Urinary tract injury in gynecologic surgery: Prevention
- Donna Gilmour, MD, FRCSC
Donna Gilmour, MD, FRCSC
- Associate Professor
- Department of Obstetrics and Gynecology
- Dalhousie University
- Section Editors
- Linda Brubaker, MD, FACS, FACOG
Linda Brubaker, MD, FACS, FACOG
- Section Editor — Urogynecology and Pelvic Organ Prolapse
- Dean and Professor of Obstetrics and Gynecology
- Stritch School of Medicine Loyola University, Chicago
- Howard T Sharp, MD
Howard T Sharp, MD
- Section Editor — Gynecologic Surgery
- Professor and Vice Chair for Clinical Activities
- Department of Obstetrics and Gynecology
- University of Utah Health Sciences Center
The reproductive and urinary tracts in women are closely related anatomically and embryologically. Knowledge of this anatomy plays an important role in the prevention of urinary tract injury during gynecologic surgery. The primary approach to prevention is careful surgical dissection and knowledge of the position of urinary tract structures within the surgical field.
The prevention of urinary tract injury in gynecologic surgery, primarily hysterectomy, will be reviewed here. The evaluation and management of urinary tract injury in gynecologic surgery, urinary tract injuries during advanced procedures performed for urinary incontinence, pelvic organ prolapse, or gynecologic malignancy, as well as during obstetric procedures are discussed separately. (See "Urinary tract injury in gynecologic surgery: Identification and management" and "Radical hysterectomy" and "Cesarean delivery: Technique" and "Operative vaginal delivery".)
The overall rate of urinary tract injury associated with pelvic surgery in women ranges from 0.3 to nearly 1 percent [1,2]. Bladder injury is more common than ureteral injury . However, the exact incidence of these injuries is difficult to ascertain because reported rates vary depending on the approach to diagnosis, the type of surgery, patient characteristics, and study design.
Factors that affect reported incidence
Use of cystoscopy — Cystoscopy (full terminology cystourethroscopy) is associated with a higher detection rate of urinary tract injuries compared with visual inspection alone, particularly for ureteral injuries. In a systematic review and meta-analysis of 79 studies that included multiple types of benign gynecologic surgeries, more than double the number of ureteral injuries were detected with routine use of cystoscopy than without (1.6 versus 0.7 per 1000 surgeries) . An increased detection rate with cystoscopy was also seen for bladder injuries, although the impact was not as large (1.0 versus 0.8 injuries per 1000 surgeries detected with cystoscopy use or non-use).
Clinical use of cystoscopy in the diagnosis of operative urinary tract injury is discussed separately. (See "Urinary tract injury in gynecologic surgery: Identification and management", section on 'Cystoscopy' and "Diagnostic cystourethroscopy for gynecologic conditions", section on 'Procedure'.)
- Teeluckdharry B, Gilmour D, Flowerdew G. Urinary Tract Injury at Benign Gynecologic Surgery and the Role of Cystoscopy: A Systematic Review and Meta-analysis. Obstet Gynecol 2015; 126:1161.
- Bai SW, Huh EH, Jung DJ, et al. Urinary tract injuries during pelvic surgery: incidence rates and predisposing factors. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:360.
- Ibeanu OA, Chesson RR, Echols KT, et al. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol 2009; 113:6.
- Vakili B, Chesson RR, Kyle BL, et al. The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy. Am J Obstet Gynecol 2005; 192:1599.
- Neumann G, Rasmussen KL, Lauszus FF. Peroperative bladder injury during hysterectomy for benign disorders. Acta Obstet Gynecol Scand 2004; 83:1001.
- Lafay Pillet MC, Leonard F, Chopin N, et al. Incidence and risk factors of bladder injuries during laparoscopic hysterectomy indicated for benign uterine pathologies: a 14.5 years experience in a continuous series of 1501 procedures. Hum Reprod 2009; 24:842.
- Shirk GJ, Johns A, Redwine DB. Complications of laparoscopic surgery: How to avoid them and how to repair them. J Minim Invasive Gynecol 2006; 13:352.
- Jung SK, Huh CY. Ureteral injuries during classic intrafascial supracervical hysterectomy: an 11-year experience in 1163 patients. J Minim Invasive Gynecol 2008; 15:440.
- Gilmour DT, Baskett TF. Disability and litigation from urinary tract injuries at benign gynecologic surgery in Canada. Obstet Gynecol 2005; 105:109.
- Gustilo-Ashby AM, Jelovsek JE, Barber MD, et al. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol 2006; 194:1478.
- Jabs CF, Drutz HP. The role of intraoperative cystoscopy in prolapse and incontinence surgery. Am J Obstet Gynecol 2001; 185:1368.
- Tulikangas PK, Weber AM, Larive AB, Walters MD. Intraoperative cystoscopy in conjunction with anti-incontinence surgery. Obstet Gynecol 2000; 95:794.
- Shoemaker ES, Wilkinson PD. Teloscopy after bladder neck suspension. J Am Assoc Gynecol Laparosc 1998; 5:261.
- Pettit PD, Petrou SP. The value of cystoscopy in major vaginal surgery. Obstet Gynecol 1994; 84:318.
- Harris RL, Cundiff GW, Theofrastous JP, et al. The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery. Am J Obstet Gynecol 1997; 177:1367.
- Mendez LE. Iatrogenic injuries in gynecologic cancer surgery. Surg Clin North Am 2001; 81:897.
- Juillard C, Lashoher A, Sewell CA, et al. A national analysis of the relationship between hospital volume, academic center status, and surgical outcomes for abdominal hysterectomy done for leiomyoma. J Am Coll Surg 2009; 208:599.
- Leung PL, Tsang SW, Yuen PM, Quality Assurance Subcommittee in Obstetrics and Gynaecology, Hospital Authority, Hong Kong. An audit on hysterectomy for benign diseases in public hospitals in Hong Kong. Hong Kong Med J 2007; 13:187.
- Sorinola O, Begum R. Prevention and management of ureteric injuries. Hosp Med 2005; 66:329.
- DeLancey J. Surgical anatomy of the female pelvis. In: Te Linde's Operative Gynecology, Rock JA, Thompson JD (Eds), Lippincott-Raven, 2011.
- Underwood P. Operative injuries to the ureter. In: Te Linde's Operative Gynecology, Rock JA, Thompson JD (Eds), Lippincott-Raven, 2011.
- Netter FH. Atlas of Human Anatomy, Ciba-Geiby Corporation, New Jersey 1989.
- Donnez O, Jadoul P, Squifflet J, Donnez J. A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures. BJOG 2009; 116:492.
- Léonard F, Fotso A, Borghese B, et al. Ureteral complications from laparoscopic hysterectomy indicated for benign uterine pathologies: a 13-year experience in a continuous series of 1300 patients. Hum Reprod 2007; 22:2006.
- Sakellariou P, Protopapas AG, Voulgaris Z, et al. Management of ureteric injuries during gynecological operations: 10 years experience. Eur J Obstet Gynecol Reprod Biol 2002; 101:179.
- Hove LD, Bock J, Christoffersen JK, Andreasson B. Analysis of 136 ureteral injuries in gynecological and obstetrical surgery from completed insurance claims. Acta Obstet Gynecol Scand 2010; 89:82.
- Gilmour DT, Dwyer PL, Carey MP. Lower urinary tract injury during gynecologic surgery and its detection by intraoperative cystoscopy. Obstet Gynecol 1999; 94:883.
- Visco AG, Taber KH, Weidner AC, et al. Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy. Obstet Gynecol 2001; 97:685.
- Schimpf MO, Gottenger EE, Wagner JR. Universal ureteral stent placement at hysterectomy to identify ureteral injury: a decision analysis. BJOG 2008; 115:1151.
- Tanaka Y, Asada H, Kuji N, Yoshimura Y. Ureteral catheter placement for prevention of ureteral injury during laparoscopic hysterectomy. J Obstet Gynaecol Res 2008; 34:67.
- Chou MT, Wang CJ, Lien RC. Prophylactic ureteral catheterization in gynecologic surgery: a 12-year randomized trial in a community hospital. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:689.
- Baggish MS. Anatomy of the tretroperitoneum and the presacral space. In: Atlas of Pelvic Anatomy and Gynecologic Surgery, 2nd ed, Baggish MS, Karram MM (Eds), Elsevier Saunders, Philadelphia 2006. p.349.
- Campbell's Urology, Retik AB, Vaughn ED, Wein AJ (Eds), Saunders, Philadelphia 2002. p.3373.
- Bader AA, Tamussino KF, Winter R. Ectopic (pelvic) kidney mimicking bulky lymph nodes at pelvic lymphadenectomy. Gynecol Oncol 2005; 96:873.
- Factors that affect reported incidence
- - Use of cystoscopy
- - Type of procedure
- RISK FACTORS
- Patient characteristics
- Procedural factors
- Mechanisms of injury
- Sequelae of injury
- APPROACH TO PREVENTION
- PREOPERATIVE EVALUATION
- Informed consent
- Medical history
- Imaging studies
- OPERATIVE SET-UP
- Patient positioning
- Bladder catheter
- Prophylactic ureteral catheters
- SURGICAL TECHNIQUE
- Avoiding ureteral injury
- - Ligation of the ovarian vessels
- - Ligation of the uterine arteries
- - Vaginal cuff closure
- Avoiding bladder injury
- Intraoperative maneuvers
- Identifying a pelvic kidney
- SUMMARY AND RECOMMENDATIONS