Best practices for repair of iatrogenic bladder injury.

Gynecologic surgery carries a known risk of injury to the urinary tract, especially in the presence of risk factors. Injury to the bladder, particularly a mechanical injury, is more common than injury to the ureter. Urinary tract injuries occur in 0.3% to 0.8% of all gynecologic procedures, and injuries to the bladder occur in 0.05% to 0.66% of such surgeries. The risk of bladder injury increases in hysterectomy procedures. Most research studies have cited occurrence of bladder injuries to be 1.0% to 1.8% in laparoscopically assisted vaginal hysterectomies and vaginal hysterectomies. Despite its frequency, there is limited research on best practices for bladder injury repair. The authors performed a literature search through the PubMed database using the terms "bladder anatomy," "bladder injury," "bladder repair," "cystotomy," "routine cystoscopy," and "vesicovaginal fistula." This review uses gynecologic and trauma literature and discusses prevention, recognition, types of iatrogenic bladder injuries, their clinical significance, current guidelines on bladder injury repair, and the expected follow-up care, and concludes by identifying areas for further research.

Endometriosis in adolescents.

BACKGROUND AND OBJECTIVES: Women with endometriosis often report onset of symptoms during adolescence; however, the diagnosis of endometriosis is often delayed. The aim of this study was to describe the experience of adolescents who underwent laparoscopy for pelvic pain and were diagnosed with endometriosis: specifically, the symptoms, time from onset of symptoms to correct diagnosis, number and type of medical professionals seen, diagnosis, treatment, and postoperative outcomes. METHODS: We reviewed a series of 25 females ≤21 years of age with endometriosis diagnosed during laparoscopy for pelvic pain over an 8-year period. These patients were followed up for 1 year after surgery. RESULTS: The mean age at the time of surgery was 17.2 (2.4) years (range, 10-21). The most common complaints were dysmenorrhea (64%), menorrhagia (44%), abnormal/irregular uterine bleeding (60%), ≥1 gastrointestinal symptoms (56%), and ≥1 genitourinary symptoms (52%). The mean time from the onset of symptoms until diagnosis was 22.8 (31.0) months (range, 1-132). The median number of physicians who evaluated their pain was 3 (2.3) (range, 1-12). The adolescents had stage I (68%), stage II (20%), and stage III (12%) disease. Atypical endometriosis lesions were most commonly observed during laparoscopy. At 1 year, 64% reported resolved pain, 16% improved pain, 12% continued pain, and 8% recurrent pain. CONCLUSIONS: Timely referral to a gynecologist experienced with laparoscopic diagnosis and treatment of endometriosis is critical to expedite care for adolescents with pelvic pain. Once the disease is diagnosed and treated, these patients have favorable outcomes with hormonal and nonhormonal therapy.

Is there a high incidence of hysterectomy and other nonbladder surgeries before and after onset of interstitial cystitis/bladder pain syndrome?

OBJECTIVE: The objective of the study was to compare with controls the incidence of nonbladder pelvic surgeries in the months before and after the onset of interstitial cystitis/bladder pain syndrome (IC/BPS). STUDY DESIGN: The design of the study used an existing database from a retrospective case-control study of 312 incident IC/BPS cases and matched controls plus a longitudinal study of the cases that examined lifetime approximated annual incidence of surgeries with that in the months before and after the onset of IC/BPS. RESULTS: In cases, in the month before the onset of IC/BPS, the approximated annual incidence of nonbladder pelvic surgeries was 15 times higher and of hysterectomy 25 times higher than the incidences of previous years and similarly higher than controls. This rate declined to preindex levels over the first 2 years of IC/BPS. CONCLUSION: There may be a very high incidence of nonbladder surgeries just before IC/BPS onset that decreases to historical levels over the first years of the syndrome.