[CG] Post-operative haematuria following gynaecological surgery

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Post-operative haematuria may be noted immediately in theatre or develop later when the patient is on the ward and can range in colour from rosy to dark red.  Haematuria could be a sign of urinary tract injury and therefore this must be considered, however clear urine does not exclude injury.

Injury of the urinary tract is the most common major complication of gynaecological laparoscopic surgery and can result in significant morbidity.  The risk of urinary tract injury is higher in laparoscopic cases compared to open.  The incidence of bladder injury is between 1-2% and the ureter is injured in 0.5-2.5% of all gynaecological procedures.  

Ideally, an injury should be identified and repaired during the primary operation, but vigilance in the immediate postoperative period may lead to early recognition and intervention.  Ureteric injuries are often not identified intra-operatively or may present later due to thermal or ischaemic injury that was not evident at the time of operation.

Lower urinary tract injury carries the potential for substantial morbidity including infection, fistula formation, and renal failure.  

In patients at high risk consider prophylactic pre-operative intervention such as insertion of ureteric stent/catheters prior to dissection to facilitate dissection and identification of potential injury to ureters intra-operatively.

If haematuria is noted in theatre at the end of a case (e.g. when removing the drapes) let the consultant know and don’t move patient / wake her up until it has been discussed.  If not expected, they may consider bladder assessment with cystoscopy depending on the procedure performed. Cystocopy would not exclude ureteric injury.

Risk factors for urinary tract injury

  • Endometriosis +/- resection of endometriosis
  • Cancer
  • Intra-abdominal adhesions
  • Severe prolapse
  • Obesity
  • Pregnant uterus
  • Fibroids
  • Previous pelvic surgery / previous pelvic sepsis
  • Hysterectomy (laparoscopic > open)

Causes of postoperative haematuria

  • Traumatic catheterisation / traction on catheter
  • Instrumentation of the bladder or ureters (e.g. cystoscopy, ureteric stents, biopsy)
  • Urinary tract infection
  • Missed bladder or ureteric injury
  • Urinary tract injury that was repaired intraoperatively will likely have haematuria develop as any clot / bleeding resolves, but also consider multiple sites of injury are possible

Clinical signs suggestive of urinary tract injury

  • Air in catheter bag at the end of a laparoscopic abdominal procedure
  • Suprapubic or flank pain
  • Low grade pyrexia
  • Haematuria
  • Oliguria
  • Possible peritonitis
  • Ileus
  • Raised inflammatory markers
  • Deranged renal function
  • Leakage of urine per vagina (usually presents later)
  • “Bypassing” of urethral catheter – may be fistula and not bypassing
  • Higher than expected drain output post op (high creatinine in drain fluid)

Management of postoperative haematuria

  • Leave catheter in situ until a minimum of 24hrs after haematuria resolves or as instructed by consultant responsible for the patient’s care
  • Consider urinary tract injury if haematuria persists and postoperative recovery not progressing as expected
  • Hydrate the patient
  • Clearly document urine volumes passed on fluid balance chart
  • Keep catheter on free drainage (ensure no blockage or flip-flo valves)
  • Exclude UTI (Dipstick tests are not useful in catheterised patients. If UTI is suspected, send urine samples for laboratory culture and commence empirical antibiotics as per local policy whilst results are awaited.)
  • Discuss with consultant in charge of the patient’s care

In most cases, CT IVU will be the primary investigation, however, discussion with the responsible consultant and radiology / urology should take place at an early stage to guide appropriate imaging.

Last reviewed: 04 February 2020

Next review: 28 February 2025

Author(s): Dr Michelle Kent

Approved By: R Jamieson, Clinical Director

Reviewer Name(s): Mr Nkem Umez-Eronini, Consultant Urological Surgeon, Dr Karen Guerrero, Consultant Urogynaecologist, Dr Veenu Tyagi, Consultant Urogynaecologist