EBCOG Part 1- Urogyenacology -Day 5(E.M.Q)

A. Antibiotics and repair 3 months later
B. Boari’s flap
C. Conservative management (leave alone)
D. Cystoscopy and repair
E. Diagnostic laparoscopy
F. Diuretics
G. Drain the air with a Verres needle
H. Exploratory laparotomy
I. Immediate fistula repair
J. Indwelling catheter and antibiotics for 10 days
K. Repair alone
L. Repair and colostomy
M. Repair and drain
N. Repair and stent for 10 days
O. Repair and indwelling catheter for 10 days
P. Retrograde cystoureteroscopy
Q. Stop the procedure, antibiotics and observe for 24 hours
R. Ureteric implantation
S. Ureteric stent
T. Urethral catheter for 10 days

Instructions: The following patients developed complications that were recognized at the time of surgery. From the option list above, choose the single most appropriate immediate step that you will take to deal with the complication. Each option may be chosen once, more than once or not at all.

1. During Wertheim hysterectomy urine is observed to be coming through the patient’s bladder. On further inspection, it is confirmed that there is a cut on the bladder.

2. A 30-year-old woman underwent laparoscopic surgical excision of extensive endometriosis 3 days ago. Following surgery she was found to have an increasing abdominal girth and pain. An intravenous urogram shows leakage of contrast from the left ureter.

3.A 46-year-old woman had an abdominal hysterectomy 4 days ago and is now complaining of continuous leaking of urine per vaginam. A dye test confirms that she has developed a vesicovaginal fistula and is understandably very distraught.

A CT urogram

B IVP

C Ultrasound scan

D CT scan of abdomen and pelvis

E Full blood count

F V/Q scan

G Urea and electrolytes

H Cystogram

I Venous leg Doppler

J Chest X-ray

K Abdominal X-ray

L Urinary catheterisation

M Intermittent self catheterisation

Match the most appropriate management to each scenario:

4.  A 48-year-old woman had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a suspicious-looking ovarian cyst. There was significant ascites of 1.5 litres. Postoperative recovery was uneventful; however, she was re-admitted with lower abdominal pain and leakage of fluid per vaginum.

5. A 67-year-old woman had a hysteroscopy and drainage of pyometra. Twelve hours postoperatively, the womanwas significantly pyrexial and very unwell.

6. Twelve hours after having a TVT procedure, a patient complains of inability to pass urine after the removal of an indwelling urinary catheter.

7. A 26-year-old woman had a perforation of her bladder during a trans-vaginal tape (TVT) operation.

8.  Seven days after a total abdominal hysterectomy and bilateral salpingo-oophorectomy for grade

A Antibiotics
B Boari flap
C Drainage
D End-to-end anastomosis
E Immediate referral to gynaecological oncologist
F Indwelling catheter for 48 h
G Indwelling catheter for 7-10 days
H Indwelling catheter for 7-10 days and antibiotics
I Laparotomy and repair
J Laparotomy and end-to-end anastomosis
K Laparotomy, repair and colostomy
L Laparoscopic repair
M Lavage and drainage
N Nil by mouth for 48 h
0 Observe for 24-48 h
P Percutaneous nephrostomy
Q Repair and colostomy
R Retrograde uteroscopy
S Stent and retropubic drainage for 10 days
T Uretero-ureteric anastomosis/implantation
U Repair and indwelling catheter for 10 days with antibiotics
V Utero-vesical anastomosis (implantation into the bladder)

Instructions: For each of the case scenarios described below, select from the option list the single most appropriate management of the gynaecological surgical complication. Each option may be selected once, more than once, or not at all.

9.A 27-year-old woman is undergoing a laparoscopic resection of rectovaginal endometriosis, and during the procedure, it is discovered that a small 0.5 x 0.5 cm hole has been made in the ileum close to its junction with the caecum. On closer inspection, this appears to have been secondary to slippage of the laser fibre

10. A 30-year-old woman is undergoing a laparotomy for a right dermoid cyst. The bowel, which is found to be attached to the ovarian cyst, is freed before the cystectomy, but the mucosa is breached and there is some anxiety that the breach might have gone into the lumen; on inspection, this was not obvious. There is only a suspicion of bowel injury, which is thought to involve only the serosa. If it had involved the mucosa, faeculent material would have been seen.

11. A 38-year-old woman is undergoing an abdominal hysterectomy and bilateral salpingo-oophorectomy for large uterine fibroids. During surgery, there is a suspicion that the bladder has been damaged by a clamp (crush injury), although there is no obvious injury seen. At the end of the procedure, an in-and-out catheter drains heavily blood-stained urine.