Urinary Tract Injury at Benign Gynecologic Surgery and the Role of Cystoscopy

Abstract

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.

Cystoscopy at the time of benign hysterectomy: a decision analysis

“…Based on prior literature, bladder injury incidence was 1.75%, 0.93%, and 2.91% for abdominal, laparoscopic/robotic, and vaginal hysterectomy, respecitvely. 2,9,11 Ureteral injuries occur in 1.61%, 0.46%, and 0.46%, respecitvely. 8,9,12,13 The model's average hysterectomy costs with no cystoscopy varied from $884.89 to $1121.91.…”

“…Selectively performing cystoscopy adds between $13.20 and $26.13 to the cost of surgery, depending on the modality of hysterectomy (Table 3). With increasing risk of urinary tract injury, these costs are offset by savings that come from intraoperative, rather than delayed diagnosis, ajog.org 11 Ibeanu et al 2 Chi et al 9 Anand et al 7 Aarts et al 1 0.0046 0.0001e0.0276…”

Urinary Tract Injury at Gynecological Surgery: Results from a Tertiary-Care Institution

“…In the most recent meta-analysis, Teeluckdharry et al (15) reported a lower but non-significant postoperative ureteric injury detection rates with the use of routine cystoscopy when compared to no cystoscopy (0.07% vs. 0.16%, p<0.054). The authors concluded that although this meta-analysis used a large pooled data from a total of 79 reports, most of these studies was retrospective and would thus tend to underestimate the actual injury rates.…”

Diagnosis and Management of Delayed Postoperative Complications in Gynecology: Neuropathy, Wound Complications, Fistulae, Thromboembolism, Pelvic Organ Prolapse, and Cuff Complications

“…The most common operative complication during hysterectomy or cesarean section is urinary tract injury. The exact prevalence of bladder and ureteral injury during obstetric/gynecologic surgery is unknown, though estimates range from 0.3 % to 4.3 % (Teeluckdharry et al 2015). The bladder is most commonly injured during (1) entry into the peritoneal cavity, (2) development of the bladder flap at the time of cesarean section or hysterectomy, or (3) closure of the vaginal cuff at the time of hysterectomy.…”