Iatrogenic injury to the urinary tract is uncommon (0.1–4%) [1, 2]; however, as urologists, we will occasionally encounter emergency referrals from our surgical colleagues (obstetricians, gynaecologists and general surgeons) requesting assistance when a bladder and/or ureteric injury inadvertently occurs. The most common settings for injuries to the ureter and/or bladder are during radical hysterectomy, complicated caesarean section  and difficult colorectal excisions .
Although numerous publications exist on the reconstructive techniques, little has been documented about the surgical mentality and approach that may be used to assist the patient, our colleagues and ourselves in such situations. These scenarios are stressful and complex both for the referring team as well as for the attending urologist as they are uncommon, may occur out of working hours and require urgent assessment and management, and not infrequently lead to litigation .
With multisite working becoming increasingly common, the theatre environment where the referring surgeon is operating may be unfamiliar, the available equipment limited and staff not accustomed to urological operating techniques and practices. Based on several recent cases referred from different sites covered by our NHS trust, we suggest a possible approach to adopt when the telephone call is received from a surgical colleague that urgent urological assistance is required.
The information deduced over the telephone is very important in assessing what potential injuries may be encountered and the possible surgical treatment options available. Before embarking on the transport between sites or coming in from home, specific preparation by the on-site theatre staff and surgeon may help control emotions, enhance teamwork and overcome frustration in an unfamiliar environment. Attempt to get as much equipment prepared before you arrive to streamline the intervention.
One approach we suggest in assessing the scenario, planning the procedure and the potential definitive management options is the ‘five Ps’: Patient, Position, Personnel, Planning and Procedure (Table 1).Once at the referring operating theatre, although the patient is the priority, an introduction to the operating team in a calm friendly and reassuring manner can help diffuse the stress that is often present. A helpful, composed and uncritical demeanour will assist you in assessing the patient, the injury and obtaining the necessary help that will be required. However, it is important to take control of the situation and indicate that you are now in charge of the situation. Usually this happens naturally by enthusiastically starting the process of assessing and reconstructing the injury.
|Patient||Who is the patient in terms of: sex, co-morbidity, body mass index, epidural/spinal/general anaesthetic? Cross match sent? Is there a urethral catheter?|
|Position||What position is the patient in? Laparoscopic operation? Is that patient on an X-ray compatible table? What does the referring surgeon think is injured?|
|Personnel||Who is around and what seniority? Has the consultant been informed, if not present? Are the theatre staff familiar with cystoscopy, stack systems and urological stenting? Is there a radiographer with an image intensifier available?|
|Planning||Is an open repair necessary or could it be done laparoscopically? Is there laparotomy instrument set available? Are the relevant sutures available? Will the patient need to be transferred to an X-ray table. Is there sufficient equipment to perform a safe retrograde and stenting? Are X-ray gowns available?|
|Procedure||Depends largely on the procedure attempted. Ureteric repair or re-implantation: guidewires, stents and contrast. If checking bladder or bilateral ureteric integrity, consider checking: the stack system is working, cystoscope, guidewires, ureteric catheter, contrast and two JJ stents. Make detailed legible medical notes. Leave contact details with clear postoperative plan.|
Identifying the team members present in theatre (especially theatre sister) is not only professional but will help you get assistance in obtaining equipment, correct sutures and positioning. Taking another member of the urological team who is familiar with urological techniques with you can help assess the injury and provide assistance in the repair. It is far better not to have the guidewire pulled out inadvertently, after the time and effort required to insert it up to the renal pelvis.
The patient may well be awake and fully aware under epidural anaesthesia and indeed the partner may be present in the operating theatre with a recent addition to the family nearby. It is important to engage with the patient and partner to explain the issue briefly and how you intend to assess and repair any possible urinary tract injury. At all points it important not to attribute fault to anyone and if asked, state that complications occasionally happen and they can be remediated early.
Obstetric delivery suites often have limited surgical equipment as they are designed for performing Caesarean sections and assisted deliveries. There will often not be major surgical sets, adequate retractors or even stack systems. Arranging with the theatre sister in charge in securing the equipment required is an early priority. If you know that you are likely to be covering a distant site with limited equipment, it may be good preparation to have emergency kit bag containing a range of stents, guidewires, ureteric catheters, suprapubic catheter insertion sets and S-curve disposable urethral dilators to cover most eventualities (Table 2). From time to time, it is worth checking on the expiry dates of any stored equipment and replacing any used items and ensuring all department members are aware of this resource.
If the patient is unstable and there is a ureteric injury, it is best to ensure the bladder is catheterised, large drains are in situ and consider tying off the damaged ureter in consideration for a postoperative nephrostomy placement and delayed re-exploration with reimplantation +/– Boari flap.
If the patient is stable, it is important to make an adequate assessment of the injury and ascertain that the rest of the urinary tract is intact. This may require cystoscopy and bilateral retrograde studies and ensuring a radiographer is present and the patient is on an X-ray lucent table will be an initial concern. It is often worth suggesting that the original team stand down for a period and have a break to diffuse tension and allow you to focus on the assessment and planning of the repair without them looking over your shoulder. It is important to ascertain the presence of two functioning kidneys and this can be confirmed by viewing previous CT/MRI/ultrasonography images. If there is any doubt, an on table IVU with 2 mL/kg of i.v. contrast with a single film taken at 10 min should give the necessary information.
Once the repair or reconstruction is completed, good documentation is paramount as such cases will more frequently be scrutinised by medico-legal teams. Documentation, clear contact details for the attending urologist and follow-up for any stents or drains and when they should be removed should be clearly communicated to the referring team. Remember these surgical teams are often not familiar with managing urinary stents and drains and precise labelling and clarification of the postoperative plans will minimise further problems. Every effort should be made to review the patient personally the next day and at least by telephone thereafter, if improving. Consider giving them your business card and always review them personally in your own urology clinic.
The careful clinical management of complications helps keep the patient's trust and confidence in the primary surgical team and is less likely to result in stressful litigation and ultimately enhance your surgical reputation. Ultimately how one manages these complicated situations makes a huge difference to the patient in difficulty.