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    Preventing urinary tract injury at the time of hysterectomy

    Four strategies for success

    Hysterectomy remains the most common gynecologic procedure in the United States; approximately 600,000 hysterectomies are performed each year, the majority of which are for benign disease.1 Minimally invasive approaches to hysterectomy have well-documented advantages, yet abdominal hysterectomy remains the most common mode of access, accounting for more than 60% of all hysterectomies performed in the United States as of 2005.1,2

    Despite the frequency with which hysterectomy is performed, urinary tract injury is not uncommon given the intimate relationship between the genital and urinary tracts.3 The various approaches to hysterectomy are accompanied by differing rates of urinary tract injury,4, 5 but the combined incidence of such events during procedures for benign disease is as high as 4.3% to 4.8%.5,6

    With regard to mode of hysterectomy, vaginal hysterectomy is reported to have a lower incidence of ureteral injury when compared with abdominal hysterectomy (0.9% vs 1.7%, although the differences did not reach statistical significance). Notably, the rate of ureteral injury did increase to 2.6% when vaginal hysterectomy was performed concomitant with pelvic floor reconstruction.5

    Illustration by Alex Baker, DNA Illustrations, Inc.


    More data have also become available on rates of urinary tract injury with laparoscopy as this approach has gained wider acceptance. In one of the first studies comparing incidence of ureteral injury in a Finnish cohort, incidence of injury was as high as 13.9 in 1000 for laparoscopic hysterectomy, versus 0.4 in 1000 for abdominal and 0.2 in 1000 for vaginal hysterectomies.7 However, in a follow-up study, incidence of ureteral injuries was 3.4 in 1000, a significant decrease that may be attributable to the learning curve associated with laparoscopic hysterectomy.8 Recent data do support a higher rate of recognized ureteral injury during total laparoscopic hysterectomy compared with other methods, including laparoscopic supracervical hysterectomy.9-11

    In the same initial Finnish cohort, incidence of bladder injury was higher in the abdominal hysterectomy group than in the vaginal or supracervical hysterectomy groups (1.3 vs 0.2 and 0.3 in 1000), but incidence of injury was highest with the laparoscopic approach (8.9 in 1000).7 The follow-up to this initial study also demonstrated a higher incidence of bladder injury with laparoscopic hysterectomy (3.4 in 1000).8 Notably, no significant difference has been shown with regard to incidence of bladder injuries for total versus subtotal laparoscopic hysterectomy.11

    The eVALuate study was a 2-part, randomized controlled trial that examined outcomes with laparoscopic hysterectomy versus abdominal hysterectomy and laparoscopic hysterectomy versus vaginal hysterectomy.12 In both arms of the trial, bladder injuries were encountered in all forms of hysterectomy, though ureteral injuries were noted only in laparoscopic hysterectomy cases. Laparoscopic hysterectomy was associated with a significantly higher rate of all major complications (including urinary tract injuries) than was abdominal hysterectomy. Although this difference was not detected in the vaginal hysterectomy arm of the trial, it was underpowered to detect such a difference.

    In terms of mode of access for hysterectomy, gynecologic surgeons’ familiarity with vaginal and abdominal approaches may explain the favorable rates of urinary tract injury associated with these procedures. Laparoscopic hysterectomy, however, is being performed more frequently due to advantages in minimizing blood loss, reducing length of hospital stay and decreasing postoperative pain and time to recovery.

    As surgeons progress on the learning curve and gain increased proficiency with laparoscopic hysterectomy, it is likely that rates of urinary tract injury will decrease. This article outlines strategies for successfully minimizing risk of urinary tract injury during hysterectomy, regardless of the operative approach.



    Sarah L. Cohen, MD, MPH
    Dr Cohen is an Assistant Professor in the Department of Obstetrics and Gynecology and Director of Research for the Division of Minimally ...


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