Iatrogenic injury to the urinary tract is a recognized complication of pelvic surgery because the bladder, distal ureters, and urethra lie in close anatomic relationship to the uterus, cervix, vagina, and pelvic sidewall. Although the absolute frequency is low, these injuries are clinically important because missed or delayed diagnosis can result in urinary leakage, fistula formation, sepsis, obstruction, impaired renal function, repeat surgery, and prolonged hospitalization. Contemporary series confirm that the bladder is injured more often than the ureter during gynecologic and obstetric procedures, while ureteral injuries are more likely to escape immediate recognition [1,2]. The consequences therefore depend not only on the site and severity of injury but also on how quickly the injury is identified and repaired. Obstetric surgery presents a distinct risk profile. During cesarean delivery, difficult dissection in the presence of previous cesarean scars, dense adhesions, advanced labor, uterine incision extension, emergency surgery, and distorted pelvic anatomy can increase the likelihood of bladder injury [3-6]. Recent evidence has reinforced the importance of adhesions, repeat cesarean delivery, emergency procedures, second-stage cesarean delivery, and difficult extraction as clinically relevant risk factors [3,4]. Bladder trauma during cesarean delivery frequently involves the dome or posterior wall, sites that are generally amenable to immediate repair when the injury is recognized intraoperatively [4,6]. Assisted vaginal delivery and extensive perineal trauma can also injure the urethra or lower urinary tract, although such injuries are encountered less frequently. Gynecologic procedures, particularly hysterectomy and complex pelvic surgery, also place the urinary tract at risk. Systematic reviews and large clinical series report variation in injury rates according to surgical route, operative complexity, previous pelvic surgery, and adhesions [7-10]. Cystoscopy and other intraoperative methods used to evaluate ureteral patency can improve recognition of unsuspected injuries, although no single technique detects every form of damage [8,9]. When ureteral injury is identified, management depends on the location and mechanism of injury; distal injuries commonly require ureteral reimplantation, with stenting used to support healing [11,14]. Early recognition is consistently associated with simpler repair and reduced downstream morbidity [11-13]. Evidence describing real-world intraoperative urology consultations during both obstetric and gynecologic surgery remains limited in many Indian tertiary-care settings. Small institutional series can still provide useful information on the spectrum of injuries, operative responses, and immediate clinical outcomes. The objective of the present study was to describe the pattern of iatrogenic urological injuries encountered during gynecologic and obstetric procedures at a tertiary care centre, document the intraoperative urological interventions used for bladder, ureteral, and urethral injuries, and summarize the early postoperative outcomes of affected patients.

Study design and setting: This retrospective observational study was conducted in the Department of Urology, Kurnool Medical College and Government General Hospital, Kurnool, Andhra Pradesh, India. The study covered the period from October 2021 through February 2024 and evaluated intraoperative urological consultations requested during gynecologic and obstetric procedures. Study population and sampling: All consecutive patients for whom an intraoperative urological consultation was sought because of a recognized or suspected urinary tract injury during a gynecologic or obstetric procedure were included. The study therefore represented a census of eligible intraoperative consultations during the predefined period. The available study dataset contained 10 patients. The index procedures included emergency cesarean section, hysterectomy, and assisted vaginal delivery. Data collection and variables: Information was abstracted from the available clinical and operative records. Variables included age, type of index gynecologic or obstetric procedure, type of urological injury, anatomic site where documented, intraoperative assessment, repair technique, type and duration of urinary drainage, ureteral stenting, and early postoperative complications. Injuries were categorized as inadvertent cystotomy, ureteral injury, combined bladder and ureteral injury, or urethral injury. For bladder injuries, the documented location of the bladder rent and relationship to the trigone were recorded. In cases of inadvertent cystotomy, ureteral patency was assessed intraoperatively by direct insertion of ureteral catheters through the ureteral orifices. Operative management: Bladder rents were repaired in two layers using either continuous simple or interrupted sutures with 3-0 and 2-0 polyglactic acid. Post-repair urinary drainage consisted of suprapubic cystostomy and per-urethral catheterization for 10-14 days, as documented in the source records. Ureteral injuries were managed by ureteroneocystostomy over an indwelling stent, with stent removal after six weeks. The principles of prompt identification, assessment of ureteral integrity, and definitive repair are consistent with published approaches to iatrogenic urinary tract injury [1,11,14]. Among the two urethral injuries, one was managed by primary repair followed by per-urethral Foley catheterization, whereas suprapubic cystostomy was performed in the patient with extensive perineal injury. Outcome measures and statistical analysis: The primary outcomes were the distribution of injury types and the operative management performed. Secondary outcomes were documented early postoperative complications. Because of the small case series and absence of a comparison group, analysis was descriptive. Continuous data were summarized using mean and range, and categorical variables were expressed as frequencies and percentages. No inferential statistical testing was undertaken. Ethical considerations: The study proposal was reviewed and approved by the Institutional Ethics Committee, Kurnool Medical College and Government General Hospital, Kurnool (IEC No. 763/2025; review letter dated 23 May 2025).

A total of 10 patients required intraoperative urological consultation during gynecological or obstetric procedures. The mean age was 32.8 years, with an age range of 20-50 years. Emergency cesarean section was the most common index procedure, accounting for 6 patients (60.0%), while hysterectomy and assisted vaginal delivery accounted for 2 patients (20.0%) each (Table 1). Table 1. Demographic characteristics and index procedures of the study population (n=10) Characteristic Result Age, years Mean: 32.8; range: 20-50 Emergency cesarean section 6 (60.0%) Hysterectomy 2 (20.0%) Assisted vaginal delivery 2 (20.0%) Values are presented as frequency (percentage) unless otherwise specified. Bladder injury constituted the predominant urological complication. Isolated inadvertent cystotomy occurred in 6 patients (60.0%). One patient (10.0%) had suspected isolated ureteral injury, another patient (10.0%) sustained combined bladder and ureteral injury, and 2 patients (20.0%) sustained urethral injuries. Considering the combined injury, bladder involvement occurred in 7 patients (70.0%), while ureteral involvement was present in 2 patients (20.0%). The bladder dome and posterior wall were the principal sites of bladder injury, whereas the trigonal region was spared. The distribution of urological injuries is presented in Table 2. Table 2. Pattern of intraoperative urological injuries (n=10) Injury pattern n % Isolated inadvertent cystotomy 6 60.0 Suspected isolated ureteral injury 1 10.0 Combined bladder and ureteral injury 1 10.0 Urethral injury 2 20.0 Total 10 100.0 The categories represent the primary injury patterns identified during intraoperative consultation. The combined injury contributed to both bladder and ureteral involvement. In patients with inadvertent cystotomy, ureteral patency was assessed intraoperatively by direct insertion of ureteral catheters through the ureteral orifices. Bladder injuries were repaired in two layers using either continuous simple or interrupted sutures with 3-0 and 2-0 polyglactic acid. Postoperative urinary drainage was maintained using both suprapubic cystostomy and per-urethral catheterization for 10-14 days. Ureteral injuries were managed by ureteroneocystostomy over a ureteral stent, followed by stent removal after 6 weeks. Among the 2 patients with urethral injury, one underwent primary urethral repair followed by per-urethral Foley catheterization. The second patient had an extensive perineal injury and was managed with suprapubic cystostomy. The intraoperative management according to injury pattern is summarized in Table 3. Table 3. Intraoperative management of urological injuries Injury pattern Intraoperative management Urinary drainage/follow-up Inadvertent cystotomy Assessment of ureteral patency by direct ureteral catheterization; two-layer bladder repair with 3-0 and 2-0 polyglactic acid sutures. Suprapubic cystostomy and per-urethral catheterization for 10-14 days Ureteral injury Ureteroneocystostomy over a ureteral stent Stent removal after 6 weeks Urethral injury requiring repair Primary urethral repair Per-urethral Foley catheterization Urethral injury associated with extensive perineal injury Suprapubic urinary diversion Suprapubic cystostomy The early postoperative course was favorable in most patients. Wound infection occurred in 2 patients (20.0%). No other major postoperative complications were observed during the reported postoperative period (Table 4). Table 4. Early postoperative outcomes (n=10) Postoperative outcome n % Wound infection 2 20.0 No major postoperative complication other than wound infection 8 80.0 Overall, bladder injuries represented the largest proportion of intraoperative urological complications, and most injuries were recognized and managed during the same operative setting. Immediate repair or urinary diversion, according to the anatomical site and extent of injury, resulted in a favorable early postoperative outcome in the majority of patients.

The present series describes 10 patients who required intraoperative urological consultation during gynecologic and obstetric surgery. Bladder injury was the predominant complication: isolated inadvertent cystotomy accounted for 6 cases (60.0%), and overall bladder involvement was present in 7 patients when the combined bladder and ureteral injury was included. Emergency cesarean section was the most frequent index procedure, accounting for 60.0% of consultations. Immediate operative management was undertaken in all cases, and the early postoperative course was favorable in most patients, with wound infection in 2 patients and no other major early postoperative complication. The predominance of bladder injury is consistent with previous reports of urinary tract injury during gynecologic and obstetric procedures. Jensen and Rudnicki observed bladder injuries more frequently than ureteral injuries, while a systematic review by Jensen et al. identified cesarean delivery as a common operative setting for iatrogenic bladder injury [1,2]. Obstetric bladder injury is particularly associated with difficult pelvic dissection in the presence of adhesions, previous cesarean delivery, emergency surgery, advanced labor, and altered pelvic anatomy [3-6]. Doroldi et al. identified several of these factors as predictors of bladder injury during cesarean delivery [3]. In the present study, 6 of 10 consultations occurred during emergency cesarean section. However, procedure-specific incidence and comparative risk could not be estimated because denominators for the total number of cesarean and other pelvic procedures were unavailable. The bladder dome and posterior wall were the principal sites of injury, whereas the trigonal region was spared. Chill et al. also reported the dome as a frequent site of cesarean-associated bladder injury [4]. Early intraoperative recognition permits immediate repair and reduces the consequences of delayed diagnosis [2,6]. In this series, bladder rents were closed in two layers with absorbable polyglactic acid sutures, followed by suprapubic and per-urethral drainage for 10-14 days. This approach is consistent with commonly described principles of bladder repair [1,2]. Ureteral involvement occurred in 2 patients, including one combined bladder and ureteral injury. Ureteral injuries are less frequent than bladder injuries but can be more difficult to recognize intraoperatively [7,11]. Assessment of ureteral integrity is therefore important when pelvic dissection is difficult or bladder injury is encountered [8,9]. Ureteral patency was assessed by direct catheterization through the ureteral orifices in patients with cystotomy. Ureteral injuries were managed with ureteroneocystostomy over a stent, with stent removal after 6 weeks, consistent with accepted management of distal ureteral injury [11,14]. The two urethral injuries were treated according to severity, with primary repair and Foley catheterization in one patient and suprapubic diversion in the patient with extensive perineal injury. Overall, the findings emphasize the importance of immediate recognition, anatomical assessment, site-specific repair, adequate urinary drainage, and close collaboration between obstetric-gynecologic and urological teams. The results are descriptive and do not establish superiority of any particular repair strategy. Nevertheless, meticulous pelvic dissection, identification of urinary tract anatomy, prompt evaluation of suspected injury, and timely urological involvement remain key measures for reducing perioperative morbidity [8,11,14]. LIMITATIONS This study has several limitations. The retrospective, single-centre design and small sample size limit statistical precision and generalizability. Inclusion was restricted to patients who required intraoperative urological consultation; therefore, the study does not provide the overall incidence of urinary tract injury across all gynecologic and obstetric procedures. Procedure-specific denominators, detailed risk-factor data, and long-term functional outcomes were also unavailable for analysis.

Iatrogenic urological injuries during gynecologic and obstetric surgery require prompt recognition and coordinated management. In this series, bladder injury was the predominant complication, and emergency cesarean section was the most frequent associated procedure. Intraoperative assessment of ureteral patency, two-layer bladder repair with absorbable sutures, appropriate urinary drainage, ureteroneocystostomy with temporary stenting for ureteral injury, and tailored management of urethral trauma were followed by favorable early outcomes in most patients. Careful bladder mobilization, avoidance of blind clamping, identification of ureteral anatomy, and timely urological consultation remain important operative principles. Larger prospective studies with defined procedural denominators and longer follow-up are required to clarify incidence, risk factors, complications, and long-term urinary functional outcomes.

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