Urologic Injury and Fistula After Hysterectomy for Benign Indications

Abstract

OBJECTIVE: To explore the rates and risk factors for sustaining a genitourinary injury during hysterectomy for benign indications. METHODS: In this population-based cohort study, all women who underwent hysterectomy for benign indications were identified from the Office of Statewide Health Planning and Development databases in California (2005–2011). Genitourinary injuries were further classified as identified at the time of hysterectomy, identified after the date of hysterectomy; or unidentified until a fistula developed. RESULTS: Of the 296,130 women undergoing hysterectomy for benign indications, there were 2,817 (1.0%) ureteral injuries, 2,058 (0.7%) bladder injuries and 834 (0.3%) genitourinary fistulas (80/834 of which developed after an injury repair). Diagnosis was delayed in 18.6% and 5.5% of ureteral and bladder injuries, respectively. Subsequent genitourinary fistula development was lower if the injury was identified immediately (compared with delayed) for both ureteral (0.7% vs 3.4% odds ratio [OR] 0.28; 95% CI 0.14–0.57) and bladder injuries (2.5% vs 6.5% OR 0.37; 95% CI 0.16–0.83). Indwelling ureteral stent placement alone was more successful in decreasing the risk of a second ureteral repair for immediately recognized ureteral injuries (99.0% vs 39.8% for delayed injuries). With multivariate adjustment, prolapse repair (OR 1.44, 95% CI 1.30–1.58), an incontinence procedure (OR 1.40, 95% CI 1.21–1.61), mesh augmented prolapse repair (OR 1.55, 95% CI 1.31–1.83), diagnosis of endometriosis (OR 1.46, 95% CI 1.36–1.56), and surgery at a facility in the bottom quartile of hysterectomy volume (OR 1.37, 95% CI 1.01–1.89) were all associated with an increased likelihood of a genitourinary injury. An exclusively vaginal (OR 0.56, 95% CI 0.53–0.64) or laparoscopic (OR 0.80, 95% CI 0.75–0.86) approach was associated with lower risk of a genitourinary injury as compared with an abdominal approach. CONCLUSION: Genitourinary injury occurs in 1.8% of hysterectomies for benign indications; immediate identification and repair is associated with a reduced risk of subsequent genitourinary fistula formation.

Endometriosis and the Urinary Tract: From Diagnosis to Surgical Treatment

“…It is commonly thought that the risks of surgery are higher when a patient has endometriosis, but this is based on general (and often retrospective) gynecologic surgery literature. For example, the odds ratio of a genitourinary injury during hysterectomy for a benign indication was 1.46 (95% confidence interval 1.36–1.56) when endometriosis was present [ 59 ]. There is less literature on the complication rate amongst those who undergo a combined gynecologic-urologic surgery for endometriosis with a thorough interdisciplinary evaluation, including preoperative imaging.…”

Cost-effectiveness Analysis of Universal Cystoscopy at the Time of Benign Laparoscopic Hysterectomy

“…When isolated to only prospective data(21-23) estimated rates of LUTI are 12-28 times higher. Moreover, recent analyses utilizing comprehensive state-wide claims-based analysis suggest that rates of LUTI are likely greater than previously estimated within retrospective data; these contemporary state database analyses report a 1.8% overall LUTI rate and 0.70-0.78% ureteral injury rate (10,24). Based on these estimates, we our model suggests that universal cystoscopy is likely costeffective among all women undergoing laparoscopic hysterectomy.…”

“…Our model also encompassed a one-year time horizon, as opposed to 30-day or 90-day outcomes which have been used to inform some prior analyses (3,7,29). Notably, a recent study revealed almost half of repairs for urologic injury from benign hysterectomy occurred outside these windows (median 84 days; IQR 21-274) (24). Third, our model incorporated dynamic estimates of the underlying rate of LUTI and its intraoperative detection by cystoscopy.…”

“…Limited prospective data utilizing routine cystoscopy have demonstrated higher rates of diagnosis of injury at the time of hysterectomy and higher overall rates of LUTI (6,(21)(22)(23). While the clinical significance of these injuries detected by intraoperative cystoscopy remains undefined, more recent research suggests LUTI is likely more prevalent than previously estimated (10,24). To address these limitations, we performed a series of threshold analyses to vary both the overall rate of LUTI and the sensitivity of Due to limited quality of life estimates for LUTI and its complications, we utilized a one-year time horizon.…”

Endometriosis and the Urinary Tract: from Diagnosis to Surgical Treatment

“…For example, the odds ratio of a genitourinary injury during hysterectomy for benign indication was 1.46 (95% confidence interval 1.36-1.56) when endometriosis was present. 55 There is less literature on the complication rate amongst those who undergo combined gynecologic-urologic surgery for endometriosis with a thorough interdisciplinary evaluation, including preoperative imaging. It is currently thought the cumulative surgical complication rate for patients surgically treated for UE is estimated to be 9%.…”