Deviation in the Standard of Surgical Care Resulting in Ureter or Bladder Injury (Bladder Laceration)

Evaluate breaches in the standard of care by using your particular fact pattern of answer the questions below to determine whether or not there has or has not been a Deviation in the Standard of Surgical Care Resulting in Ureter or Bladder Injury (Bladder Laceration)

Answer the following questions to find out if the standard of care was followed for your case.

  • Was medical history obtained?
    Yes
    No
    Risk factors not identified
    Answer unknown
    Why is this important?
    The patient’s medical history must be obtained for identification of any predisposing risk factors for anatomical uniqueness, pathology or malignancy.
    (2011) 18 JMIGYN 1 4-8

  • Was a pre-operative evaluation performed? Why is this important?
    Answer this question
    
The focus of a pre-operative evaluation for urological surgery must be two fold. First of all the focus is on preventing any unforeseen operative urinary tract injury, and secondly of evaluating the overall health of the intended patient.

    (2011) 18 JMIGYN 1 4-8 



  • Was informed consent obtained? Why is this important?
    Answer this question
    
The laws of most states require that surgeons obtain informed consent before providing treatment.

    (2011) 23 EOMSCA 3 475-484 



  • Which of the following intra-operative complications did the patient experience? Why is this important?
    Answer this question
    
The overall rate of urinary tract injury associated with pelvic surgery in women is approximately 1 percent. Bladder injury is more common than ureteral injury.
2008) 88 ESRCNA 2 343-359 



  • Was bladder injury suspected during the surgical procedure? Why is this important?
    Answer this question
    
The female urinary bladder is vulnerable to injury during laparoscopic gynecologic surgery. It is estimated that between 50% and 80% of all surgical complications involving the lower urinary tract are associated with gynecologic surgery.

    (2011) 18 JMIGYN 1 4-8 



  • Were intra operative evaluations performed to assess for bladder injury? Why is this important?
    Answer this question
    
Intra-operative recognition of a bladder injury allows for immediate repair and decreased post-operative morbidity rates.

    (2011) 18 JMIGYN 1 4-8 



  • Was the bladder injury recognized and repaired during the Initial surgery? Why is this important?
    Answer this question
    
If damage occurs, intra-operative recognition and repair ultimately results in the best outcome for the patient.

    (2011) 18 JMIGYN 1 4-8 



  • Was the patient catheterized postoperatively? Why is this important?
    Answer this question
    
Continuous bladder drainage allows the bladder to heal completely and prevents elevated intra-vesical pressure and disruption of the suture line.

    (2011) 18 JMIGYN 1 4-8 



  • Did the clinician provide discharge instructions and recommend follow-up visits? Why is this important?
    Answer this question
    
When urinary bladder catheters are required after discharge, the patient and caregivers must receive formal education to avoid complications related to placement, ensure proper care, and to promptly recognize and treat complications expeditiously if they do occur.

    (2011) 18 JMIGYN 1 4-8 



  • Was the ureteric injury identified during the procedure? Why is this important?
    Answer this question
    
Intra-operative discovery of injury permits prompt repair.

    (2008) 88 ESRCNA 2 343-359 



  • Were intra operative evaluations performed to assess for ureter injury? Why is this important?
    Answer this question
    
The various intra-operative tests to identify ureter injury include direct exploration and visualization of the ureter and injecting dyes like methylene blue.

    (2006) 33 EURCNA 1 55-66 



  • Was a urologist consulted? Why is this important?
    Answer this question
    
A surgeon with experience in the anatomy of the urinary tract, typically a urologist or urogynecologist, must be consulted intra-operatively.

    (2006) 33 EURCNA 1 55-66 



  • Was the patient’s ureteric injury recognized and repaired during the initial surgery? Why is this important?
    Answer this question
    
Many ureteral injuries go unrecognized at the time of injury. In fact, of all recognized ureteral injuries, 50% to 70% are not recognized acutely. Minor injuries may heal without sequelae.

    (2006) 33 EURCNA 1 55-66 



  • Postoperatively, were the patient’s vital signs frequently assessed? Why is this important?
    Answer this question
    
Assessment and recording of vital signs will alert he clinician to early signs of hemodynamic instability.

    (2011) 18 JMIGYN 1 4-8 



  • Was the fluid intake and urine output assessed? Why is this important?
    Answer this question
    
Post-operatively, the patient’s fluid balance should be observed continually.

    (2006) 33 EURCNA 1 55-66 



  • Were laboratory studies performed? Why is this important?
    Answer this question
    
Laboratory studies are invaluable in alerting the clinician of surgical injury.

    (2006) 33 EURCNA 1 55-66 



  • Were there any symptoms suggestive of ureteric injury or bladder injury? Why is this important?
    Answer this question
    
The post-operative symptoms suggestive of urinary tract injury include urine leakage, abdominal/flank pain, abdominal swelling, fever, hematuria, low urine output, hypotension, and tachycardia.

    (2011) 18 JMIGYN 1 4-8 



  • Which of the following diagnostic tools were used to assess for surgical injury? (Choose all that apply) Why is this important?
    Answer this question
    
If surgical injury is suspected, the clinician must conduct further diagnostic investigations.

    (2006) 33 EURCNA 1 55-66 



  • Was the injury managed appropriately? Why is this important?
    Answer this question
    
Upon post-operative diagnosis of a urinary tract injury, the first priorities are to relieve renal obstruction, treat infection and stop urine leakage. In some cases, obstruction or leakage can be managed with ureteral stents, a minimally invasive procedure. Otherwise, surgical exploration is required for repair of the injury.

    (2006) 33 EURCNA 1 55-66