptomatic uterine fibroid	Lt ureteric obstruction with unilateral non -functioning kidney	Requested for referral abroad	Lost to follow up
8.	46	Hysterectomy for symptomatic uterine fibroid (3previous abdominal operations)	VVF	Repair	Satisfactory
9.	50	Excision of huge ovarian cyst	Rt ureteric transection	Ureteroureteral anastomosis	Satisfactory
10.	46	Hysterectomy for symptomatic uterine fibroid	Lt ureteric injury + huge urinoma causing ureteric obstruction	Excision of urinoma and Ureteric re-implantation	Satisfactory
11.	49	Hysterectomy for symptomatic uterine fibroid	Ureterovaginal fistula	Ureteric re-implantation	Satisfactory
Abbreviations EVF – Entero-vesical fistula ;VVF- Vesico-vaginal fistula; D&C -Dilatation and CurettageLt- Left ; Rt- Right

Discussion

Generally, most iatrogenic urological injuries arise from obstetrics and gynaecological procedures8.This is due to the fact that the urinary tract is in close proximity to the female genital organs.

Complications following surgical operations are not desirable but they occur and continue to pose challenges to the managing surgical teams. This is because they may become sources of significant morbidity and mortality with the attendant cost to the patients and the healthcare system. Post-operative complications may also significantly affect the career of the surgeon or even the workings of a surgical unit. They may also be sources of litigation involving the practitioners and the health care institution.

Analysis of postoperative complications is important in helping the surgeon to audit his practice, understand why things went wrong and devise means of avoiding such complications in future patients. The need for proper documentation has long been recognized and this has led to the design of grading systems for postoperative complications9, 10. The grading systems provide for uniform and standardized documentations across units in different locations and objective comparisons of practices can be made.

Although it may not be possible at this time to completely eliminate post operative complications, many of them are potentially avoidable. The incidence of postoperative complications can therefore be greatly reduced with good understanding of their pathogeneses.

There were 11 patients with urological complications following obstetrics and gynaecological procedures over a three-year period which is about 4 patients per year. This compares well with 42 in 12 years reported by Peng et al11. However the number reported in this study may only be a fraction of the total number of patients affected since more than two third of operations done in our geographical area are by personnel in peripheral hospitals who are not qualified to carry out such operations12. Some of these patients may not have not presented yet as was the case of one of the patients in this series who did not present for the treatment of ureterovaginal fistula (UVF) which complicated D&C until 12 years after the procedure. In addition, some of the complications may be ‘silent’, such as an asymptomatic unilateral ureteric obstruction when the contra lateral kidney has normal function13.

This study has brought out some of the underlying causes for some of the complications and also provides some suggestions on how to reduce the complications. First of these suggestions is the need to have enforceable regulations to safe-guard surgical practices. In resource poor countries, public health care systems are still evolving especially in the rural areas where large proportion of the population live. To make up for the inadequacies of these health facilities, many private hospitals /clinics with inadequate competencies make up for the gap in health care services in rural communities. Many of these are staffed by nurses, midwives, and doctors with just basic medical training, carrying out various surgical operations which they do not have formal prerequisite training for 14. More than half of the patients in this series were operated upon by doctors without appropriate specialist training. One of these patients had an ultrasound scan which reported a twelve week gestation sac as an ovarian cyst. This patient based on the misdiagnosis of an ovarian cyst by the inexperienced sonologist had partial excision of the urinary bladder and bilateral ligation of the ureters. This patient survived after an initial diversion of the urinary tract by a left tube ureterostomy, had a successful delivery of a male child after six months of hospitalization and eventually and had an augmentation of the urinary bladder using the ileum as shown in Fig.1.

The second is adequate preoperative planning. This is important as it provides the opportunity to actually know more of the surgical patient just before operation. Various models and software have been developed for preoperative assessment. Every surgical unit should irrespective of whether they have access to sophisticated preoperative planning software or not, should as much as possible, have formal preoperative unit or interdisciplinary planning sessions for surgical operations/ procedures. These sessions are also important to ensure availability of certain important items needed for the operations which may have to be sourced outside the system and adaptations of available equipment or prosthesis may be considered. Preoperative planning also helps to decide which appropriate personnel of requisite experience should be involved in the procedure. This ensures that the patient gets the possible best treatment from the beginning of the procedure and thus reduces the need to call in more experienced hands after the operation has commenced. With prolongation of the procedure time, fatigue sets in and the risk for human error is higher15. Analysis of some of the cases in this report showed that the principles of proper preoperative planning were not observed. This is well illustrated by the cases 2&8 on Table 1. The cases posed challenges because of adhesions from previous abdominal operations. The patients with repeated abdominal operations have been reported to have higher incidence of complications16 so such cases should have been attended to by the most experienced surgeons available. Furthermore, certain procedures in gynaecology have been associated with higher incidences of complications. Hysterectomy has been found to be associated with the highest incidence of complications especially ureteric injuries17.In this study, 73% of the obstetrics and gynaecological procedures developed complications followed total abdominal hysterectomy. Six out of the 8 cases were performed by doctors without appropriate specialist training. Case number 9 is a patient with huge ovarian cyst, which caused obstruction of the ipsilateral upper urinary tract. This resulted in non-visualization of the ureter on intravenous urogram even after delayed films. In such patients, further mapping or identification of the urinary tract should have been made. The foreknowledge of the anatomy of the ureter is important especially when operating in the pelvic region where the ureter is most vulnerable18. If a clear anatomy of the ureter is not well defined, the possibility of ureteric injury is high especially in the females who have twice as much the incidence of ureteric anomalies as in the males5. In addition to this, masses in the pelvic or abdomen could distort the usual anatomic location of the ureter. In order to avoid ureteric complications in such cases, intravenous urogram and or retrograde ureterogram should be carried out, and when this is impossible in the centre, the patient should be referred to an appropriate health facilities where this is possible for further management. Adequate preoperative planning may also require the involvement of multi disciplinary team cooperation. This is well demonstrated by the report from Kuwait by Al Awadi et al19. They reported significant reduction in ureteric injuries from colonic operations through preoperative ureteric stent insertion by the urologists in the centre.

In conclusion, complications following obstetric and gynaecological procedures are preventable if the procedures are performed by trained and experienced surgeons in the appropriate settings. And when complications arise, they should be identified early and corrected promptly.

Figure 1. Patient with iatrogenic partial excision of the urinary bladder at augmentation .