For vaginal surgical procedures, it is easier to avoid the ureter. However, not all surgeons can palpate a nonstented ureter, which may be required during a high uterosacral ligament suspension. A stent can readily take the surgeon to the ureter and avoid injury in most cases. This may be helpful for less experienced operators.
What should residents be trained to do?
Do most obstetrics and gynecology residency programs appropriately train young physicians to evaluate and manage lower urinary tract injury during pelvic surgery?
CUNDIFF: I am afraid not. Although residency directors increasingly recognize the importance of educating doctors to prevent and manage these injuries, this recognition has not yet risen to the policy level.
For example, the Council on Resident Education in Obstetrics and Gynecology (CREOG) includes a bladder surgery educational model that necessitates dissection of the ureter, cystoscopy, ureteral stenting, bladder repair, and ureteral reanastomosis.
However, the CREOG surgical curriculum makes no mention of protecting or evaluating the lower urinary tract during pelvic surgery.
This spectrum seems to reflect the wide variation among residency programs, too. While some programs such as ours at Johns Hopkins provide comprehensive training in prevention, evaluation, and management of lower urinary tract injury, many others do not. This might be because some programs lack technically skilled faculty. Interdisciplinary politics also likely influences local credentialing.
BARBER: In my opinion, a graduating ObGyn resident should be able to:
- identify and mobilize the ureter to avoid injury during abdominal and laparoscopic surgery
- safely mobilize the bladder during abdominal, vaginal, or laparoscopic hysterectomy
- perform intraoperative cystoscopy to evaluate for injury
- repair bladder injuries abdominally and vaginally
However, I don’t think it is realistic for a graduating resident to be able to manage ureteral injuries, as residents are unlikely to encounter very many during training. These injuries are best left to our urology colleagues.
BENT: Very little or no education is provided in preventing lower urinary tract injury; evaluation is better managed in many programs. A conservative estimate is that 20% of programs have a reasonable curriculum for preoperative assessment and evaluation of incontinence and prolapse.
The management of pelvic floor disorders is better handled in almost all programs, especially as it relates to surgery. Many residents spend a lot of time on the urogynecology service and are exposed to the surgical aspect of rotations.
Dr. Karram and Dr. Barber have no financial relationships relevant to this article. Dr. Bent serves on the gynecology advisory board of ACMI and is a speaker for Novartis, Pfizer, Watson, and Asetellas (formerly Yamanouchi). He also has received research funding from Cook, Eli Lilly, and Mentor; and is a consultant for C.R. Bard. Dr. Cundiff has received grant/research support from Cook, is a consultant to C.R. Bard and Eli Lilly, and is a speaker for GlaxoSmithKline.