Most ureteric injuries are caused by gynecologic surgery, with most occurring during procedures for benign diseases. Although such injuries are relatively rare, they are associated with significant morbidity. It is important to detect a urinary tract injury by cystoscopy intraoperatively; this allows for immediate referral and repair by a urologist during the same surgical procedure. Several medical societies have issued guidelines on the selective use of intraoperative cystoscopy. However, there are no strict recommendations on the role of universal cystoscopy in benign gynecologic surgery.The aims of this study were to calculate the rates of urinary tract injury detected during and after benign gynecologic surgery, to explore the role of routine intraoperative cystoscopy at benign gynecologic surgery and determine whether it helps reduce injuries detected postoperatively. A systematic search was conducted for articles published from 2004 to August 2014 reporting urinary tract injuries at benign gynecologic surgery using databases of PubMed, EMBASE, and ClinicalTrials.gov. Articles were identified that described rates of urinary tract injuries that did or did not use intraoperative cystoscopy. An additional search of Web of Science was performed to identify studies involving robotic surgery, which are fairly new. These results were combined with a database search from a previously published systematic review to include earlier studies.Data were extracted from 79 studies that met inclusion criteria; most were retrospective. Excluded were letters to the editor, case reports, studies involving only selective cystoscopy in higher-risk patients, and reports including injuries resulting from obstetric or oncologic procedures. Data from each article were classified according to type of surgery as follows: vaginal hysterectomy, abdominal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, other gynecologic and urogynecologic surgery, and other robotic gynecologic and urogynecologic surgery.The ureteric and bladder injury rates were determined for each surgery type for which there are reported injury rates from data in studies with and without routine intraoperative cystoscopy. There was up to a 5-fold increase for detected rates of ureteric and bladder injury with routine intraoperative cystoscopy. The adjusted ureteric injury rate was 0.3%, and the bladder injury rate was 0.8%. Postoperative ureteric injury detection rates per 1,000 surgeries were marginally higher with routine cystoscopy (1.6) than without routine cystoscopy (0.7). There was also little difference in postoperative bladder injury detection rates: 0.8 per 1,000 surgeries with routine cystoscopy and 1.0 without routine cystoscopy.Routine cystoscopy clearly increases the intraoperative detection rate of urinary tract injuries but does not seem to have any meaningful effect on the postoperative injury detection rate.

Although routine cystoscopy clearly increases the intraoperative detection rate of urinary tract injuries, this systematic review of 79 mostly retrospective studies shows that it does not appear to have much effect on the postoperative injury detection rate.