Introduction
Hysterectomy is the most common gynecologic surgery performed worldwide, with 500,000–600,000 hysterectomies performed in the United States each year. Hysterectomy is also one of the most common causes of iatrogenic urinary tract injury because of the frequency with which the surgery is performed and the close proximity of the upper female genital tract to the urinary tract. Historically, gynecologic surgery accounted for most cases of urinary tract injury, but this has changed over the years with fewer hysterectomies and more procedures in urology, vascular, colorectal, and orthopedic surgery being performed. In one recent review, gynecologic surgery accounted for 34% of ureteral injuries, still coming second to urologic procedures, which accounted for 42% of such injuries. Minimally invasive urologic surgery has now become the most common cause of iatrogenic urinary tract injury.
Urinary tract injury during gynecologic surgery requires longer operative time for repair, longer hospital stay, prolonged bladder catheterization, and repeat surgery if unrecognized at the time of initial procedure. Women with urinary tract injury during abdominal hysterectomy were found to have greater blood loss, more febrile morbidity, and more frequent transfusions. There may be complications of the repair, such as fistula formation, ureterovesical reflux or ureteral stricture, which can result in further surgery for the patient. These may all result in more pain, days lost from work, anxiety, depression, and worsening quality of life for the patient.
In a study published in 2005 in which universal cystoscopy was performed, among 471 hysterectomies (abdominal, vaginal and laparoscopic), the total urinary tract injury rate was 4.8% (1.7% ureteral injury, 3.6% bladder injury); no difference in rate of injury by type of hysterectomy was identified. However, a recent meta-analysis of 30 studies found that urinary tract injuries are more common during laparoscopic hysterectomy (OR 2.61, 95% CI 1.22–5.60), although much of that is believed to be due to operator inexperience rather than to the approach itself. The rate of ureteral injury was lowest with vaginal hysterectomy (0.2 per 1000), followed by supracervical abdominal hysterectomy (0.5 per 1000), total abdominal hysterectomy (0.9 per 1000), and laparoscopic hysterectomy (7.3 per 1000). For bladder injury, the rates were 2.7, 0.3, 2.1, and 6.0 per 1000 for vaginal, supracervical abdominal, total abdominal, and laparoscopic hysterectomy, respectively. There does not appear to be a significant difference in rates of total urinary tract injury between total abdominal and vaginal hysterectomy, but ureteral injury may be more common with the total abdominal hysterectomy and bladder injury more common with vaginal hysterectomy. Possible predisposing factors for urinary tract injury are pelvic adhesions, distortion of normal pelvic anatomy, previous radiation, and history of previous pelvic surgery.
Between 1968 and 1998, 155 incidental cystotomies occurred at Los Angeles County-University of Southern California (LAC-USC) Medical Center, with a rate of 1.2% for vaginal hysterectomy and 0.7% for abdominal hysterectomy.
Bladder injury during hysterectomy may be avoided by using sharp instead of blunt dissection when operating near the vesicouterine space. Utilizing the intrafascial rather than extrafascial technique of hysterectomy also aids in avoiding bladder injury. Many bladder injuries are easily identified at the time of surgery due to efflux of urine or visualization of the Foley catheter. However, if there is any suspicion of bladder injury, it is crucial for the surgeon fully to evaluate the bladder and ureters. Injury to the bladder can be confirmed by filling the bladder through a transurethral catheter with methylene blue dye.
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