Risk factors for lower urinary tract injury at the time of hysterectomy for benign reasons

Abstract

DISCLOSURES None of the authors has any conflicts of interest to report except for Dr. Rebecca G. Rogers, who is DSMB chair for American Medical Systems Transform Trial, UptoDate royalties, ACOG royalties, and is on the executive board of the ACOG. Dr. Gena Dunivan is a member of the AUGS Education Committee. OBJECTIVE To identify risk factors associated with lower urinary tract injury at the time of performing hysterectomy for benign indications. METHODS We conducted a multi-center case–control study of women undergoing hysterectomy for benign disease. Cases were identified via ICD-9 codes for lower urinary tract injury at the time of hysterectomy from 2007 to 2011: controls were two subsequent hysterectomies following the index case in the same institution that did not have lower urinary tract injury. Logistic regression was used to perform univariate and multivariate comparisons between groups. RESULTS At 7 centers, 135 cases and 270 controls were identified. Cases comprised 118 bladder injures and 25 ureteral injuries: 8 women had both bladder and ureteral injury. Bladder injury was associated with a history of prior cesarean section OR 2.9 (95% CI 1.7–5), surgery by a general obstetrician and gynecologist OR 2.4 (95% CI 1.2–5.2), and total abdominal hysterectomy OR 1.9 (95% CI 1.06–3.4). Ureteral injury was more likely among women who underwent laparoscopic-assisted vaginal hysterectomy (LAVH) OR 10.4 (95% CI 2.3–46.6) and total abdominal hysterectomy (TAH) OR 4.7 (95% CI 1.4–15.6). CONCLUSION Bladder injury at the time of benign hysterectomy is associated with a prior history of Cesarean section and TAH as well as surgery by generalist OB-GYN; ureteral injury is associated with LAVH and TAH.

Impact of clinicopathological variables on laparoscopic hysterectomy complications, a tertiary center experience

“…The presence of urinary tract complications in about half of postoperative major complications is a main cause of this significance. Anatomical distortions and the inability to obtain an optimal surgical field of vision secondary to causes such as increased blood loss, pelvic adhesions, and endometriosis are found to be associated with increased urinary tract injury [8,17], increased length of surgery and large uterus size was the described as the other risk factor in many studies [18,19]. As the prior reported data, deep infiltrating endometriosis was another reason for ureter complications in the present study.…”

“…Hence, this resulted with bladder and ureter complications in many studies [16,17]. Although the previous cesarean section was not directly related to intraoperative complications in the present study, there were notable effects on postoperative major complications.…”

<p>Perioperative Complications of Hysterectomy After a Previous Cesarean Section: A Systematic Review and Meta-Analysis</p>

“…14,17,29,32,33 Ten of the remaining included studies assessed the odds of surgical complications following minimally invasive hysterectomy (laparoscopic-assisted vaginal hysterectomy, total laparoscopic hysterectomy, and roboticassisted hysterectomy) 16,[20][21][22][23]27,28,31,34,35 and 11 included studies assessed the odds of various types of hysterectomy including total abdominal hysterectomy and vaginal hysterectomy. 4,6,15,18,19,[24][25][26]30,36,37 Study designs of the included studies were cohort studies (24) 4,6,14-25,27-29,31-37 and case-control studies (two) 26,30 (Tables S3 and S4). Figure 2 shows the summary of the risk of biases stratified by the type of study design.…”

“…6,14,15,17,18,22,27,29,31,33,34,37 No cohort study was judged as having a high risk of selection bias. The two case-control studies 26,30 included in this review were determined as having low-to-moderate risks of bias for all items.…”

A Review on the Etiology, Prevention, and Management of Ureteral Injuries During Obstetric and Gynecologic Surgeries

“…The possible causes of iatrogenic ureteric injuries include gynecologic procedures like abdominal hysterectomy, vaginal hysterectomy, anterior colporrhaphy, laparoscopic hysterectomy; 8 obstetric causes and predisposing factors like cesarean hysterectomy, fetal macrosomia, cephalopelvic disproportion, placenta previa, and morbidly adherent placentas involving the pelvic sidewalls, difficult neonatal extraction, prolonged labor, and abnormal fetal lie. 9 , 10 Other risk factors for iatrogenic injury include causes of pelvic adhesion like the previous surgeries, 11 endometriosis, and prior radiation therapy, advanced abdominopelvic cancers, 12–14 enlarged uterus at hysterectomy, cervical fibroids, and broad ligament fibroids, limited experience of the surgeon, bleeding, and excessive use of diathermy, 3 and transvaginal retrieval of oocytes (TOVR).…”