To determine the incidence, risk factors and morbidity of unintended operative injury to the bladder or ureter during hysterectomy, a retrospective case-control study of women with these injuries from 1 January 1993 to 1 January 1998 was performed. The incidence of bladder and ureter injury, respectively, was 0.58% and 0.35% for abdominal hysterectomy, 1.86% and 0% for vaginal hysterectomy, and 5.13% and 1.71% for hysterectomies performed for obstetric indications. Women with injury during abdominal hysterectomy were found to have greater blood loss, longer operative times, longer postoperative stays, more febrile morbidity, and more frequent transfusions. Similar trends were seen for other hysterectomy types. The incidence of operative bladder or ureter injury is relatively low. However, even when recognized, these individuals experience greater operative and postoperative morbidity. This highlights the importance of surgical technique directed toward minimization of these injuries, and careful intra- and postoperative surveillance aimed at early detection.

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We sought to identify the variation in estimated blood loss (EBL) at the time of benign hysterectomy and to analyze how blood loss is associated with measures of utilization and complications. MATERIALS AND METHODS: Hysterectomies for benign indications at hospitals in the Michigan Surgical Quality Collaborative (MSQC) between January 1, 2013 and April 30, 2015 were analyzed. A sensitivity analysis to identify how estimated blood loss was associated with measures of utilization (transfusion, readmission, reoperation, and length of stay) and complications was undertaken. The association between estimated blood loss and patient and hospital characteristics was also analyzed. Postoperative complications were assessed up to 30 days after surgery and included deep/organ space surgical site infection, venous thromboembolism, unplanned postoperative intubation, cerebral vascular accident, pneumonia, myocardial infarction, cardiac arrest, Clostridium difficile infection, acute kidney injury, and sepsis. A hierarchical logistic regression model was used to identify patient level factors independently associated with EBL >400 mL and to calculate a risk and reliability adjusted rate for each hospital and the MSQC. RESULTS: There were 18,963 benign hysterectomies from 61 MSQC hospitals after exclusion of 459 cases because an EBL was not reported and 14 cases because two hospitals reported fewer than 20 hysterectomies. The median EBL was 200 mL, and the 90th percentile for EBL was 400 mL. Compared to hysterectomies with an EBL <200 mL and 200-400 mL, those with an EBL >400 mL, had significantly higher rates of transfusion (0.6% vs. 2.6% vs. 13%, p < 0.001), readmission (3.3% vs. 3.9%, vs. 6.3%, p < 0.001), reoperation (1.8% vs. 2.1% vs. 3.9%, p < 0.001), length of stay !4 days (2.3% vs. 8.7% vs. 20.7%, p < 0.001), and post-operative complications (1.0% vs. 1.8% vs. 3.2%, p < 0.001). The proportion of hysterectomies at MSQC hospitals with an EBL >400 mL ranged from 3.7% to 17.2%. The rate of three hospitals was significantly lower than the mean rate, and that of five hospitals was significantly greater than the mean (see Figure). The risk factors with the highest adjusted odds for an EBL >400 mL were found among women who underwent an abdominal hysterectomy (reference robotic, OR 14.5, CI 11.9-17.7), who had a surgical time >3 hours (OR 4.0, CI 3.52-4.71), and who had a specimen weighing >250 grams (OR 5.0, CI 4.13-6.15). Using these risk factors, the model C-stat for predicting EBL >400 mL was 0.85. Adhesive disease (OR 1.7, CI 1.46-1.90), age <40 years old (OR 1.5, CI 1.14-1.96), BMI >35 (OR 2.4, CI 1.97-2.88), and need for a preoperative transfusion (OR 2.3, CI 1.58-3.43) were also statistically significant. When these were added to the model, the C-statistic improved to 0.86. CONCLUSION: The percentage of benign hysterectomies with an EBL >400 mL (>90th percentile) varies significantly across hospitals in MSQC. An EBL >400 mL is associated with higher rates of utilization and complications. To improve efficiency and qualit...

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