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Urinary tract injury in gynecologic surgery: Prevention

Donna Gilmour, MD, FRCSC
Section Editors
Linda Brubaker, MD, FACOG
Howard T Sharp, MD
Deputy Editor
Kristen Eckler, MD, FACOG


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: Surgical 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. Up to 2.4 percent of patients may require concomitant urologic intervention after hysterectomy-related injury to the urinary tract [3].

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) [1]. 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). Specific to hysterectomy, a retrospective cohort study from an academic center that instituted universal cystoscopy at the time of hysterectomy reported significantly fewer delayed urologic complications in the postuniversal care patients compared with the pre-universal cystoscopy group (0.1 versus 0.7 percent) [4].

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'.)

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Literature review current through: Nov 2017. | This topic last updated: Sep 27, 2017.
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