Laparoscopic Hysterectomy and Urinary Tract Injury: Experience in a Health Maintenance Organization

Abstract Study Objectives To evaluate the incidence, detection, characteristics, and management of urinary tract injury in a cohort undergoing laparoscopic hysterectomy, and to identify potential risk factors for urinary tract injury with laparoscopic hysterectomy. Design Retrospective analysis (Canadian Task Force classification II-2). Setting Kaiser Permanente San Diego Medical Center, 2001 to 2012. Patients Women who underwent attempted laparoscopic hysterectomy for benign indications. Interventions Total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparoscopic supracervical hysterectomy. Measurements and Main Results Demographic and clinical characteristics, surgical techniques, and perioperative complications were abstracted from the medical record. Multivariable logistic regression analysis assessed independent risk factors for ureteral or bladder injury. Results A total of 3523 patients (mean age, 45.9 ± 8.0 years; median parity, 2; range, 0–10), with a median body mass index (BMI) of 29 kg/m2 (range, 16–72 kg/m2 ), underwent laparoscopic hysterectomy; 20% had intraoperative cystoscopy. The incidence of urinary tract injury was 1.3% (46 of 3523); of the 46 patients with injuries, 19 (0.54%) had ureteral injuries, 25 (0.71%) had bladder injuries, and 2 (0.06%) had both types. Of the 21 ureteral injuries, 6 (29%) were diagnosed intraoperatively and 15 (71%) were diagnosed postoperatively, including 4 with normal intraoperative cystoscopy. Of the 27 bladder injuries, 23 (85%) were identified intraoperatively. In multivariable logistic analysis, a BMI of 26 to 30 kg/m2 (compared with >30 kg/m2 ) was associated with an increased risk of ureteral injury, and a BMI ≤25 kg/m2 (compared with >30 kg/m2 ) and the presence of endometriosis were associated with an increased risk of bladder injury. Conclusion Urinary tract injury occurred in 1.3% of laparoscopic hysterectomies, with ureteral injuries almost as common as bladder injuries. Normal intraoperative cystoscopy findings did not exclude the presence of ureteral injury.