Intraoperative Injuries to the Lower Urinary Tract during Hysterectomy

Operative complications of intrafascial hysterectomy have been widely investigated with the question of which surgical approach—abdominal, vaginal, laparoscopic, or robotic—is optimal for management of benign disease. The rate of mortality for a benign hysterectomy is approximately 0.1%. Yet, even at this low rate, given that approximately 600,000 hysterectomies are performed annually in the United States, an estimated 600 women die from hysterectomy-related complications each year. The major morbidities of hysterectomy include, but are not limited to, hemorrhage requiring transfusion, infection, pulmonary embolus, wound dehiscence, injury to bowel, nerves, and the lower urinary tract including the bladder and ureter. The overall complication rate ranges between 6% and 19%. Laparoscopic hysterectomy, despite being associated with shorter hospitalizations and better short-term patient function, has consistently been associated with a higher risk of lower urinary tract injuries. The surgeon’s failure to recognize a lower urinary tract injury can complicate matters further both in the short term (e.g., uremia, ileus) and long term (e.g., kidney failure or vesicovaginal or ureterovaginal fistula).

The bladder is the most commonly injured urinary structure in gynecologic surgery for both benign and malignant disease. Overall, the average incidence of bladder injury from major gynecologic surgery (the majority from hysterectomy) is 0.8%. In a Finnish study by of greater than 10,000 hysterectomies, the rate of bladder injury was 0.2%, 0.5%, and 1.3% for vaginal, abdominal, and laparoscopic hysterectomy, respectively. The ureter is the second most commonly injured organ during major gynecologic surgery with abdominal hysterectomy accounting for 86% of all injuries. The Finnish study, reflecting a trend seen among other studies, found the ureter injury rate for vaginal hysterectomy was 0%; after abdominal and laparoscopic hysterectomy, it was 0.2% and 1.1%, respectively.

reported on lower urinary tract injury in women in the United States from 1979 to 2006 based on the National Hospital Discharge Survey. This large cohort includes data on nearly 50 million gynecologic procedures including 11.7 million abdominal hysterectomies, 4.3 million vaginal hysterectomies, 591,069 laparoscopic-assisted vaginal hysterectomies (LAVH), 327,857 supracervical abdominal hysterectomies, 141,938 radical abdominal hysterectomies, and 38,887 laparoscopic supracervical hysterectomies. This study found the bladder injury rate was highest in LAVH (13.8/1000) and vaginal hysterectomy (13.1/1000). The bladder injury rate was 10.3/1000 for supracervical abdominal hysterectomy. Total abdominal hysterectomy, radical abdominal hysterectomy, and laparoscopic supracervical hysterectomy all had the lowest rates of bladder injury at 6.9/1000, 2.2/1000, 0/1000, respectively. Ureteral injury rates were most common with radical hysterectomy at 7.7/1000. This is not unexpected given the extensive dissection around the ureter that is routinely done at the time of a radical hysterectomy for malignancy. Lower ureteral injury rates were seen for vaginal hysterectomy (0.7/1000), supracervical abdominal hysterectomy (0.6/1000), laparoscopic supracervical hysterectomy (0.6/1000), and laparoscopic-assisted vaginal hysterectomy (0/1000). The authors note that the rate of ureteral injury with LAVH in their study may be underestimated as their dataset used procedure codes and an LAVH with a recognized ureteral/bladder injury is likely to be converted to an open procedure.

also addressed the primary surgical indication for women who sustained nonobstetric bladder injuries ( n = 315,755) and found that 21.8% of the cohort with bladder injuries were undergoing surgery for urinary incontinence as compared to 8.1% with bladder injuries who were undergoing surgery for gynecologic malignancy. When looking at the primary indication for surgery in women who sustained ureteral injuries ( n = 109,589), the majority were undergoing surgery for malignancy at 7.5% with endometriosis being the next most common operative indication in women with ureteral injuries at 4.0%. The question of how hysterectomy precipitates urinary tract injury answered in these studies teaches that overall the rate of injury is low but varies with surgical approach, with that likely reflecting case complexity and surgeon experience.

Applying these lessons to the treatment of gynecologic malignancies is complicated by the added complexity and morbidity of lymph node sampling that may be done along with the “standard” intrafascial hysterectomy. Additionally, patient characteristics such as prior pelvic irradiation as may be the case in hysterectomy for cervical cancer, tumor infiltration and distortion of tissues as in ovarian cancer, or morbid obesity as in endometrial cancer can all lead to the potential for increases in ureteral and bladder injuries. Offsetting any rise in urologic injuries that may occur because of this added complexity is the overall greater surgical experience among gynecologic oncologists. Despite these potential confounders, more data are becoming available for injury rates specific to surgical management of gynecologic malignancy. In the largest Gynecologic Oncology Group study comparing laparoscopy with laparotomy for surgical staging of endometrial cancer, looked at operative complications as a secondary outcome. This multi-institutional study found no difference for intraoperative bladder or ureter complications between the surgical approaches, with each at a rate of 1%. The postoperative complication rate of urinary fistula was also no different between the laparotomy and laparoscopy groups at less than 1% each. In a subsequent study, performed a retrospective, multisite study at high-volume cancer centers comparing minimally invasive surgery versus laparotomy in women with high-grade endometrial cancer finding identical urinary tract injury rates at 1/192 for laparotomy and 1/191 for minimally invasive surgery. These data, taken with the improved quality of life scores seen for women undergoing minimally invasive surgical staging for endometrial cancer, have transformed management of this malignancy to one primarily approached laparoscopically or robotically.

Similar minimally invasive management trends are being seen in cervical cancer staging. reported on 42 cases of Type II and III robotic radical hysterectomies and found a bladder injury rate of 0.02% (1/42) and an identical ureteral injury. In the largest published comparative series on radical hysterectomy for cervical cancer, examined 1894 women undergoing radical hysterectomy by various routes and reported rates of bladder and ureteral injury. This study found no statistically significant difference in bladder injury rate by route of surgery with a 2.2% rate for abdominal radical hysterectomy, 2.8% for laparoscopic radical hysterectomy, and 3.0% for robotic radical hysterectomy. There was also no difference seen in ureteral injury rate among the different approaches, with 1.9% for abdominal radical hysterectomy, 0% for laparoscopic radical hysterectomy, and 3.0% for robotic radical hysterectomy.

Postoperative Effects of Hysterectomy on the Lower Urinary Tract

Of the available studies on the postoperative effects of hysterectomy on the lower urinary tract, only one is randomized and all are limited by small size (between 16 and 72 subjects) and short duration (all but one 6 months or less). The message from these studies is conflicting. A minority of studies documents some bladder dysfunction following hysterectomy, whereas the majority finds either no effect or improvement in bladder function. The minority view holds that, with hysterectomy, there is a disruption of the autonomic and sensory nerves to the bladder—a view more substantiated with radical hysterectomy. Retrospective reviews of incontinent patients have uncovered an association between women symptomatic for some lower urinary tract dysfunction (e.g., incontinence, voiding dysfunction) and hysterectomy. A large population study by investigating this issue queried 7949 American women over the age of 65 and found daily urinary incontinence was more common in women who had had previous hysterectomy than those who had not (adjusted odds ratio 1.4; 95% CI 1.1-1.6). Among these retrospective studies, the variability in definitions of urinary incontinence and the unknown indications for hysterectomy (e.g., pelvic organ prolapse) make interpretation of their results difficult. Furthermore, these studies are hindered by selection and/or recall bias.

, in a prospective study of 43 women before and after hysterectomy, found no change in reported stress or urge incontinence at a mean follow-up of 14.2 months. Yet studies that find either no association or a beneficial effect of hysterectomy on bladder function could suffer from inadequate follow-up times to uncover the issues seen in the long-term population-based studies. Notably, a number of studies have compared urodynamic findings before and after hysterectomy and all have found no significant changes in mean cystometric capacity, occurrence of spontaneous detrusor contractions, postvoid residual volumes, or uroflowmetry values. Taken together, the quality evidence available to date supports the conclusion that intrafascial hysterectomy is unlikely to cause any lower urinary tract dysfunction in the short term and any long-term effects are unclear.

Bladder Dysfunction

Despite documenting stable bladders on urodynamic studies of women following radical hysterectomy, the majority of studies report abnormal spontaneous contractions of the bladder. A number of studies have shown decreased bladder compliance and resultant increased bladder pressures in patients following radical hysterectomy. Table 42.3 lists these reported urodynamic bladder changes following radical hysterectomy. These findings, however, are usually transient with spontaneous resolution or development of bladder areflexia and overflow incontinence over the following year. Both and reported patients with permanent inability to void following radical hysterectomy, presumably from an atonic bladder. In a study of women who had undergone a radical hysterectomy no less than 10 years prior, found 18 of 20 had absent bladder contractility requiring abdominal straining to void. Detrusor function can be impaired irrespective of intravesical pressure. Decreased bladder compliance and increased intravesical pressure would be expected to correspond with increased flow rates and less residual urine, but this is not always the case following radical hysterectomy.

The etiologies of bladder and urethral effects after radical hysterectomy are difficult to decipher. Several studies have investigated the effects of sparing some portion of the cardinal ligaments on bladder function. The concept has merit as studies confirm the presence of abundant nerve tissue in the cardinal and uterosacral ligaments, particularly at their site of origin along the pelvic sidewall. , and all documented less-impaired bladder function among patients undergoing radical hysterectomy in whom portions of the cardinal ligaments were preserved. The inferior hypogastric plexus consists mainly of parasympathetic fibers from sacral roots S3 and S4 as well as some sympathetic fibers from the lumbosacral trunk. These nerves are present at least in part in the cardinal and uterosacral ligaments and supply the large bowel (to the level of the internal anal sphincter), the bladder and urethra, and the entire genital tract. Division of these nerves during radical hysterectomy alters the neurologic control of the lower urinary tract, resulting in dysfunction. In 1973, Roman-Lopez and Barclay postulated that parasympathetic overdominance following radical hysterectomy accounted for the initial bladder dysfunction. However, this theory fell into disfavor when parasympatholytic agents did not reverse the bladder effects. Alternatively, argued that damage to the sympathetic portion of the hypogastric plexus accounted for the bladder dysfunction. Difficulty with this mechanism, however, arises in investigations such as that did not find any correlation between the radicality of the surgery and any lower urinary tract dysfunction. Moreover, discounted the effects of denervation, citing a German study wherein the amount of cardinal ligament resected did not correlate with degree of lower urinary tract dysfunction. They argued that direct operative trauma, edema, hematoma, and scar formation accounted for the majority of dysfunction following radical hysterectomy.

Detrusor sensation is diminished in every study of the effects of radical hysterectomy on lower urinary tract function. Cervical cancer per se probably does not affect bladder sensation. Following radical hysterectomy, patients report replacement of the normal bladder sensation with a vague sense of fullness in the lower abdomen. With lost physiologic cortical sensory input from the bladder following radical hysterectomy, patients may become aware of less sensitive indicators of vesical distention such as peritoneal stretching or pressure on adjacent abdominal viscera. Often this altered sensation improves over the course of a year. However, decreased bladder sensation can lead to bladder atony if careful early postoperative bladder drainage is not maintained.

Urethral Dysfunction

The etiology of urethral dysfunction after radical hysterectomy has not been clearly determined, although recent work suggests that outlet dysfunction works in concert with the known bladder dysfunction. The most consistent urodynamic finding following radical hysterectomy is decreased urethral pressure. The functional urethral length is decreased in many studies, although this appears to resolve over time. Table 42.4 catalogs the changes in the urethra following radical hysterectomy. Anatomic support defects resulting in stress incontinence are not usually found following radical hysterectomy. Notably, argued that anti-incontinence procedures designed to suspend the bladder neck would be largely unsuccessful because intrinsic sphincter deficiency is more often the etiology of urinary incontinence among these patients. The success of contemporary mid-urethral slings on treatment of urinary incontinent women following radical hysterectomy is beginning to emerge. reported on two patients with stress urinary incontinence following radical hysterectomy for cervical cancer treated with a single-incision mid-urethral sling. Both women reported favorable stress urinary incontinence (SUI) management outcomes, but one had a minor mesh extrusion and the other required treatment for urinary urgency. Given the general inferiority of single-incision mid-urethral slings to the traditional retropubic approach, the success in this case portends mid-urethral sling surgical approaches are a viable option for SUI management among women who have had cervical cancer.

Table 42.4

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