The pattern of urologic injuries and treatment outcomes in obstetric and Gynaecologic surgeries as seen at Muhimbili National Hospital

Abstract

ABSTRACT Background: It is estimated that0.5% to 10% of urologic injuries are caused by obstetric and gynaecologic surgeries worldwide. However, there is paucity of information regarding the magnitude, pattern and treatment outcome of urologic injuries occurring as a result of obstetric and gynaecologic surgeries in Muhimbili National Hospital. This study is designed to describe the magnitude, pattern and treatment outcomes of iatrogenic urologic injuries complicating obstetric and gynaecologic surgeries in Muhimbili National Hospital. Broad Objective: To determine the magnitude, pattern, treatment and treatment outcomes of urological injuries after obstetric and gynaecological surgeries as seen at Muhimbili National Hospital. Methodology: This was a cross sectional study conducted in departments of urology and obstetrics and gynaecology of Muhimbili National Hospital. The study population included all females who were diagnosed to have urinary tract injury in MNH following obstetric orgynaecologic surgery done in MNH or referred from other hospitals for 10 years from June 2006 to May 2016. Data was collected from patient files using structured data sheet.. Results: During the 10 years of the study, there were a total of 1083 patients aged 18 and above with urologic injuries seen at MNH. Among these, those that met inclusion criteria were 52 (4.8%). Among these, 27 (45%) had bladder injuries, 29 (48.3%) had ureteric injuries. The total urologic injuries were 60 because 2 patients had both ureteric and bladder injuries and 2 patients had both bladder and urethral injuries. Fourteen (51.9%) of bladder injuries were caused by laceration; 2 (7.4%) by transection, 1 (3.7%) by devascularization. There were 9 (33.3%) bladder injures with unspecified causes. Ligation of ureter(s) caused 10 (34.5%) of ureteric injuries followed by transaction and lacerations having caused 6 (29.4%) and 5 (20.7%) respectively. Most of mechanism of ureteric injury was unspecified in 12 (39.1%) cases. Thirteen of bladder injuries were managed by bladder repair, 7 cases by VVF repair; 5 cases by urethral catheterization and 2 cases were not yet repaired. Twenty two of ureteric injuries were managed through ureteric reimplantation, 2 injuries by ureterostomy (ureteric exteriorization) . Other ureteric injuries were managed by nephrostomy (1), ureteroureterostomy (3) and catheterization (1).

Post management repairoutcomewas good in 19 of bladder and 25 of ureteric injuries. It was fair in 6 bladder and 3 ureteric injuries and was poor in 2 bladder and 1 ureteric injuries.

Conclusions and recommendations: Urologic complications following gynaecological and obstetric surgeries are common in MNH at a prevalence of 4.8%. These iatrogenic injuries to the urinary tract occur more common during trans-abdominal hysterectomies and caesarean sections. Most of these injuries (70.3%) seen at MNH were referral from non academic hospitals. Surgeries done by Assistant Medical Officers contributed to 53.6% of these injuries which is twice than injuries caused by specialists and medical officers/registrars altogether. Post treatment/management outcomes were good for these injuries. However, documentation and reporting was found, in this study, to be inadequate. It is therefore recommended from this study that: • There is a need to improve documentation in case notes of injuries in theatres so that accurate data/information may be available when needed.

• Obstetrics and gynaecolocal surgeries are highly specialized surgeries that should be done by surgeons who have acquired good training on surgical skills and relevant anatomical relations of pelvic organs. Assistant Medical Officers should not perform such surgeries.

• Hysterectomies are the main surgery that led to many urologic injuries (both bladder and ureteric injuries). Extra care should be practiced while OBGY surgeons perform such surgeries to avoid causing such urological injuries. • The government through Ministry of Health, Social Welfare, Gender and Children should train more medical officers and OBGY specialists and distribute them in non teaching hospitals.

• Most of bladder injuries are originating from emergency obstetric surgeries. It is clear that knowledge of correct protocols and adherence to precautions are important and should be maximally practiced while emergency obstetric surgeries are performed to avoid bladder injuries.