Intraoperative Genitourinary Injuries During a Hysterectomy: Risks, Management, and Mitigation Strategies

Abstract

Surgical removal of the uterus is one of the most performed procedures in women, with >600,000 hysterectomies performed per year in the United States alone, most for benign indications. Over the past decade, laparoscopy has become the more popular approach for completion of the hysterectomy globally. The increased uptake of minimally invasive approaches played a role in the adoption of outpatient hysterectomy with estimated volume ranging between 200,000 and 300,000 cases per year. And with more surgeries done in a same-day-discharge setting, screening for iatrogenic surgical injuries would be of paramount importance. The risk of iatrogenic injury to the bladder or ureters during the hysterectomy was estimated to be 0.21%. The rate of injury varied significantly between the different routes, with the highest being for total laparoscopic hysterectomy (0.31%), followed by laparoscopic assisted vaginal hysterectomy (0.29%), total vaginal hysterectomy (0.24%), total abdominal hysterectomy (0.2%), and laparoscopic subtotal hysterectomy (0.14%). Even though the risk of urinary tract injury is extremely low, the consequences related to additional repair, prolonged recovery, resulting disability, and loss of employment, especially if not immediately recognized, could be substantial. The most common risk factors for urinary tract injury are pelvic malignancy, history of pelvic radiation, history of cesarean delivery, prior abdominal surgery, endometriosis, adhesions, broad ligament leiomyomas, and low-volume surgeons (<10 per year). Prompt intraoperative recognition and repair of iatrogenic injuries reduce the risk of significant morbidity (e.g., fistulae formation, deep pelvic infections, and possible deterioration of kidney function). Although cystoscopy may be used intraoperatively to detect such an injury, the question of how often it should be used remains controversial. Although the value of routine cystoscopy per case may be low, the value of routine cystoscopy for the patient and the low-volume surgeon could be high. So, although universal cystoscopy is not required, surgeons early in their career might wish to adopt universal cystoscopy until surgical fortitude is established and experience in assessing level of risk is possible. At that stage, selective cystoscopy could be utilized more appropriately in a cost-effective manner. When index of suspicion is high, or when injury is detected, timely consultation with a urologist may help alleviate the long-term complications by prompt diagnosis and repair when needed. Practice environments that foster collegiality and surgical mentorship for young surgeons optimize outcome and expedite their progress to proficiency, similar to what surgical fellowship programs offer their trainees.

Double-J Stent Misplacement in the Inferior Vena Cava and Right Atrium: A Urovascular Nightmare

“…UI most often results iatrogenically from surgical procedures. Hysterectomy, as in our case, accounts for >50% of iatrogenic UI cases, with incidence rates estimated at 0.03–1.5% [16] , [17] , [18] . Failure to recognize UI intraoperatively, as occurred in our case, has been reported at rates of 60–90%, with considerable implications for patient outcomes [19] .…”

“…Delayed UI detection is associated with significantly higher rates of 90-d readmission, sepsis, urinary fistula, acute renal injury, and death [19] , [21] . Furthermore, postoperative UI detection typically requires temporary urinary diversion and multiple procedures or operations for definitive management, which has a considerable negative impact on patient mental health, patient-partner relationships, employment, litigation, and health care costs [17] , [20] , [21] .…”

A case of a blind‐ending right ureter first identified intraoperatively during total laparoscopic hysterectomy for uterine adenomyosis and fibroids in a woman with severe ipsilateral kidney hypoplasia

“…Several risk factors for urinary tract injury during TLH have been reported, including a history of abdominal surgery, cesarean section, endometriosis, intra‐abdominal adhesions, broad ligament fibroids, pelvic malignancy, and pelvic radiation and a surgeon with limited surgical experience (<10 operations/year) 8 . By contrast, Chan et al suggested that congenital abnormalities, such as ureteral duplication, megaureter, and ectopic ureter or kidney, are risk factors for ureteral injury due to anatomical changes distorting the position of the ureters 9 .…”

Major Perioperative Complications of Benign Gynecologic Procedures at a University-Affiliated Hospital

“…(4) Although rare, major complications such as hemorrhage, bowel or urinary tract injuries and vaginal cuff dehiscence still arise and often require additional surgical or pharmacological interventions, resulting in higher morbidity and mortality risks. (5)(6)(7) Risk factors for complications include multiple surgeon and center-specific factors. Surgeon volume has repeatedly been found to be a predictive factor, as surgeries performed by high-volume surgeons are usually associated with shorter hospitalizations, fewer perioperative complications, and fewer conversions to laparotomy.…”