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MRCOG Part 2, MRCOG II

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MRCOG 2 Past Questions Tutorial: GROUP 3: Sat 16/11 from 10:00 - Statistics. Sun 17/11 from 10:00 - Oncology 1. Group 2: Sat 16/11 from 19:00 - Contraception & STI. See DISCUSSIONS below for details.

 

 

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Forum >> ESSAY 255 - HYSTERECTOMY
ESSAY 255 - HYSTERECTOMY Posted by PAUL A.
Fri Jan 18, 2008 11:29 pm
A 40 year old woman is due to have a hysterectomy because of a large fibroid uterus. (a) What will you tell her about the potential consequences of hysterectomy on her urinary tract function? [8 marks] (b) How would you minimise the risk of urinary tract injury during hysterectomy in this woman? [6 marks]. (c) Outline your peri-operative interventions to minimise the risk of venous thrombo-embolism in this woman. [6 marks].
Posted by S M.
Sat Jan 19, 2008 02:02 am
I will tell her that having a hysterectomy will eliminate pressure on the bladder. And thus potentially improve pressure symtoms like frequency. However hysterectomy for a large fibroid is a complicated surgery and there is a risk of injury to bladder (1 in 200) and ureter (1 in 500) during surgery. If bladder injury takes place, it would be repaired intraoperatively but she would require indwelling bladder catheter for atleast 2 weeks. Ureteric injury might require stenting. The other complications following hysterectomy can be urinary tract infections, retention following removal of cathter, long term voiding difficulties due to injury to the nerve plexus supplying the bladder, development of a vaginal fistula and sometimes unmasking of detrusor instability ( not proven). Also there is a risk prolapse of vaginal vault prolapse later in life which can be associated with voiding problems.

Risk of urinary tract injury can be minimized by adequate pre operative prepration including IVU if ureteric pathology suspected,
preop catheterization, selecting the correct approach(vaginal/laparoscopic/ abdominal), ensuring adequate exposure, knowing the anatomy of lower urinary tract well, knowing the sites where the ureter is at the maximum risk of injury, mobilizing the bladder, delineating the ureter prior to operating on the pathology, avoiding blind clamping and judiciously using the diathermy. If any injury is suspected intraoperative administration of IV indigo carmine and cystoscopy can be performed. At all times a high index of suspicion should be maintained. If in doubt, Urological help should be sought.Trainnes should receive direct consultant supervision if they are performing the surgery.

Preop reduction of weight ,cessation of smoking, treatment of any concurrent ailment is impotant in prevention of thromboembolism. If there is a previous history of thrombosis or a family history of thrombophilia, heparin should be given 2hrs preoperatively. Patient should be informed about the benefits of TEDS, early mobilization and adequate hydration preoperatively. Also it must be ensured that post op thromboprophylaxis and adequate analgesia is prescribed. During surgery, the least invasive approach, which consumes the shortest time and results in the smallest amont of blood loss should be used. Flutons should be used during surgery.
Posted by Sahathevan S.
Sat Jan 19, 2008 06:08 am
(a) What will you tell her about the potential consequences of hysterectomy on her urinary tract function? [8 marks]
I will tell the patient removal of pelvic mass (fibroid) potentially relieve the pressure symptoms (eg: frequency of micturition). Postoperative urinary tract infection (UTI) is common and it is related to catheterisation and stasis of the urine. Short-term Voiding difficulties and Urinary retention could be the complications after surgery. This could be to related to post operative pain, immobility, excess intravenous fluid and also current medication (drugs). Ureteric damage occurs in 1:500 cases for benign disease and 1:100 in malignancy. This damage can occur as immediate (cutting, ligating) or late (avascular necrosis) complication. Risk can be high in hysterectomy for fibroid uterus as anatomy distorted.Bladder injuries occur as a result of blunt or penetrating trauma during operation. This occurs in 1:200 cases, and is more common after a previous caesarian section. Genuine stress incontinence and detrusor instability are unlikely consequences and urological fistulae are rare complication of hysterectomy but needs appropriate management if diagnosed.Long term disorders are due to nerve plexus damage with an increase incidence in radical surgery and such complications are very rare after hysterectomy for fibroid (benign pathology).

(b) How would you minimise the risk of urinary tract injury during hysterectomy in this woman? [6 marks].
Surgeon should have had appropriate training in performing hysterectomy and managing complications or adequate supervision should be obtained. Bladder damage can be prevented by number of measures. Keeping the bladder empty during operation and careful dissection of tissues. If any difficulties are anticipated performing subtotal hysterectomy will cause less risk for baldder and ureter damage. Other strategies of prevention are Use of longer catheterisation with difficult dissection or presence of haematuria and recognition and repair of injuries occur.Ureteric injuries can be prevented by surgeon?s awareness of the risk of injury to the ureters throughout the entire pelvic dissection. Also it can be avoided by proper selection of cases and use of subtotal hysterectomy. If injury happens during operation, Urologist assistance should be required for repair surgery.

(c) Outline your peri-operative interventions to minimise the risk of venous thrombo-embolism in this woman. [6 marks].
Risk factors for venous thrombo embolism (VTE) should be identified according to unit protocol. high risk factors includes Family / personal History of VTE, thrombophilia, long term immobilisation / paralysis and three or more moderate risk factors. Moderate risk factors are Age > 40 years, Obesity, Gross varicose veins, Immobility prior to surgery, Current infection, Major current illness, use of COCP or HRT. If she is high risk for VTE management should liased with anaesthetist and haematologist as a multidisciplinary input .Thromborophylaxis should be considered with intermittent calf (Pneumo) compression during surgery, TEDS stocking and Administering of Pre-operative Low molecular weight heparin (LMWH) 2h pre-op in moderate risk patients or 12h pre-op in high risk patients reduce the risk of VTE. LMWH also has the benefit of reduce the risk of haemorrhage. This has to be continued until patient is fully mobile or discharge from hospital. Early mobilisation and maintaining good hydration is also important to prevent VTE. If patient has any clinical symptoms suggestive of VTE she should be investigated with Doppler studies /venograms and also lung perfusion scan should be arranged for definitive diagnosis. Appropriate treatment should be started while waiting for objective diagnosis to reduce the mortality and morbidity.



Posted by hoping ..
Sat Jan 19, 2008 04:53 pm
I will enquire if she has any associated current problems of urinary tract as surgery may releive some and worsen or unmask others.Symptoms like urgency and frequency if secondary to pressure of bulky uterus should be improved with surgery. However stress incontinence can be unmasked when removal of uterus unkinks the urethra or displaces bladder neck.Although stress incontinence is rare at her age , she may have predisposing factors. Urinary tract infection is commonest infection leading to postoperative pyrexia. Long term consequence can be early onset of menopause leading to urgency and dysuria like symptoms secondary to low estrogen.
Hysterectomy for large fibroid uterus carries comparitively higher risk of urinary tract injury which can involve bladder ( 1:200), ureters( 1:500).These if repaired properly should not lead to long term problems.
Urinary tract injury can be minimised by recognising the fact that she is at higher risk of injury and appropriate measures should be taken. Preoperative assesment of renal tract anatomy with IVP as distortion of ureters is likely . Renal function should be asssesed if signs of hydronephrosis present.Reasonable length of time should be allocated for surgery. Experienced surgeon and anaesthetist should be part of the team.Indwelling catheter reduces risk of bladder injury. Skin incision should provide adequate exposure. Ureters should be identified in entire lenght in pelvis before and after removing uterus. If total hysterectomy is performed uterine artery pedicle should be ligated as medial as possible. If total hysterectomy appears to significantly increase risk of bladder injury subtotal hysterectomy should be considered. If bladder injury is suspected methylene blue dye can be injected to rule out injury and can also be used to define bladder to aid in dissection.

Patient should be assesed for risk category of venous thromboembolism. Specific enquiry regarding any tthromboembolic event in her or first degree relatives should be made. Patient should be advised regarding smoking, weight according to her risk. If she is on combined pill with third generation progestogens they should be swapped for alternative measures if she is high risk.She should be advised to avoid immobility and long flights during perioperative periods. Keeping well hydrated and avoiding sitting or lying with crossed legs should be avoided as far as possible. Use of TEDS stockings and prophylactic heparin cover reduces VTE risk.
Posted by S D.
Sat Jan 19, 2008 08:10 pm
a) I would explain that the pressure symptoms on bladder such as frequency of urine will be relieved as well as voiding of urine will be complete. Also pressure on the ureters will be relieved and consequently the back-pressure on kidneys decreases resulting in better functioning of the kidneys. But the procedure also carries risks such as ureteric injury because of distorted anatomy due to large fibroid. So careful dissection is required and ureters should be identified before clamps applied at potential sites of injury. In the event of injury to ureters, urologist should be summoned and appropriate repair undertaken including stenting. There is also potential risk of injury to bladder of about 1 in 500 especially if the woman had previous caesarean sections when the bladder could be adherent to the uterus. In cases of bladder injury, senior help should be summonedand should be repaired in layers. This should be followed by testing of integrity of bladder by injection of methylene blue. If bladder is intact then catheter should be left in for atlkeast 7 days. There is also increased risk of urinary tract infection postoperatively because of catheterisation and also risk of retention of urine due to pain, immobility and also due to medications such as morphine which causes drowsiness. There can also be long term voiding difficulties due to damage to nerve plexus around the bladder.
b) Careful identification of ureters throughput its course either by administration of IV indigo carmine or by stenting will help minimise the risk of injury. Also the bladder should be carefully dissected and pushed down to avoid any injury.
c) Pre-operatively, I would advise weight loss if she is overweight, cessation of smoking, stabilisation of any medical disorders such as anaemia, HTN should be done. I would also give her GnRH analogues to shrink the fibroids to decrease blood loss during surgery and it would also be possible to do the hysterectomy vaginally which is the least invasive route. I would do a risk assessment for VTE. If she is low risk, then adequate hydration and mobilisation should suffice. If she is moderate risk (Obesity, Age >40 yrs, Prolonged immobility, Renal or heart disease, on COCP or HRT) then pre-op LMWH 2hrs preop followed by twice daily LMWH should be given. If she is high risk ( Personal H/O VTE, Family H/O Thrombophilia, 3 or more moderate risk factors), then liasion with senior anaesthetist and haematologist should be done and their advice should be documented in the notes. Intra-operatively adequate hydration should be maintained and flowtrons should be given. TED stockings, early mobilisation and hydration should be given.
Posted by M M A.
Sat Jan 19, 2008 09:38 pm
(a)We inquire from her first whether this large fibroid causing any pressure effect on bladder and if she has frequency , urgency or incontinence. We tell her that these symptom will be improved by removing the fibroid.

There is little evidence that hysterectomy by itself can cause stress incontinence or Detrosur over activity, however, the patient may have long term voiding dysfunction due to intervention with pelvic nerve plexus and there will be no difference between total or subtotal hysterectomy.

She may experience postoperative urine retention because of pain or anaesthetic drugs, we reassure her that she will be offered adequate analgesia but she may need short term catheterization.

She also may have symptoms like burning micturition and frequency as a result of urinary tract infection caused by the catheter.

There are other urinary symptoms that can occur like continuous dribbling of urine as a result of fistula formation or bloody urine as a result of urinary tract injury, but it is unwise to make the patient anxious, we inform her that incidence of such operative complication as very low.


(b) Primary prevention is by avoiding injury .We advise the patient to empty her bladder preoperatively also the bladder is drained by folly\'s catheters. Incidence of bladder injury is 1:200-300. We should take care while entering the abdominal cavity , we try to open parietal peritoneum superiorly to avoid injuring the bladder. We try to do appropriate reflection of the bladder downward to protect the ureters from injury while ligating uterine artery and dissecting transverse cervical ligament.
Also we should take care while dissecting infundibulo- pelvic ligament at pelvic brim and while doing oopherectomy as the ureter pass over the ovarian fossa , these sites are commonly associated with ureteric injury.

If the patient had adhesions or difficulties anticipated , we involve urological surgeon.

Careful surgical technique with visualization of the course of ureter and avoiding blind dissection will help minimize injury. Also taking care while using diathermy. Risk of ureteric injury is 1:500.

Secondary and tertiary prevention is by intraoperative recognition of injury and repair to minimize morbidity and sequelae.


(c) We try to detect risk factors for developing thromboembolism and try to adjust them, if the patient is obese , we advise her to loss weight before operation. If she is using combined contraceptive pill, we advice to use another method of contraception. Also we try to treat intercurrent infections and optimizing any co-morbidities if present.

We advise the woman to avoid prolong immobility, pre- and postoperatively. If she is t moderate to high risk of developing VTE we advise for prophylactic dose of LMWH , 2 hours preoperatively and to continue postoperatively for 3-5 days or the patient is fully mobile.

We should ensure adequate hydration and encourage the use of TED stockings and intermittent calf compression to minimize risk of thromboembolism.
Posted by Azza S.
Sat Jan 19, 2008 10:09 pm
I will tell her that urinary pressure symptoms such as frequency and nocturnal are likely to improve after operation The operation is not associated with increased risk of urinary dysfunction However there is increased risk of urinary tract infection which can be reduced by the use of prophylactic antibiotic. There is risk of injury to the bladder in 3 out of 1000 operations and this will be minimized by the insertion of a Foley\'s catheter pre- operative. There is also a risk of uretric injury in 2 out of 1000 operations . If any injury identified it will treated in appropriate way with the help of urologist if required. The Foleys will be removed in 24 hours, but in case of injury it may be left for longer time and indwelling catheter may be needed as well in that case.
Prophylactic anti- biotic may reduce the risk of urinary tract, it can be advised for longer use until the catheter is removed. Foleys catheter inserted just before the procedure may minimized the risk of injury to the bladder on entry particularly if the fibroid uterus have displaced the bladder high. The anatomy may be distorted by the presence of the fibroids and meticulous care to identify the ureters especially at infundiopelvic ligaments and at sites of clamping the uterine arteries. A sub-total hysterectomy may minimize risk of injury to the ureters at the vaginal vault. Identification of injury and prompt repair with help of a urologist to minimize further damage
Pre-operative assessment of risk for venous-thromboembolism [ VTE] an a plan for prophylaxis should be discussed with the woman and documented in the records. General health advise such as to stop smoking, to reduce her weight will decrease the risk of VTE. If she is on combined contraceptive pill she can be advice to change to another birth control method to reduce the risk of VTE. If she has high risk of VTE 2 hours before operation a low molecular weight heparin should be given.
Intra- operative, to shorten the procedure and to minimize the intra- operative bleeding. Avoid calf muscle pressure.
Post- operative ensure adequate hydration and analgesia. Give second does heparin at 12 hours after procedure and continue for 5 days. Advise graduated stocking. Advice early mobilization. On discharge advise to report symptoms of VTE if developed.
Posted by Lekshmi B.
Sat Jan 19, 2008 11:19 pm
a) I will tell her that hysterectomy for benign tumors like fibroid does not produce adverse effects on urinary tract function in the majority of women undergoing surgery. But there is a risk of bladder injury in 0.3 % cases. This risk is even more if she has history of previous abdominal or pelvic surgeries because of the increased risk of adhesions. There is also a risk of ureteric injury if the anatomy is distorted severely by the fibroid as in a broad ligament or large cervical fibroid. In those women with chronic retention of urine due to pressure by fibroid, the bladder will be hypertrophic and it is likely that voiding difficulty may persist in post operative period requiring catherisation. Even in others, post operative bladder catheterization for 24 hrs may be required taking into account the difficulties in mobilisation. Risk of urinary tract infection is high in the post operative period. In the long term there is also a risk of vault prolapse and associated cystocele with resultant voiding problems.
b) I would cathetrise the bladder preoperatively to empty it and maintain CBD in order to reduce the chance of injury during surgery. If there is previous history abdominal surgery, peritoneum will be opened as high as possible after identifying a thin area, to avoid injury to an adherent pulled up bladder. In case of a large broad ligament fibroid, I would locate the path of ureter by intravenous urogram with the help of a urologist and place a stent in the ureter to facilitate easy identification per operatively. Intra capsular dissection will be carried out to minimize injury to ureter. Adequate mobilisatrion of bladder by sharp and blunt dissection prior to clamping parametrium will be done to displace ureters down . In case of large cervical fibroids, hemi section of uterus will be done and the fibroid enucleated prior to applying clamps to minimize risk of ureteric injury.
c) I will advise her to reduce her weight if her BMI is more than 30 and to quit smoking prior to surgery. If she is on COCP for contraception I will ask her to stop it and postpone her surgery for four weeks. I will make an assessment of her risk factors for thromboembolism based on the proforma. Age of 40 and major surgery lasting for more than 30 minutes, puts her in a moderate risk category. If there are additional risk factors she will be in a high risk category and hence will be started on LMWH prophylaxis 12 hrs before surgery with use of graduated elastic compression stockings and continuation of prophylaxis for 3 to 5 days post operatively. If moderate risk LMWH will be started 2 hrs prior to surgery and continued for 3 to 5 days postoperatively. I will also allow early ambulation in post operative period and ensure measures to prevent dehydration which is a risk factor for VTE.
Posted by Anna A.
Sun Jan 20, 2008 10:58 am
a. Hysterectomy in the presence of large uterine fibroid is associated with distortion of pelvic anatomy; therefore she should be made to understand that she is at higher risk of having ureteric injury. Her lower urinary tract symptoms like difficulty of passing urine or pressure symptom will be improved after the surgery. There is also increased change of urinary tract infection as the patient will require insertion of urinary catheter. Her risk of bladder injury is also high due to huge fibroid. She might suffer short term voiding difficulty due to pain, excess intravenous fluid or immobilized after surgery but long term voiding difficulty due to hypotonic bladder is unlikely to occur as simple hysterectomy does not involve massive dissection of bladder. This patient is not at increased risk to develop GSI (Genuine Stress Incontinence) or Detrusitor instability as the pudendal nerve and the pelvic floor is intact. Formation of urinary fistula is serious complication of surgery but seldom occur for simple hysterectomy. Written information, further follow up and contact detail should be provided.

b. Large uterine fibroid is associated with distortion of urinary tract anatomy therefore preoperative IVU is prudent to asses the course of urinary tract system and the presence of hydronephrosis. Early referral and involvement of urologist is essential steps to reduce risk of urinary tract injury in anticipating difficulty to locate the course of ureter. Appropriate operative approach with adequate surgical exposure is essential to enable proper assessment of pelvic anatomy. Avoid blind clamping of blood vessel will prevent inadvertent clamping of ureter. Dissection of ureter and direct visualization of ureter before clamping any tissue or blood vessel is good practice. Proper dissection and mobilized the bladder away from surgical field will protect the bladder from accidental injury. Short diathermy application will help to avoid avascular injury to urinary tract system.

c. VTE (venus thrombo-embolism) risk assessment should be done before surgery. Personal or family history of VTE, thromboifillia, and 3 or more moderate risk factor is classified as having high risk of VTE. Referral to hematologist and anesthetist should be arranged earlier if the patient has high risk factor to develop VTE especially those patients with anti-trombin III deficiency. Weight reduction, stop smoking and treatment of chronic diseases should be ensured. OCP should be stop earlier before major gynecological surgery. Administration of heparin 2 hours before surgery and 12 hourly after surgery is prudent but if the patient has higher risk to develop VTE then heparin should be given 12 hours before surgery and then 8 hourly. Low molecular weight heparin (LMWH) has less risk of bleeding and easy daily dose of injection. Maintain of good hydration during the surgery and post operation should be acertained. Encourage early immobilization and ensure the heparin or LMWH is given until the patient is fully ambulating. TED stoking and intermitten pneumatic calf during surgery would help to reduce risk of VTE.
Posted by Dr seema jain J.
Sun Jan 20, 2008 09:31 pm
a)A large fibroid can impinge on the bladder and cause frequency of micturition and feeling of incomplete emptying of bladder.Both these complaints are likely to be relieved following surgery.Incidence of recurrent urinary tract infections because of incomplete emptying of bladder will be reduced after surgery.Any effect on the kidney following back pressure changes is likely to be resolved if there has been no permanent damage already caused.Genuine stress incontinence can be unmasked sometimes after surgery and should not be considered as a complication of surgery.
This surgery is a high risk for urinary tract injury because of anatomic distortion of the ureter and\\or bladder.Prolonged catheterization in event of an injury may be required which in turn may lead to urinary tract infection.In some cases suprapubic catheterization may be required. Urinary retention is one of the commonest post operative occurrences.An unrecognized injury leading to fistula may present as continuous leakage of urine .In rare cases complete loss of renal function may occur.

b)Though this is a high risk case for urinary tract injury,following some basic principles of surgery can minimize the risk.Preop catheterization to empty the bladder and an adequate incision for thorough exposure are essential.Care should be taken while opening the parietal peritoneum because the bladder may be advanced-peritoneum should be opened under vision.Bladder should be retracted down adequately by blunt dissection or by sharp dissection in case of previous surgery.All the bleeding points shou ld be ligated \\cauterised under vision and any attempt towards blind clamping should be avoided.Intrafascial technique can reduce the risk of injury.Identifying the ureter by dissecting it throughout its path before clamping the pedicles or ureteric stenting can be helpful especially in case of a broad ligament fibroid.Hemisection of the uterus should be done in case of a cervical fibroid before oroceeding with hysterectomy. The changed anatomy of the bladder\\ureter as seen on IVP plates should be kept in mind. I

c)Preoperatively I will inquire whether she has a personal or family history of venous thromboembolism and screen her for hereditary thrombophiliasA accordingly.Identification of other risk factors like obesity,smoking ,oral contraceptive hypertension will be looked out for and properly managed.She will be asked to quit smoking,stop COC a month prior and lose weight in case of obesity.Preop ambulation and hydration will be encouraged.Postoperatively apart from proper hydration,early hydration and use of graduated elastic compression stockings should be done.If required prophylactic or therapeutic use of subcutaneous LMWH can be considered after deciding on her grade of risk for VTE.Infection or anemia if any should be promptly treated.
Posted by Dr seema jain J.
Sun Jan 20, 2008 09:33 pm
a)A large fibroid can impinge on the bladder and cause frequency of micturition and feeling of incomplete emptying of bladder.Both these complaints are likely to be relieved following surgery.Incidence of recurrent urinary tract infections because of incomplete emptying of bladder will be reduced after surgery.Any effect on the kidney following back pressure changes is likely to be resolved if there has been no permanent damage already caused.Genuine stress incontinence can be unmasked sometimes after surgery and should not be considered as a complication of surgery.
This surgery is a high risk for urinary tract injury because of anatomic distortion of the ureter and\\or bladder.Prolonged catheterization in event of an injury may be required which in turn may lead to urinary tract infection.In some cases suprapubic catheterization may be required. Urinary retention is one of the commonest post operative occurrences.An unrecognized injury leading to fistula may present as continuous leakage of urine .In rare cases complete loss of renal function may occur.

b)Though this is a high risk case for urinary tract injury,following some basic principles of surgery can minimize the risk.Preop catheterization to empty the bladder and an adequate incision for thorough exposure are essential.Care should be taken while opening the parietal peritoneum because the bladder may be advanced-peritoneum should be opened under vision.Bladder should be retracted down adequately by blunt dissection or by sharp dissection in case of previous surgery.All the bleeding points shou ld be ligated \\cauterised under vision and any attempt towards blind clamping should be avoided.Intrafascial technique can reduce the risk of injury.Identifying the ureter by dissecting it throughout its path before clamping the pedicles or ureteric stenting can be helpful especially in case of a broad ligament fibroid.Hemisection of the uterus should be done in case of a cervical fibroid before oroceeding with hysterectomy. The changed anatomy of the bladder\\ureter as seen on IVP plates should be kept in mind. I

c)Preoperatively I will inquire whether she has a personal or family history of venous thromboembolism and screen her for hereditary thrombophiliasA accordingly.Identification of other risk factors like obesity,smoking ,oral contraceptive hypertension will be looked out for and properly managed.She will be asked to quit smoking,stop COC a month prior and lose weight in case of obesity.Preop ambulation and hydration will be encouraged.Postoperatively apart from proper hydration,early hydration and use of graduated elastic compression stockings should be done.If required prophylactic or therapeutic use of subcutaneous LMWH can be considered after deciding on her grade of risk for VTE.Infection or anemia if any should be promptly treated.
Posted by Idris O.
Sun Jan 20, 2008 11:10 pm
a)I would inform her that removal of a pelvic mass may reduce lower urinary tract symptoms if present. Minor postoperative symptoms are common and transient. The potential consequences of surgery on the urinary tract include UTI from catheterization and stasis of urine. There is the risk of voiding disorder which may be due to pain or denervation during dissection and this may present as urinary retention. Other short term risk include damage to the ureter and this may cause uretero-vaginal fistula. There may also be damage to the bladder leading to vesico-vaginal fistula. Long term risk include stress and urgency incontinence.There may also be prolapse of the anterior vaginal wall leading to a cystocele.This usually presents as a lump in the vagina or a feeling of incomplete emptying. I would document this discussion and also offer her information leaflet on hysterectomy.
b)Pre-operatively, I would arrange for an IVU to delineate the course of the ureter. This is because the anatomy may be distorted by a big fibroid or if there are pelvic adhesions. Intra-operatively, I would empty her bladder to ensure not in the way of the operation. Surgery should be performed by an adequately trained person or under supervision. A subtotal hysterectomy is associated with lower risk of injury to the urinary tract.Adequate knowledge of anatomy and dissection along tissue planes. Clamps should be placed under good vision and close to the uterus. The bladder should be reflected downwards from the operating field before clamps are placed over the uterine pedicle. The course of the ureter could also be identified at the utero cervical junction before clamps are applied. Avoid blind ligature or diathermy. Suspected injury can be confirmed with indigo carmine for ureteric injury or instillation of methylene blue into the bladder if suspect bladder injury. If injury occurs, repair should be undertaken with the help of urologist.Postoperatively, catheter drainage may be required for 5-7days if suspect bladder injury and IVU and advice of the urologist if ureteric injury.
c)This woman is at moderate to high risk for TE. This is because age > 35 and pelvic surgery likely to last > 30minutes. Additional risk factors to ask for would be BMI> 30 or presence of underlying medical problems like Inflammatory bowel disease, nephrotic syndrome or recent MI.Hx of thromboembolism or a family history would also be important. Pre-operatively, her risk of thrombo-embolism should be assessed in conjunction with an haematologist and appropriate thrombo-prophylaxis planned. If on Warfarin, this should be changed to heparin before surgery.There is the need to correct anaemia and dehydration before surgery. Counsel and offer LMWH 3h before surgery. Surgery should be undertaken with the use of pneumatic compression stockings. Meticulous haemostasis during surgery . Avoid subcutaneous haematoma and use non absorbable sutures for skin closure in an interrupted fashion if obese patient.
Post-operatively, LMWH should be offered for 3-5d after the surgery until fully mobilised. She should be given TEDS. Encourage early mobilization and good hydration.

Posted by PAUL A.
Mon Jan 21, 2008 03:35 am
I will tell her that having a hysterectomy will eliminate pressure on the bladder. And thus potentially improve pressure symtoms like frequency (1) . However hysterectomy for a large fibroid is a complicated surgery and there is a risk of injury to bladder (1 in 200) (1) and ureter (1 in 500) (1) during surgery. If bladder injury takes place, it would be repaired intraoperatively but she would require indwelling bladder catheter for atleast 2 weeks thermal injury might not present till later . Ureteric injury might require stenting. The other complications following hysterectomy can be urinary tract infections, retention following removal of cathter, long term voiding difficulties due to injury to the nerve plexus supplying the bladder, development of a vaginal fistula and sometimes unmasking of detrusor instability ( not proven) (1) DO NOT WRITE A LIST ? this is a post-graduate exam. Why will you tell the woman about a risk which is ?unproven???. Also there is a risk prolapse of vaginal vault prolapse later in life which can be associated with voiding problems.

Risk of urinary tract injury can be minimized by adequate pre operative prepration including IVU if ureteric pathology suspected,
preop catheterization, selecting the correct approach(vaginal/laparoscopic/ abdominal), ensuring adequate exposure, knowing the anatomy of lower urinary tract well, knowing the sites where the ureter is at the maximum risk of injury, mobilizing the bladder, delineating the ureter prior to operating on the pathology, avoiding blind clamping and judiciously using the diathermy
this is all one sentence ? you have simply written a list . If any injury is suspected intraoperative administration of IV indigo carmine and cystoscopy can be performed. At all times a high index of suspicion should be maintained. If in doubt, Urological help should be sought (1) . Trainnes should receive direct consultant supervision if they are performing the surgery should trainees always be directly supervised? .

Preop reduction of weight ,cessation of smoking, treatment of any concurrent ailment is impotant in prevention of thromboembolism Peri-operative means around the time of the operation the woman is unlikely to lose weight over this period? . If there is a previous history of thrombosis this makes her high HIGH risk and she should be treated 12h pre-op or a family history of thrombophilia, heparin should be given 2hrs preoperatively. Patient should be informed about the benefits of TEDS, early mobilization and adequate hydration (1) preoperatively. Also it must be ensured that post op thromboprophylaxis for how long? and adequate analgesia is prescribed. During surgery, the least invasive approach, which consumes the shortest time and results in the smallest amont of blood loss should be used what do you think is the most appropriate approach in this situation? Large fibroid uterus ? will you do it vaginally? . Flutons should be used during surgery.

You need a more detailed answer focused on the facts presented in the question
Posted by PAUL A.
Mon Jan 21, 2008 03:48 am

(a) What will you tell her about the potential consequences of hysterectomy on her urinary tract function? [8 marks]
I will tell the patient removal of pelvic mass (fibroid) potentially relieve the pressure symptoms (1) (eg: frequency of micturition). Postoperative urinary tract infection (UTI) (1) is common and it is related to catheterisation and stasis of the urine. Short-term Voiding difficulties and Urinary retention could be the complications after surgery. This could be to related to post operative pain, immobility, excess intravenous fluid and also current medication (drugs) (1) . Ureteric damage occurs in 1:500 cases for benign disease and 1:100 in malignancy has she got a malignancy? Why are you telling her about this? She may assume you think she has cancer . This damage can occur as immediate (cutting, ligating) or late (avascular necrosis) complication. Risk can be high in hysterectomy for fibroid uterus as anatomy distorted.Bladder injuries occur as a result of blunt or penetrating trauma during operation. This occurs in 1:200 cases (1) , and is more common after a previous caesarian section. Genuine stress incontinence and detrusor instability are unlikely consequences does hysterectomy cause these? and urological fistulae are rare complication of hysterectomy but needs appropriate management if diagnosed.Long term disorders are due to nerve plexus damage with an increase incidence in radical surgery Why are you telling her about this? Is she having radical surgery? (-1) and such complications are very rare after hysterectomy for fibroid (benign pathology).

(b) How would you minimise the risk of urinary tract injury during hysterectomy in this woman? [6 marks].
Surgeon should have had appropriate training in performing hysterectomy and managing complications or adequate supervision should be obtained. Bladder damage can be prevented by number of measures. Keeping the bladder empty during operation (1) and careful dissection of tissues. If any difficulties are anticipated performing subtotal hysterectomy (1) will cause less risk for baldder and ureter damage. Other strategies of prevention are Use of longer catheterisation with difficult dissection or presence of haematuria and recognition and repair of injuries occur.Ureteric injuries can be prevented by surgeon?s awareness of the risk of injury to the ureters throughout the entire pelvic dissection (1) . Also it can be avoided by proper selection of cases and use of subtotal hysterectomy. If injury happens during operation, Urologist assistance (1) should be required for repair surgery.

(c) Outline your peri-operative interventions to minimise the risk of venous thrombo-embolism in this woman. [6 marks].
Risk factors for venous thrombo embolism (VTE) should be identified according to unit protocol (1) . high risk factors includes Family / personal History of VTE, thrombophilia, long term immobilisation / paralysis and three or more moderate risk factors. Moderate risk factors are Age > 40 years, Obesity, Gross varicose veins, Immobility prior to surgery, Current infection, Major current illness, use of COCP or HRT. If she is high risk for VTE management should liased with anaesthetist and haematologist as a multidisciplinary input NO. Will you call a haematologist if you are doing a TAH on a 45 year old with a BMI of 38? She has 3 mod. risk factors = high risk .Thromborophylaxis should be considered with intermittent calf (Pneumo) compression during surgery, TEDS stocking (1) and Administering of Pre-operative Low molecular weight heparin (LMWH) 2h pre-op in moderate risk patients or 12h pre-op in high risk patients reduce the risk of VTE (1) . LMWH also has the benefit of reduce the risk of haemorrhage How can heparin possibly reduce the risk of haemorrhage? (-1) . This has to be continued until patient is fully mobile or discharge from hospital. Early mobilisation and maintaining good hydration is also important to prevent VTE (1) . If patient has any clinical symptoms suggestive of VTE she should be investigated with Doppler studies /venograms and also lung perfusion scan should be arranged for definitive diagnosis. Appropriate treatment should be started while waiting for objective diagnosis to reduce the mortality and morbidity.
Posted by PAUL A.
Mon Jan 21, 2008 04:00 am
I will enquire TELL HER, not ask her if she has any associated current problems of urinary tract as surgery may releive some and worsen or unmask others.Symptoms like urgency and frequency if secondary to pressure of bulky uterus should be improved with surgery (1) . However stress incontinence can be unmasked when removal of uterus unkinks the urethra or displaces bladder neck there is no basis for this (-1) .Although stress incontinence is rare at her age , she may have predisposing factors. Urinary tract infection (1) is commonest infection leading to postoperative pyrexia. Long term consequence can be early onset of menopause leading to urgency and dysuria like symptoms secondary to low estrogen.
Hysterectomy for large fibroid uterus carries comparitively higher risk of urinary tract injury which can involve bladder ( 1:200) (1) , ureters( 1:500) (1) .These if repaired properly should not lead to long term problems.
Urinary tract injury can be minimised by recognising the fact that she is at higher risk of injury and appropriate measures should be taken. Preoperative assesment of renal tract anatomy with IVP as distortion of ureters is likely . Renal function should be asssesed if signs of hydronephrosis present.Reasonable length of time should be allocated for surgery. Experienced surgeon and anaesthetist should be part of the team.Indwelling catheter reduces risk of bladder injury (1) . Skin incision should provide adequate exposure. Ureters should be identified in entire lenght in pelvis before and after removing uterus (1) . If total hysterectomy is performed uterine artery pedicle should be ligated as medial as possible. If total hysterectomy appears to significantly increase risk of bladder injury subtotal hysterectomy (1) should be considered. If bladder injury is suspected methylene blue dye can be injected to rule out injury and can also be used to define bladder to aid in dissection.

Patient should be assesed for risk category of venous thromboembolism (1) . Specific enquiry regarding any tthromboembolic event in her or first degree relatives should be made. Patient should be advised regarding smoking, weight according to her risk ? meaning . If she is on combined pill with third generation progestogens they should be swapped for alternative measures if she is high risk will you only stop COCP if she is high risk or they contain third generation progestogens??? (-1) .She should be advised to avoid immobility and long flights during perioperative periods. Keeping well hydrated and avoiding sitting or lying with crossed legs should be avoided as far as possible no evidence that this makes any difference and you will be restricting her without good reason (-1) . Use of TEDS stockings (1) and prophylactic heparin cover reduces VTE risk more information required on timing and duration of heparin therapy .
Posted by PAUL A.
Mon Jan 21, 2008 04:11 am

a) I would explain that the pressure symptoms (1) on bladder such as frequency of urine will be relieved as well as voiding of urine will be complete. Also pressure on the ureters will be relieved and consequently the back-pressure on kidneys decreases resulting in better functioning of the kidneys. But the procedure also carries risks such as ureteric injury because of distorted anatomy due to large fibroid wht is the risk? . So careful dissection is required and ureters should be identified before clamps applied at potential sites of injury. In the event of injury to ureters, urologist should be summoned and appropriate repair undertaken including stenting you were not asked about how to prevent / manage injury . There is also potential risk of injury to bladder of about 1 in 500 1:200 especially if the woman had previous caesarean sections when the bladder could be adherent to the uterus. In cases of bladder injury, senior help should be summonedand should be repaired in layers. This should be followed by testing of integrity of bladder by injection of methylene blue. If bladder is intact then catheter should be left in for atlkeast 7 days not asked about this . There is also increased risk of urinary tract infection (1) postoperatively because of catheterisation and also risk of retention of urine due to pain, immobility and also due to medications (1) such as morphine which causes drowsiness. There can also be long term voiding difficulties due to damage to nerve plexus around the bladder.
b) Careful identification of ureters throughput its course (1) either by administration of IV indigo carmine or by stenting will help minimise the risk of injury. Also the bladder should be carefully dissected and pushed down to avoid any injury (1) .
c) Pre-operatively, I would advise weight loss if she is overweight, cessation of smoking, stabilisation of any medical disorders such as anaemia, HTN should be done You were asked about the PERI-operative period . I would also give her GnRH analogues to shrink the fibroids to decrease blood loss during surgery and it would also be possible to do the hysterectomy vaginally which is the least invasive route. I would do a risk assessment for VTE (1) . If she is low risk, then adequate hydration and mobilisation should suffice COULD SHE POSSIBLY BE LOW RISK? 40 year old undergoing major surgery?? (-1). You are telling the examiner you have not read the question . If she is moderate risk (Obesity, Age >40 yrs, Prolonged immobility, Renal or heart disease, on COCP or HRT) then pre-op LMWH 2hrs preop followed by twice daily LMWH should be given. If she is high risk ( Personal H/O VTE, Family H/O Thrombophilia, 3 or more moderate risk factors), then liasion with senior anaesthetist and haematologist this is for very high risk patients otherwise you will call a haematologist if you are doing a TAH on a 45 year old with a BMI of 38. Do you? should be done and their advice should be documented in the notes. Intra-operatively adequate hydration should be maintained and flowtrons should be given. TED stockings (1) , early mobilisation and hydration should be given (1) .
Posted by Reiaz M.
Mon Jan 21, 2008 05:47 am

A large fibroid uterus can exert pressure effects on the urinary bladder resulting in symtoms of urinary frequency and urgency. The patient can be couseled about a likely improvemnt in these symptoms if they are present.
Hemorrhage is a complication of hysterectomy. Severe hemorrhage can result in acute renal failure.
Distortion of anatomy by the fibroid uterus increases the risk of ureteric damage. She is told that if this occurs repair of the injury by a urologist will be undertaken. This will need post operative follow up by the urologist.
Injusy to the bladder will necessitate placement of a urinary catheter to be kept in situ for 10-14 days. Intermittent self catheterisation may also be necessary.
Placement of a urinary catheter increases her risk of urinary tract infection.
There is a small risk of development of a urinary fistula which can result in continuos leakage of urine vaginally.
Hysterectomy does not increase her risk of urinary incontinence or detrusor instability.

b)
The urinary bladder should be catheterised preoperatively. The catheter line should be placed below the patients popliteal fossa to avoid obstruction of urinary flow.
Placement of a ureteral stent preoperatively can help in identification of the ureters at the time of surgery.
The hysterectomy should be performed by a gynecologist skilled in surgery for large pelvic masses and there should be a low threshold to seek the assistance of the urologist.
A retroperitoneal approach to the hysterectomy is advised as this allows identification of the ureter. This decreases the risk of inadvertent ureteric injury.
The urinary bladder should be well retracted throughout the procedure to diminsh the risk of bladder injury.
If trauma to the urinary tract is suspected cystoscopy can be performed to investigate and if necessary corrective measures are implicated.

c) Preoperatively the patient should be counseled to stop smoking. If she is using the combined oral contraceptive pill this should be discontinued three months prior to surgery and a non oestrogen containing form of contraception prescribed in the interim. Weight loss should be encouraged if time permits.
She should be started on low molecular weight heaparin 12 hours prior to the procedure. During the procedure she should be kept well hydrated.Pressure on the lower limbs should be avoided.
Post operatively the LMWH is continued for 5 days post operatively. Dehydration should be avoided by use of appropriate IV fluids. Early ambulation assisted by a physiotherapist is essential. Intermittent pneumatic compression devices are of unproven value. TED stockings can be worn prophylactically to decrease the incidence of VTE.
Posted by Shankaralingaia N.
Mon Jan 21, 2008 07:24 am
a)Hysterectomy is a major surgery with lot of complications associated with it.Technically access can be a problem when operating on a large fibroid uterus.It can be beneficial in terms of reducing bladder retension due to compression if any.
When consenting women for hysterectomy we should explain about 0.7% risk of damage to the bladder and ureters.Urinary tract complications could be immediate or late onset.
During the surgery there could be tear in the bladder.Once recognised it needs suturing and leaving a catheter in for 10 days.
There could be damage to the ureters because of distorted anatomy due to fibroids.If recognised at the time of operation urologist are involved to perform the surgery.Sometimes if not identified during surgery they present with abdominal pain and electrolyte imbalance in the post operative period.
There would be common complications in terms of urinary tract infections in the post operative perios due to cathetarisation.This needs treating with antibiotics.
Hysterectomy can have implications on bladder function in long term due to detrusor instability causing increased frequency,urgency,urge incontinence and sometimes double micturition.If they have any symptoms previously it can get worse due to the surgery and also may require intermittent self cathetarisation
Rarely it can cause vesico vaginal fistula with constant watery vaginal discharge in the post operative period can be diagnosed.
Rarely due to blood loss and ureteric damage they could have renal failure requiring renal physician involvement for further management.
Information leaflets are given and informed consent is obtained prior to the surgery.

b)First of all cathetarising the bladder would reduce the damage.At the time of the surgery rmobilising the bladder,less handling of the tissue and identifying the ureters before putting any clamps on would reduce the damage.Appropriate training and competency is essential in performing the procedure to minimise the risk.Sometimes doing a subtotal hysterectomy in a large fibroid uterus and with deep pelvis might avoid damage to the ureter.With distorted anatomy there is a scope for preoperative stenting to prevent damage to the ureters.
Propylactic antibiotics during surgery and early removal of catheter would reduce the chance of urinary tract infection.Psychological support.pelvic floor exercise and bladder training post operatively would reduce symptoms of urgency and urge incontinence.

c)In the pre operative clinic a risk assessment for venous thromboembolism is made and documented in the notes.Life style changes in terms of reducing weight and reduce smoking has to be discussed.If she is on clexane/heparin then she should continue and last dose should be administered 2 hours before the procedure.If on warfarin it has to be changed to heparin/clexane when she is admitted to the ward.
Ted stockings should be applied at the time of admission until discharge.Make sure she is well hydrated before ,during and after the surgery.
Early mobilisation would reduce the risk of thrombosis.Heparin/Clexane should be administered after 6 hours,dosage depending on the risk.If there is an excess of intra or post operative bleeding then liasing with the haematologist is essential before administering it.It is ideally given for 3-5 days in low and moderate risk cases.In high risk cases it is essential to give it for 6 weeks depending on the giuidelines.
Posted by Hala T.
Mon Jan 21, 2008 09:10 am
a)I would tell her about the potenitially beneficial urological consequences like relief of pressure symptoms ( frequency ) if uterine mass is removed . I would inform her that the long term voiding disorders like stress incontinence or detrusor instability are unlikely.
I would tell her about the possibility of urinary tract infections due to stasis of urine or catheterization .It is reduced by use of prophylactic antibiotics.
I would tell her about the risk of developing extra-problems (known as complication)may occur .I would inform her that fibroids growing in her womb may force the bladder up ,so that , it may be wounded when the anterior abdominal wall being opened .
The incidence of bladder injury in abdominal hysterectomy is 0.3%. Subsequent continuous bladder drainage may be needed by putting a tube in bladder outlet ,( urethra ),and maintained on free flow for 7-10 days.
I would tell her that short term voiding disorders as urinary retention is mainly due to due to pain, immobility and anaesthetic drugs. It could be prevented by short term catheterization.
I would tell her that the pelvic organs and structures are distorted by the large fibroid ,so that , the ureters may be damaged or cruched during the operation. It occurs in about
1: 500 cases for benign disease. In such case splints may be used with the assistance of urological colleague .
b) Intra-operative bladder catheterization reduces the risk of bladder injury and urinary retention. Careful dissection , use of sub-total hysterectomy . Choice of abdominal incision that provides adequate exposure. The bladder may be displaced from normal pelvic situation by the large fibroid, so ,the peritoneal cavity should be opened high up .
Ureteric injury to be minimized through appropriate operative approach , adequate exposure , and full examination of the fibroid uterus in the pelvis . Also, blind clamping of the blood vessels should be avoided , as it is the most common cause of ureteric injuiries. The ureters should be dissected sufficiently to allow their identification with adequate mobilization of bladder downward away from the operative site . So, the ureter moved away from the uterine vessels .
When direct visualization is not possible from the huge fibroid , the ureter can be identified above the pelvic brim and followed in to the pelvis. Also, short diathermy application reduce the risk of ureteric injury. Seeking early urological surgical assistance when appropriate.
c) The interventions would include pre-operative assessment of venous thromboemolism risk in this woman . I would look in this woman the moderate risk factors include age of 40 years , having major pelvic surgery and operation more likely to last more than 30 minutes. The high risk group include three or more moderate risk factors.
Pre-operative weight reduction , advice for life style modification is essential to stop smoking , alcohol and COCP if using it. Thrombophilia screen if she has personal or family history of VTE.
Low molecular heparin (LMWH) should be administered 2hrs ( if moderate risk ) or 12 hrs ( if high risk ) pre-operatively . It should be administered at site away from the proposed surgery and continued until 5 days or fully mobile.
The daily dosage of LMWH q 8-12 hrs depending on the risk of VTE. It is effective and has the advantage of reducing the risk of haemorrhage.
Intra-operative measures include avoiding prolonged operation , using meticulous haemostasis ,use of drains and interrupted sutures for skin.
Post-operatively, good hydration ,chest physiotherapy , early mobilization should be encouraged. Use of thromboembolic deterrent ( TED ) stockings would reduce the risk of VTE.
Posted by Farina A.
Mon Jan 21, 2008 08:21 pm
I would like to tell her about the routes of hysterectomy as different routes have slightly different incidences of the complications. In case TAH is selected for large fibroids, ureter is vulnerable to have avascular necrosis, ligation and transaction at its various parts. Timely recognition and reconstructive surgery involving the urologist can minimize the adverse outcome. In rare instances this injury goes unrecognized at the time of surgery but could be diagnose postoperatively. Serious injury to the urinary tract, however are less likely for this surgery. Injury to the bladder can occur during its reflection away from the uterus but is usually diagnosed and treated per operatively and again is less likely for this surgery. Inadvertent ureterovaginal or vesicovaginal fistula results in continuous dribbling of urine which is relatively uncommon in this surgery and the damage is reparable.
If the fibroid is the cause of pelvic organ prolapse the surgery can improve the symptoms. Similarly stagnant urine in a distorted bladder causes repeated UTI which may get improve after the surgery so the patient may feel an improvement in her urinary frequency, urgency and incontinence. However during reflection of bladder from the uterus may produce an unavoidable damage to the nerve plexus resulting in voiding difficulties. She should be told about the long term risk of vault prolapse however measures to prevent it are taken during the surgery.

Preop wt reduction advise, IVU for having an idea about the course of the ureter, cathetrasition , Appropriate exposure through the most appropriate skin incision, anatomical knowledge about the course of the ureter and its vulnerable sites should be well known by the surgeon. Care should be taken during clamping the infundibulo pelvic ligament at the lateral pelvic side wall, as the ureter may be about 0.9 cm away from the clamp. Identification of ureter with its usual relations may not be sufficient so its characteristics peristalsis and paler appearance should be kept in mind. To recognize the fact that ureter get its blood supply from its medial aspect in its upper 2/3 and from its lateral aspect in its lower 1/3, so the dissection should be from the direction vice versa. Care should be taken during dividing the broad ligaments as ureter lies in a tunnel beneath the lower medial part of the broad ligament. From the cervical internal os its distance is about 1.2 cm this relation should be kept in mind during dividing the broad ligament and if too much bleeding is encountered and the field is not clear subtotal hysterectomy can be considered.
Peroperative diagnosis of site and extent of injury by metheline blue dye test and IV indigocarmine test and earlier involvement of senior gynaecologist and urologist improves the outcome. Meticulous haemostasis, antibiotics prophylaxis, supervised training and expertise all together improves the outcome

History of any risk factor for thromboembolism like APS, thrombophillias, protein C and S deficiency, personal/family history of DVT, use of COCP, presence of medical diseases like HTN, cardiac valvuloplasty, sickle cell disease and obesity, sedentary life style pattern, occupations involving prolong immobilization or long haul traveling should be inquired. The patient should be categorized in a low, moderate, high risk for thromboembolism. Prophylactic LMW heparin can be given to low and moderate risk women 2 hrs preop and after 6 hrs postop upto 3 days. However high risk women may continue therapeutic dose of heparin 12 hrs postop and replacement with warfarin from 3rd postoperative day upto 6 weeks. Early mobilization, TED stockings and hydration are important in the early postoperative period.
Pre-op advice to stop smoking wt reduction, and treatment of intercurrent illnesses all are important in minimizing the risk of thromboembolism.
Posted by maha G.
Tue Jan 22, 2008 12:57 am
{a}
I would ask about secondary pressure symptoms and its secondary effect on the quality of her life which are likely to be improved after hysterectomy. Then, I would inform her that subtotal hysterectomy is associated with lower urinary morbidity. she is likely to have lower urinary tract infection due to catheterization and stasis of urine.
Also, intra-operatively she is liable to urinary tract injury especially with broad ligament fibroid. The incidence of bladder injury and ureteric injury in such cases are 1:200 and 1:500, respectively. However, the incidence of ureteric injury is only about 0.01% in vaginal hysterectomy. Other urinary tract symptoms are short-term voiding difficulties due to pain. Further, detrusor instability is likely to happen with any pelvic surgery especially with bladder dissection and consequent denervation. However, it is still controversial with hysterectomy and may be unlikely.
{b}
I would assess her risk if any history of previous surgery, large fibroid or broad ligament fibroid is more likely to be associated with distortion of anatomical features. In such case, I would involve senior help furthermore I would involve Urologist.
Preoperative intravenous pyelography will give idea about the anatomical features especially duplicate ureter which is present in 1% however it has no role in reducing urinary tract injury. Well knowledge and understanding of the anatomy is essential to avoid urinary tract injury. Indwelling Folly?s catheter would reduce the risk of bladder injury.
Also, gentle dissection of the bladder during hysterectomy is crucial. Ureteric stent intra-operative would not reduce the risk of ureteric injury however; it will help in its recognition as only one third can be detected intra-operatively. I would delineate and trace the ureter along its course and avoid of blind clamping of the pedicles. Exploration of the upper two thirds of the ureter should be from lateral side while exploration of the lower third should be from the medial side in such way, we avoid the injury of its blood supply.
{c}
I would assess her risk for venous thromboembolism (VTE) such as age, body mass index (BMI), personal and family history of VTE, medical co-morbidity, smoking habit, if on combined oral contraceptive (COCC) pills especially the ones containing third generation progetogens.
She already has 2 risk factors; her age and pelvic surgery for more than 30 minutes. In the presence of 3 or more risk factors she will be considered moderate risk for VTE.
I would advice her to reduce her weight if her BMI is >30k/m2, to stop smoking and combined COCC pills. Prophylactic low-molecular weight heparin 3 hours preoperatively should be given along with proper hydration and treatment of any concurrent infection.
Intra-operatively, proper hydration is essential, pneumatic stockings will be applied, avoidance of long operating time and excessive blood loss and meticulous hemostasis.
Post-operatively, I would advice her to wear TED stockings and early mobilization, proper hydration, and avoidance of excessive alcohol and caffeine. Prophylactic heparine is to be continued until discharge from hospital or mobilization.



Posted by Mahmud  K.
Tue Jan 22, 2008 06:21 am
(a).Infection of urine is a common postoperative problem which is transient and is related to catheterization and stasis of urine.It is reduced by prophylactic antibiotic. It is unlikely to represent long term problem.
Short term retention of urine occurs due to pain and immobility. Longer term are due to nerve plexus damage. .Ureteric injury occurs in about 1 in 500 cases for benign disease .Anatomical distortion by large fibroid specially broad ligament fibroids is a risk factor for ureteric injury. Immediate Injury may result from ligation with suture ,cutting or late ischemic. Bladder injury occurs in about 1 in 200 cases.Immediate injury occurs by sharp or blunt dissection and later by avascular injury. Incontinence both genuine and stress incontenence and detrusor instability are unlikely consequences since the pelvic floor and pudendal nerve remailn intact.

(b.)An adequate incision must be made for proper exposure of important pelvic structures. A sound knowledge of abdominal and pelvic anatomy is important.Palpated or inspected or tracing of ureter if at any doubt before clamping tissues.Adequate mobilization of the bladder during hysterectomy also reduce injury. Careful dissection, use of splint may reduce urinary tract injury. Avoidance of blind clamping for homeostasis may reduce injury. Recognition of urinary tract injury during operation is important. So that immediate repair can take place with help of urological colleagues. Judicious use of subtotal hysterectomy may reduce both ureter and bladder injury.

(c)she has no other risk factors for venous thromboembolism she need once daily low molecular weight heparin( LMWH )started immediately before surgery and used continuously whilst the patient is not ambulant.If she has additional VTE risk factor LMWH should be used until discharge and in case of very high risk thromboprophylaxis should be continued for 2-4 weeks after hospital discharge. Early mobilization and perioperative hydrartion is important. Use of TED stockings also may prevent VTE. Judicious use of subtotal hysterectomy may minimize the risk of thromboembolism by less intra-operative blood loss, reduce operation time and less peri-and postoperative complication.

Posted by PAUL A.
Tue Jan 22, 2008 04:48 pm
(a)We inquire you were not asked to take a history from her first whether this large fibroid causing any pressure effect on bladder and if she has frequency , urgency or incontinence. We tell her that these symptom will be improved by removing the fibroid (1) .

There is little evidence that hysterectomy by itself can cause stress incontinence or Detrosur over activity is there any evidence? , however, the patient may have long term voiding dysfunction due to intervention ? interruption of?? with pelvic nerve plexus and there will be no difference between total or subtotal hysterectomy where is the nerve plexus typically interrupted? .

She may experience postoperative urine retention (1) because of pain or anaesthetic drugs, we reassure her that she will be offered adequate analgesia but she may need short term catheterization.

She also may have symptoms like burning micturition and frequency as a result of urinary tract infection (1) caused by the catheter.

There are other urinary symptoms that can occur like continuous dribbling of urine as a result of fistula formation or bloody urine as a result of urinary tract injury, but it is unwise to make the patient anxious, we inform her that incidence of such operative complication as very low. ? bladder / ureteric injury??


(b) Primary prevention is by avoiding injury .We advise the patient to empty her bladder preoperatively also the bladder is drained by folly\'s catheters (1) . Incidence of bladder injury is 1:200-300 you did not tell the woman this in (a) . We should take care while entering the abdominal cavity , we try to open parietal peritoneum superiorly to avoid injuring the bladder. We try to do appropriate reflection of the bladder (1) downward to protect the ureters from injury while ligating uterine artery and dissecting transverse cervical ligament.
Also we should take care while dissecting infundibulo- pelvic ligament at pelvic brim and while doing oopherectomy as the ureter pass over the ovarian fossa , these sites are commonly associated with ureteric injury.

If the patient had adhesions or difficulties anticipated , we involve urological surgeon (1) .

Careful surgical technique with visualization of the course of ureter (1) and avoiding blind dissection will help minimize injury. Also taking care while using diathermy. Risk of ureteric injury is 1:500 should have been mentioned in (a) .

Secondary and tertiary prevention is by intraoperative recognition of injury and repair to minimize morbidity and sequelae.


(c) We try to detect risk factors for developing thromboembolism and try to adjust them, if the patient is obese , we advise her to loss weight before operation peri-operative = around the time of the operation . If she is using combined contraceptive pill, we advice to use another method of contraception. Also we try to treat intercurrent infections and optimizing any co-morbidities if present.

We advise the woman to avoid prolong immobility, pre- and postoperatively. If she is t moderate to high risk of developing VTE we advise for prophylactic dose of LMWH , 2 hours preoperatively and to continue postoperatively for 3-5 days or the patient is fully mobile 2h is for moderate risk, 12h for high risk .

We should ensure adequate hydration ? early mobilisation and encourage the use of TED stockings (1) and intermittent calf compression to minimize risk of thromboembolism.
Posted by PAUL A.
Tue Jan 22, 2008 05:11 pm
I will tell her that urinary pressure symptoms such as frequency and nocturnal ? are likely to improve after operation The operation is not associated with increased risk of urinary dysfunction However there is increased risk of urinary tract infection (1) which can be reduced by the use of prophylactic antibiotic not asked about this here ? you will repeat yourself . There is risk of injury to the bladder in 3 out of 1000 operations (1) and this will be minimized by the insertion of a Foley\'s catheter pre- operative not asked about this . There is also a risk of uretric injury in 2 out of 1000 operations (1) . If any injury identified it will treated in appropriate way with the help of urologist if required. The Foleys will be removed in 24 hours, but in case of injury it may be left for longer time and indwelling catheter may be needed as well in that case.
Prophylactic anti- biotic may reduce the risk of urinary tract (1) , it can be advised for longer use until the catheter is removed no evidence to support this (-1) . Foleys catheter inserted just before the procedure may minimized the risk of injury to the bladder (1) on entry particularly if the fibroid uterus have displaced the bladder high. The anatomy may be distorted by the presence of the fibroids and meticulous care to identify the ureters (1) especially at infundiopelvic ligaments and at sites of clamping the uterine arteries. A sub-total hysterectomy (1) may minimize risk of injury to the ureters at the vaginal vault. Identification of injury and prompt repair with help of a urologist (1) to minimize further damage
Pre-operative assessment of risk for venous-thromboembolism [ VTE] an a plan for prophylaxis should be discussed with the woman and documented in the records. General health advise such as to stop smoking, to reduce her weight cannot be achieved peri-operatively will decrease the risk of VTE. If she is on combined contraceptive pill she can be advice to change to another birth control method to reduce the risk of VTE. If she has high risk of VTE 2 hours before operation a low molecular weight heparin should be given 2h is for moderate, not high risk women .
Intra- operative, to shorten the procedure and to minimize the intra- operative bleeding. Avoid calf muscle pressure.
Post- operative ensure adequate hydration early mobilisation and analgesia. Give second does heparin at 12 hours why 12h if you are using LMWH? after procedure and continue for 5 days. Advise graduated stocking (1) . Advice early mobilization (1) . On discharge advise to report symptoms of VTE if developed.
Posted by PAUL A.
Tue Jan 22, 2008 05:42 pm
a) I will tell her that hysterectomy for benign tumors like fibroid does not produce adverse effects on urinary tract function in the majority of women undergoing surgery (1) good . But there is a risk of bladder injury in 0.3 % cases (1) . This risk is even more if she has history of previous abdominal or pelvic surgeries because of the increased risk of adhesions. There is also a risk of ureteric injury if the anatomy is distorted severely by the fibroid as in a broad ligament or large cervical fibroid what is the risk? . In those women with chronic retention of urine due to pressure by fibroid, the bladder will be hypertrophic does chronic retention cause a hypertrophic bladder? and it is likely that voiding difficulty may persist in post operative period requiring catherisation. Even in others, post operative bladder catheterization for 24 hrs may be required taking into account the difficulties in mobilisation. Risk of urinary tract infection is high (1) increased rather than high in the post operative period. In the long term there is also a risk of vault prolapse and associated cystocele with resultant voiding problems.
b) I would cathetrise the bladder preoperatively (1) to empty it and maintain CBD ?? in order to reduce the chance of injury during surgery. If there is previous history abdominal surgery, peritoneum will be opened as high as possible after identifying a thin area, to avoid injury to an adherent pulled up bladder. In case of a large broad ligament fibroid, I would locate the path of ureter by intravenous urogram with the help of a urologist (1) and place a stent in the ureter to facilitate easy identification per operatively. Intra capsular dissection will be carried out to minimize injury to ureter. Adequate mobilisatrion of bladder by sharp and blunt dissection prior to clamping parametrium will be done to displace ureters (1) down . In case of large cervical fibroids, hemi section of uterus will be done and the fibroid enucleated prior to applying clamps to minimize risk of ureteric injury ? evidence that this is effective?? This may be a personal technique .
c) I will advise her to reduce her weight how long will it take her to lose weight? Cannot be achieved peri-operatively if her BMI is more than 30 and to quit smoking prior to surgery. If she is on COCP for contraception I will ask her to stop it and postpone her surgery for four weeks. I will make an assessment of her risk factors for thromboembolism based on the proforma (1) . Age of 40 and major surgery lasting for more than 30 minutes, puts her in a moderate risk category. If there are additional risk factors she will be in a high risk category and hence will be started on LMWH prophylaxis 12 hrs (1) before surgery with use of graduated elastic compression stockings (1) and continuation of prophylaxis for 3 to 5 days post operatively why 3-5 days? Will you do this if she is not fully mobile? . If moderate risk LMWH will be started 2 hrs prior to surgery and continued for 3 to 5 days postoperatively. I will also allow early ambulation in post operative period and ensure measures to prevent dehydration (1) preventing dehydration is not the same as providing good hydration which is a risk factor for VTE.
Posted by PAUL A.
Tue Jan 22, 2008 06:02 pm
a. Hysterectomy in the presence of large uterine fibroid is associated with distortion of pelvic anatomy; therefore she should be made to understand that she is at higher risk of having ureteric injury how high is the risk? . Her lower urinary tract symptoms like difficulty of passing urine or pressure symptom will be improved after the surgery (1) will use ?may? in this instance . There is also increased change risk of urinary tract infection (1) as the patient will require insertion of urinary catheter. Her risk of bladder injury is also high what is the risk? Who decides if 1:200 is ?high?? due to huge fibroid. She might suffer short term voiding difficulty (1) due to pain, excess intravenous fluid or immobilized after surgery but long term voiding difficulty due to hypotonic bladder is unlikely to occur as simple hysterectomy does not involve massive dissection of bladder. This patient is not at increased risk to develop GSI (Genuine Stress Incontinence) urodynamic stress incontinence or Detrusitor instability overactivity as the pudendal nerve and the pelvic floor is intact. Formation of urinary fistula is serious complication of surgery but seldom occur for simple hysterectomy. Written information, further follow up and contact detail should be provided.

b. Large uterine fibroid is associated with distortion of urinary tract anatomy therefore preoperative IVU is prudent to asses the course of urinary tract system and the presence of hydronephrosis. Early referral and involvement of urologist (1) is essential steps to reduce risk of urinary tract injury in anticipating difficulty to locate the course of ureter. Appropriate operative approach with adequate surgical exposure is essential to enable proper assessment of pelvic anatomy. Avoid blind clamping of blood vessel will prevent inadvertent clamping of ureter. Dissection of ureter and direct visualization of ureter (1) before clamping any tissue or blood vessel is good practice. Proper dissection and mobilized the bladder (1) away from surgical field will protect the bladder from accidental injury. Short diathermy application will help to avoid avascular injury to urinary tract system.

c. VTE (venus thrombo-embolism) risk assessment should be done before surgery (1) . Personal or family history of VTE, thromboifillia, and 3 or more moderate risk factor is classified as having high risk of VTE. Referral to hematologist and anesthetist should be arranged earlier if the patient has high risk this is for VERY high risk patients factor to develop VTE especially those patients with anti-trombin III deficiency. Weight reduction cannot be achieved peri-operatively , stop smoking and treatment of chronic diseases should be ensured. OCP should be stop earlier before major gynecological surgery. Administration of heparin 2 hours before surgery and 12 hourly after surgery is prudent but if the patient has higher risk to develop VTE then heparin should be given 12 hours before surgery and then 8 hourly (1) is this LMW or unfractionated heparin?. Low molecular weight heparin (LMWH) has less risk of bleeding and easy daily dose of injection. Maintain of good hydration during the surgery and post operation should be acertained. Encourage early immobilization (1) and ensure the heparin or LMWH is given until the patient is fully ambulating. TED stoking (1) and intermitten pneumatic calf during surgery would help to reduce risk of VTE.
Posted by PAUL A.
Tue Jan 22, 2008 09:13 pm
a)A large fibroid can impinge on the bladder and cause frequency of micturition and feeling of incomplete emptying of bladder.Both these complaints are likely to be relieved following surgery (1) .Incidence of recurrent urinary tract infections because of incomplete emptying of bladder will be reduced after surgery.Any effect on the kidney following back pressure changes is likely to be resolved if there has been no permanent damage already caused. Genuine stress incontinence can be unmasked ?? mechanism?? sometimes after surgery and should not be considered as a complication of surgery.
This surgery is a high risk for urinary tract injury because of anatomic distortion of the ureter and\\or bladder.Prolonged catheterization in event of an injury may be required which in turn may lead to urinary tract infection is risk of UTI not increased in the absence of prolonged cath.? .In some cases suprapubic catheterization may be required. Urinary retention (1) is one of the commonest post operative occurrences.An unrecognized injury leading to fistula may present as continuous leakage of urine . In rare cases complete loss of renal function may occur have you ever encountered such a case??? .

b)Though this is a high risk case for urinary tract injury,following some basic principles of surgery can minimize the risk.Preop catheterization (1) to empty the bladder and an adequate incision for thorough exposure are essential.Care should be taken while opening the parietal peritoneum because the bladder may be advanced ? ? meaning -peritoneum should be opened under vision.Bladder should be retracted reflected down adequately by blunt dissection or by sharp dissection in case of previous surgery.All the bleeding points shou ld be ligated \\cauterised under vision and any attempt towards blind clamping should be avoided.Intrafascial technique can reduce the risk of injury.Identifying the ureter by dissecting it throughout its path before clamping the pedicles or ureteric stenting (1) can be helpful especially in case of a broad ligament fibroid.Hemisection of the uterus should be done in case of a cervical fibroid before oroceeding with hysterectomy. The changed anatomy of the bladder\\ureter as seen on IVP plates should be kept in mind. I

c)Preoperatively I will inquire whether she has a personal or family history of venous thromboembolism and screen her for hereditary thrombophiliasA accordingly.Identification of other risk factors (1) like obesity,smoking ,oral contraceptive hypertension will be looked out for and properly managed.She will be asked to quit smoking,stop COC a month prior and lose weight how long will it take her to lose weight? Can this be achieved PERI-operatively? in case of obesity.Preop ambulation and hydration will be encouraged.Postoperatively apart from proper hydration,early hydration and use of graduated elastic compression stockings (1) should be done. If required she is 40 and having major surgery. You are expected to know that heparin IS required prophylactic or therapeutic will you use a THERAPEUTIC dose of LMWH peri-operatively? (-1) use of subcutaneous LMWH can be considered after deciding on her grade of risk for VTE.Infection or anemia if any should be promptly treated.
Posted by PAUL A.
Tue Jan 22, 2008 09:26 pm
a)I would inform her that removal of a pelvic mass may reduce lower urinary tract symptoms if present any lower urinary tract symptoms? . Minor postoperative symptoms are common and transient. The potential consequences of surgery on the urinary tract include UTI from catheterization and stasis of urine (1) . There is the risk of voiding disorder which may be due to pain or denervation during dissection and this may present as urinary retention (1) . Other short term risk include damage to the ureter what is the risk? and this may cause uretero-vaginal fistula. There may also be damage to the bladder leading to vesico-vaginal fistula ? what is the risk? . Long term risk include stress and urgency incontinence ? evidence that hysterectomy causes incontinence .There may also be prolapse of the anterior vaginal wall leading to a cystocele.This usually presents as a lump in the vagina or a feeling of incomplete emptying. I would document this discussion and also offer her information leaflet on hysterectomy.
b) Pre-operatively, I would arrange for an IVU to delineate the course of the ureter do you do this in all women having hysterectomy for large fibroids? . This is because the anatomy may be distorted by a big fibroid or if there are pelvic adhesions. Intra-operatively, I would empty her bladder (1) to ensure not in the way of the operation. Surgery should be performed by an adequately trained person or under supervision. A subtotal hysterectomy (1) is associated with lower risk of injury to the urinary tract.Adequate knowledge of anatomy and dissection along tissue planes. Clamps should be placed under good vision and close to the uterus. The bladder should be reflected (1) downwards from the operating field before clamps are placed over the uterine pedicle. The course of the ureter could also be identified (1) at the utero cervical junction before clamps are applied. Avoid blind ligature or diathermy. Suspected injury can be confirmed with indigo carmine for ureteric injury or instillation of methylene blue into the bladder if suspect bladder injury. If injury occurs, repair should be undertaken with the help of urologist (1) .Postoperatively, catheter drainage may be required for 5-7days if suspect bladder injury and IVU and advice of the urologist if ureteric injury.
c)This woman is at moderate to high risk for TE. This is because age > 35 and pelvic surgery likely to last > 30minutes. Additional risk factors (1) to ask for would be BMI> 30 or presence of underlying medical problems like Inflammatory bowel disease, nephrotic syndrome or recent MI.Hx of thromboembolism or a family history would also be important. Pre-operatively, her risk of thrombo-embolism should be assessed in conjunction with an haematologist do you need a haematologist to assess risk? and appropriate thrombo-prophylaxis planned. If on Warfarin, this should be changed to heparin before surgery.There is the need to correct anaemia and dehydration before surgery. Counsel and offer LMWH 3h before surgery why 3h? 2h moderate risk, 12h high risk . Surgery should be undertaken with the use of pneumatic compression stockings. Meticulous haemostasis during surgery . Avoid subcutaneous haematoma and use non absorbable sutures for skin closure in an interrupted fashion if obese patient.
Post-operatively, LMWH should be offered for 3-5d after the surgery until fully mobilised (1) . She should be given TEDS (1) . Encourage early mobilization and good hydration (1) .
Posted by Jilly L.
Wed Jan 23, 2008 02:25 am
a) Removal of the fibroids may improve any pressure symptoms such as frequency and nocturia she may have experienced. There is a small risk of urinary tract infection postoperatively and a small risk of urinary tract injury during the operation, which will be increased due to the size of the uterus and if she has had previous abdominal surgery. She may experience vault prolapse in the future which could affect bladder neck function and lead to symptoms of stress incontinence.

b) Pre-operative weight loss if she is obese will make surgery easier, reducing the risk of injury. Pre-operative gonadotrophin analogue therapy will reduce fibroid size and as a result make surgery easier, reducing risk. The bladder should be catheterised. Adequate exposure and access is important so a midline incision may be necessary. The surgeon should be appropriately trained to perform a difficult hysterectomy and the urologists involved if there is difficulty identifying the ureters or concern about injury.

c) She is at moderate risk of thromboembolic disease due to her age, large fibroids and major pelvic surgery. Pre-operative assessment should aim to identify other risk factors such as a personal or family history of thromboembolic disease (TED) or thrombophilia, or varicose veins. Weight reduction should be advised pre-operatively if she is obese. The combined oral contraceptive pill should be stopped pre-operatively. If she is found to be at high risk of TED pre-operative prophylatic heparin can be considered. She should be well hydrated pre and post-operatively and mobilised early. Intraoperatively calf compression should be used. Major haemorrhage increases the risk of TED. Sepsis also increases the risk so antibiotics may be needed if signs of sepsis occur. Postoperatively she needs compression stockings and low molecular weight heparin prophylaxis until fully mobile.
Posted by PAUL A.
Thu Jan 24, 2008 04:04 am
A large fibroid uterus can exert pressure effects on the urinary bladder resulting in symtoms of urinary frequency and urgency. The patient can be couseled about a likely improvemnt in these symptoms if they are present (1) .
Hemorrhage is a complication of hysterectomy. Severe hemorrhage can result in acute renal failure.
Distortion of anatomy by the fibroid uterus increases the risk of ureteric damage what is the risk? 10%? . She is told that if this occurs repair of the injury by a urologist will be undertaken. This will need post operative follow up by the urologist.
Injusy to the bladder will what is the risk? You were not aske about management of these complications necessitate placement of a urinary catheter to be kept in situ for 10-14 days. Intermittent self catheterisation may also be necessary.
Placement of a urinary catheter increases her risk of urinary tract infection (1) .
There is a small risk of development of a urinary fistula which can result in continuos leakage of urine vaginally.
Hysterectomy does not increase her risk of urinary incontinence or detrusor instability.

b)
The urinary bladder should be catheterised preoperatively (1) . The catheter line should be placed below the patients popliteal fossa to avoid obstruction of urinary flow ?? .
Placement of a ureteral stent preoperatively can help in identification of the ureters at the time of surgery.
The hysterectomy should be performed by a gynecologist skilled in surgery for large pelvic masses and there should be a low threshold to seek the assistance of the urologist (1) .
A retroperitoneal approach to the hysterectomy is advised as this allows identification of the ureter. This decreases the risk of inadvertent ureteric injury.
The urinary bladder should be well retracted throughout the procedure to diminsh the risk of bladder injury (1) .
If trauma to the urinary tract is suspected cystoscopy can be performed to investigate and if necessary corrective measures are implicated.

c) Preoperatively the patient should be counseled to stop smoking. If she is using the combined oral contraceptive pill this should be discontinued three months prior to surgery and a non oestrogen containing form of contraception prescribed in the interim. Weight loss should be encouraged if time permits.
She should be started on low molecular weight heaparin 12 hours prior to the procedure why 12h? Is she at moderate or high risk? . During the procedure she should be kept well hydrated.Pressure on the lower limbs should be avoided.
Post operatively the LMWH is continued for 5 days post operatively until fully mobile . Dehydration should be avoided avoiding dehydration is not the same as maintaining good hydration by use of appropriate IV fluids. Early ambulation (1) assisted by a physiotherapist is essential. Intermittent pneumatic compression devices are of unproven value. TED stockings (1) should can be worn prophylactically to decrease the incidence of VTE. you need to demonstrate better understanding of risk assessment and thromboprophylaxis
Posted by PAUL A.
Thu Jan 24, 2008 04:29 am
a)Hysterectomy is a major surgery with lot of complications associated with it.Technically access can be a problem when operating on a large fibroid uterus.It can be beneficial in terms of reducing bladder retension due to compression if any ? meaning?? .
When consenting women for hysterectomy we should explain about 0.7% risk of damage to the bladder (1) and ureters is the risk of bladder injury the same as the risk of ureteric injury? .Urinary tract complications could be immediate or late onset.
During the surgery there could be tear in the bladder. Once recognised it needs suturing and leaving a catheter in for 10 days you were not asked to explain the management of any injury .
There could be damage to the ureters because of distorted anatomy due to fibroids. If recognised at the time of operation urologist are involved to perform the surgery you were not asked about this .Sometimes if not identified during surgery they present with abdominal pain and electrolyte imbalance in the post operative period.
There would be common complications in terms of urinary tract infections in the post operative perios due to cathetarisation (1) .This needs treating with antibiotics.
Hysterectomy can have implications on bladder function in long term due to detrusor instability causing increased frequency,urgency,urge incontinence and sometimes double micturition ? evidence .If they have any symptoms previously it can get worse due to the surgery and also may require intermittent self cathetarisation
Rarely it can cause vesico vaginal fistula with constant watery vaginal discharge in the post operative period can be diagnosed.
Rarely due to blood loss and ureteric damage they could have renal failure requiring renal physician involvement for further management.
Information leaflets are given and informed consent is obtained prior to the surgery.

b)First of all cathetarising the bladder (1) would reduce the damage.At the time of the surgery rmobilising the bladder (1) ,less handling of the tissue and identifying the ureters before putting any clamps on would reduce the damage.Appropriate training and competency is essential in performing the procedure to minimise the risk.Sometimes doing a subtotal hysterectomy (1) in a large fibroid uterus and with deep pelvis might avoid damage to the ureter.With distorted anatomy there is a scope for preoperative stenting to prevent damage to the ureters (1) .
Propylactic antibiotics (1) during surgery and early removal of catheter would reduce the chance of urinary tract infection.Psychological support.pelvic floor exercise and bladder training post operatively would reduce symptoms of urgency and urge incontinence.

c)In the pre operative clinic a risk assessment for venous thromboembolism is made and documented in the notes (1) .Life style changes in terms of reducing weight not attainable in the PERI-operative period and reduce smoking has to be discussed. If she is on clexane/heparin why should she be? then she should continue and last dose should be administered 2 hours before the procedure.If on warfarin it has to be changed to heparin/clexane when she is admitted to the ward.
Ted stockings (1) should be applied at the time of admission until discharge.Make sure she is well hydrated before ,during and after the surgery.
Early mobilisation (1) would reduce the risk of thrombosis. Heparin/Clexane is heparin = clexane or are they different drugs? should be administered after 6 hours why? 2h pre-op if moderate risk, 12h if high risk ,dosage depending on the risk NO ? dosage depends on weight (-1) .If there is an excess of intra or post operative bleeding then liasing with the haematologist is essential before administering it.It is ideally given for 3-5 days in low and moderate NO ? low risk women do not require heparin (-1) risk cases.In high risk cases it is essential to give it for 6 weeks depending on the giuidelines

which guidelines? You need to read about thromboprophylaxis. .
Posted by PAUL A.
Thu Jan 24, 2008 06:29 pm
a)I would tell her about the potenitially beneficial urological consequences like relief of pressure symptoms (1) ( frequency ) if uterine mass is removed . I would inform her that the long term voiding disorders like stress incontinence or detrusor instability are unlikely.
I would tell her about the possibility of urinary tract infections due to stasis of urine or catheterisation (1) you were not asked about how to reduce risks .It is reduced by use of prophylactic antibiotics.
I would tell her about the risk of developing extra-problems (known as complication)may occur .I would inform her that fibroids growing in her womb may force the bladder up ,so that , it may be wounded when the anterior abdominal wall being opened .
The incidence of bladder injury in abdominal hysterectomy is 0.3% (1) . Subsequent continuous bladder drainage may be needed by putting a tube in bladder outlet ,( urethra ),and maintained on free flow for 7-10 days not asked about management of complications .
I would tell her that short term voiding disorders as urinary retention (1) is mainly due to due to pain, immobility and anaesthetic drugs. It could be prevented by short term catheterization.
I would tell her that the pelvic organs and structures are distorted by the large fibroid ,so that , the ureters may be damaged or cruched during the operation. It occurs in about
1: 500 cases (1) for benign disease. In such case splints may be used with the assistance of urological colleague .
b) Intra-operative bladder catheterization (1) reduces the risk of bladder injury and urinary retention. Careful dissection , use of sub-total hysterectomy this is not a sentence . Choice of abdominal incision that provides adequate exposure. The bladder may be displaced from normal pelvic situation by the large fibroid, so ,the peritoneal cavity should be opened high up .
Ureteric injury to be minimized through appropriate operative approach , adequate exposure , and full examination of the fibroid uterus in the pelvis . Also, blind clamping of the blood vessels should be avoided , as it is the most common cause of ureteric injuiries. The ureters should be dissected sufficiently to allow their identification with adequate mobilization of bladder downward away from the operative site (1) . So, the ureter moved away from the uterine vessels .
When direct visualization is not possible from the huge fibroid , the ureter can be identified above the pelvic brim and followed in to the pelvis. Also, short diathermy application reduce the risk of ureteric injury. Seeking early urological (1) surgical assistance when appropriate.
c) The interventions would include pre-operative assessment of venous thromboemolism risk in this woman (1) . I would look in this woman the moderate risk factors include age of 40 years , having major pelvic surgery and operation more likely to last more than 30 minutes. The high risk group include three or more moderate risk factors.
Pre-operative weight reduction cannot be attained PERI-operatively , advice for life style modification is essential to stop smoking , alcohol and COCP if using it. Thrombophilia screen if she has personal or family history of VTE.
Low molecular heparin (LMWH) should be administered 2hrs ( if moderate risk ) or 12 hrs ( if high risk ) pre-operatively (1) . It should be administered at site away from the proposed surgery and continued until 5 days or fully mobile (1) .
The daily dosage of LMWH q 8-12 NO ? LMWH has long half life and not used 8 hourly hrs depending on the risk of VTE. It is effective and has the advantage of reducing the risk of haemorrhage NO ? it does not reduce the risk of haemorrhage. Are you suggesting that she is less likely to bleed if she had LMWH compared to nothing or placebo? (-1) .
Intra-operative measures include avoiding prolonged operation , using meticulous haemostasis , use of drains and interrupted sutures for skin how do these prevent VTE? .
Post-operatively, good hydration ,chest physiotherapy , early mobilization (1) should be encouraged. Use of thromboembolic deterrent ( TED ) stockings (1) would reduce the risk of VTE.
Posted by PAUL A.
Thu Jan 24, 2008 09:46 pm
I would like to tell her about the routes of hysterectomy as different routes have slightly different incidences of the complications. In case TAH is selected for large fibroids, ureter is vulnerable to have avascular necrosis, ligation and transaction at its various parts what is the risk of injury? . Timely recognition and reconstructive surgery involving the urologist can minimize the adverse outcome not asked about this ? you will be repeating yourself in (b) . In rare instances this injury goes unrecognized at the time of surgery but could be diagnose postoperatively. Serious injury to the urinary tract, however are less likely compared to what? for this surgery. Injury to the bladder can occur during its reflection away from the uterus but is usually diagnosed and treated per operatively and again is less likely for less likely compared to what? What is the risk of bladder injury? 10%?? this surgery. Inadvertent ureterovaginal or vesicovaginal fistula results in continuous dribbling of urine which is relatively uncommon in this surgery and the damage is reparable.
If the fibroid is the cause of pelvic organ prolapse do fibroids CAUSE prolapse?the surgery can improve the symptoms. Similarly stagnant urine in a distorted bladder causes repeated UTI which may get improve after the surgery so the patient may feel an improvement in her urinary frequency, urgency and incontinence (1) . However during reflection of bladder from the uterus may produce an unavoidable damage to the nerve plexus resulting in voiding difficulties. She should be told about the long term risk of vault prolapse however measures to prevent it are taken during the surgery.

Preop wt reduction advise, IVU for having an idea about the course of the ureter, cathetrasition , Appropriate exposure through the most appropriate skin incision, anatomical knowledge about the course of the ureter and its vulnerable sites should be well known by the surgeon ? single sentence addressing several points with the word ?catheterisation? simply thrown in. You should use simple and complete sentences . Care should be taken during clamping the infundibulo pelvic ligament at the lateral pelvic side wall, as the ureter may be about 0.9 cm away from the clamp. Identification of ureter (1) with its usual relations may not be sufficient so its characteristics peristalsis and paler appearance should be kept in mind. To recognize the fact that ureter get its blood supply from its medial aspect in its upper 2/3 and from its lateral aspect in its lower 1/3, so the dissection should be from the direction vice versa. Care should be taken during dividing the broad ligaments as ureter lies in a tunnel beneath the lower medial part of the broad ligament. From the cervical internal os its distance is about 1.2 cm this relation should be kept in mind during dividing the broad ligament and if too much bleeding is encountered and the field is not clear subtotal hysterectomy (1) can be considered.
Peroperative diagnosis of site and extent of injury by metheline blue dye test and IV indigocarmine test and earlier involvement of senior gynaecologist and urologist (1) improves the outcome. Meticulous haemostasis, antibiotics prophylaxis, supervised training and expertise all together improves the outcome

History of any risk factor for thromboembolism like APS, thrombophillias, protein C and S deficiency, personal/family history of DVT, use of COCP, presence of medical diseases like HTN ?? , cardiac valvuloplasty is this a risk factor for VTE? , sickle cell disease and obesity, sedentary life style pattern, occupations involving prolong immobilization or long haul traveling should be inquired. The patient should be categorized in a low, moderate, high risk (1) for thromboembolism. Prophylactic LMW heparin can be given to low and moderate risk low risk women do not require heparin women 2 hrs preop and after 6 hrs postop upto 3 days why only UP TO 3 days??? (-1) . However high risk women may continue therapeutic dose of heparin 12 hrs why do they need a THERAPEUTIC dose? They do not have a VTE so you should not be treating them. They need prophylaxis (-1) postop and replacement with warfarin from 3rd postoperative day upto 6 weeks. Early mobilization, TED stockings (1) and good hydration (1) are important in the early postoperative period.
Pre-op advice to stop smoking wt reduction cannot be achieved in PERI-operative period , and treatment of intercurrent illnesses all are important in minimizing the risk of thromboembolism.

You need to read-up on thromboprophylaxis in gynae surgery. Suggest you refer to the BNF
Posted by PAUL A.
Thu Jan 24, 2008 09:58 pm
{a}
I would ask about secondary pressure symptoms and its secondary effect on the quality of her life which are likely to be improved after hysterectomy (1) . Then, I would inform her that subtotal hysterectomy is associated with lower urinary morbidity. she is likely to have lower urinary tract infection what is the risk of UTI? It is not appropriate to describe the probability as LIKELY due to catheterization and stasis of urine.
Also, intra-operatively she is liable to urinary tract injury especially with broad ligament fibroid. The incidence of bladder injury and ureteric injury in such cases are 1:200 (1) and 1:500 (1) , respectively. However, the incidence of ureteric injury is only about 0.01% in vaginal hysterectomy. Other urinary tract symptoms are short-term voiding difficulties (1) due to pain. Further, detrusor instability is likely to happen with any pelvic surgery NO ? THERE IS NO EVIDENCE THAT DETRUSOR OVERACTIVITY IS CAUSED BY HYSTERECTOMY. DOES ANY PELVIC SURGERY INCLUDE REMOVAL OF ECTOPIC PREGNANCY??? (-1). When you say something is likely to happen, you mean the risk is > 50% especially with bladder dissection and consequent denervation. However, it is still controversial with hysterectomy and may be unlikely.
{b}
I would assess her risk if any history of previous surgery, large fibroid or broad ligament fibroid is more likely to be associated with distortion of anatomical features. In such case, I would involve senior help furthermore I would involve Urologist (1) .
Preoperative intravenous pyelography will give idea about the anatomical features especially duplicate ureter which is present in 1% however it has no role in reducing urinary tract injury what is the point in doing an investigation which you KNOW is useless? (-1) . Well knowledge and understanding of the anatomy is essential to avoid urinary tract injury. Indwelling Folly?s catheter would reduce the risk of bladder injury (1) .
Also, gentle dissection of the bladder during hysterectomy is crucial (1) . Ureteric stent intra-operative would not reduce the risk of ureteric injury however; it will help in its recognition as only one third can be detected intra-operatively. I would delineate and trace the ureter along its course (1) and avoid of blind clamping of the pedicles. Exploration of the upper two thirds of the ureter should be from lateral side while exploration of the lower third should be from the medial side in such way, we avoid the injury of its blood supply.
{c}
I would assess her risk (1) for venous thromboembolism (VTE) such as age, body mass index (BMI), personal and family history of VTE, medical co-morbidity, smoking habit, if on combined oral contraceptive (COCC) pills especially the ones containing third generation progetogens.
She already has 2 risk factors; her age and pelvic surgery for more than 30 minutes. In the presence of 3 or more risk factors she will be considered moderate risk for VTE.
I would advice her to reduce her weight if her BMI is >30k/m2 not possible in PERI ?operative period , to stop smoking and combined COCC pills. Prophylactic low-molecular weight heparin 3 hours 2h for mod. Risk, 12h for high risk preoperatively should be given along with proper hydration and treatment of any concurrent infection.
Intra-operatively, proper hydration is essential, pneumatic stockings will be applied, avoidance of long operating time and excessive blood loss and meticulous hemostasis.
Post-operatively, I would advice her to wear TED stockings (1) and early mobilization, proper hydration (1) , and avoidance of excessive alcohol and caffeine. Prophylactic heparine is to be continued until discharge from hospital or full mobilization (1) .
Posted by PAUL A.
Fri Jan 25, 2008 12:45 am
(a).Infection of urine is a common postoperative problem which is transient and is related to catheterization and stasis of urine (1) .It is reduced by prophylactic antibiotic. It is unlikely to represent long term problem.
Short term retention of urine occurs due to pain and immobility (1) . Longer term are due to nerve plexus damage. .Ureteric injury occurs in about 1 in 500 (1) cases for benign disease .Anatomical distortion by large fibroid specially broad ligament fibroids is a risk factor for ureteric injury. Immediate Injury may result from ligation with suture ,cutting or late ischemic. Bladder injury occurs in about 1 in 200 cases (1) .Immediate injury occurs by sharp or blunt dissection and later by avascular injury. Incontinence both genuine and stress incontenence and detrusor instability are unlikely consequences since the pelvic floor and pudendal nerve remailn intact.

(b.)An adequate incision must be made for proper exposure of important pelvic structures. A sound knowledge of abdominal and pelvic anatomy is important.Palpated or inspected or tracing of ureter (1) if at any doubt before clamping tissues.Adequate mobilization of the bladder (1) during hysterectomy also reduce injury. Careful dissection, use of splint may reduce urinary tract injury. Avoidance of blind clamping for homeostasis may reduce injury. Recognition of urinary tract injury during operation is important. So that immediate repair can take place with help of urological colleagues (1) . Judicious use of subtotal hysterectomy may reduce both ureter and bladder injury (1) .

(c)she has no other risk factors for venous thromboembolism she need once daily low molecular weight heparin( LMWH )started immediately 2 hours before surgery and used continuously whilst the patient is not ambulant.If she has additional VTE risk factor LMWH should be 12h pre-op used until discharge (1) and in case of very high risk thromboprophylaxis should be continued for 2-4 weeks after hospital discharge. Early mobilization and perioperative hydrartion (1) is important. Use of TED stockings (1) also may prevent VTE. Judicious use of subtotal hysterectomy may minimize the risk of thromboembolism by less intra-operative blood loss, reduce operation time and less peri-and postoperative complication.
Posted by PAUL A.
Fri Jan 25, 2008 12:52 am
a) Removal of the fibroids may improve any pressure symptoms (1) such as frequency and nocturia she may have experienced. There is a small risk of urinary tract infection (1) postoperatively and a small risk of urinary tract injury what is the risk of bladder / ureteric injury? You are expected to quote figures. ? risk of retention during the operation, which will be increased due to the size of the uterus and if she has had previous abdominal surgery. She may experience vault prolapse in the future which could affect bladder neck function and lead to symptoms of stress incontinence.

b) Pre-operative weight loss if she is obese will make surgery easier, reducing the risk of injury. Pre-operative gonadotrophin analogue therapy will reduce fibroid size and as a result make surgery easier, reducing risk (1) . The bladder should be catheterised (1) . Adequate exposure and access is important so a midline incision may be necessary. The surgeon should be appropriately trained to perform a difficult hysterectomy and the urologists (1) involved if there is difficulty identifying the ureters or concern about injury. prophylactic antibiotics, sub-total hysterectomy

c) She is at moderate risk of thromboembolic disease due to her age, large fibroids and major pelvic surgery. Pre-operative assessment should aim to identify other risk factors (1) such as a personal or family history of thromboembolic disease (TED) or thrombophilia, or varicose veins. Weight reduction cannot be achieved PERI-operatively should be advised pre-operatively if she is obese. The combined oral contraceptive pill should be stopped pre-operatively. If she is found to be at high risk of TED pre-operative prophylatic heparin can be SHOULD BE administered to moderate (2h pre-op) and high (12h pre-op) risk women considered. She should be well hydrated pre and post-operatively and mobilised early (1) . Intraoperatively calf compression should be used. Major haemorrhage increases the risk of TED. Sepsis also increases the risk so antibiotics may be needed if signs of sepsis occur. Postoperatively she needs compression stockings (1) and low molecular weight heparin prophylaxis until fully mobile (1) .
Posted by PAUL A.
Sat Jan 26, 2008 10:46 pm
A good candidate should

(a)
? Explain that the majority of women do not experience any changes in urinary tract function following hysterectomy (1)

? Explain that most post-operative symptoms are transient (1)

? Removal of fibroid uterus may alleviate pressure symptoms like urinary frequency and urgency (1)

? UTI is common and related to catheterisation and urinary stasis (1)

? Voiding dysfunction may lead to urinary retention ? related to pain, immobility or drugs ? usually transient. Long-term voiding dysfunction is rare and may be due to damage to autonomic plexus (1)

? Bladder injury occurs in 1:200-300 operations ? may be immediate (due to sharp / blunt dissection) or delayed secondary to thermal injury or avascular necrosis (2)

? Ureteric injury occurs in ~1:500 cases and associated with distorted anatomy (1)

(b) With respect to reducing the risk of urinary tract injury

? Pre-operative treatment with GnRH analogues will reduce the size of the fibroid and potentially make the operation easier (1)

? Prophylactic antibiotics reduce the risk of UTI (1)

? Emptying the bladder & careful dissection reduces the risk of bladder injury (1)

? Palpation / identification of the ureters and careful dissection should minimise ureteric injury. Use of ureteric splints / assistance from urologist would reduce risk (2)

? Sub-total hysterectomy reduces risk of bladder / ureteric injury (1)

(c ) Peri-operative measures to minimise the risk of VTE

? Ensure adequate risk assessment with prophylactic heparin 2h pre-op (moderate risk) or 12h pre-op (high risk). Manage very high risk patients with haematologist (2)

? Continue heparin until fully mobile / discharge (1)

? Know the value of TED stockings (1)

? Ensure early mobilisation and good hydration (1)
Posted by Ritu J.
Thu Feb 7, 2008 05:41 am
I would tell that if she had frequency, urgency related to large fibroid ,symptoms would be relieved.Small risk ok urinary tract infection due to catherisation.1in 200 chances of urerteric injurymay be slightly increased due to large fibriod or position of fibroid.Incontinence [stress] would be more after subtotal hystrectomy than total.Per operative chances of bladder injury are relatively increased as bladder may be reflected at a higher level.
Iwould do preoperative IVP in case fibriod is located laterally ,towards broad ligament to map the course of ureters.Catheterise the bladder beore surgery.Reflect uterovesical fold carefully after defining anatomy carefully.Trace the ureter before clamping uterines.Incase of any bleeding avoid any blind clamps.Ureteric stents may be of some help. Close vault carefully to avoid bladder injury.Early identification and help of urosurgeon in suspected cases.
Otimise weight and BMI if possiblle,avoid smoking and take detailed history of preexisting thrombophillia in self or 1st degee relative,any DVT during pregnancy or on OCP.Educate about need of good hydration and mobilisation.Give prophylactic LMWH 2 hrs before surgery ,use compression pnematic stocking during if surgery lasts more than 1/2 hr.In high risks existing factors involve heamotologist and prophylaxis extending 8hrly after surgery.Encouraging ambulation early.
s Posted by PAUL A.
Mon May 7, 2012 01:41 am

s