Which Surgeries are Most Likely to Lead to Urinary Tract Injury?
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. State the complication rate for ureteric and bladder injuries during gynecologic laparoscopy for benign indications 2. Discuss the authors’ conclusion regarding the use of routine cystoscopy as part of gynecologic laparoscopic procedures
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from March 4 2018 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
Studies report incidences from 0.2% to 1.6% of injury to lower urinary tract during gynecologic laparoscopy
Wong et al. (Obstetrics & Gynecology, 2018) examined the current urinary tract injury trends in gynecologic laparoscopy for benign indications
Systematic review and meta-analysis
Comprehensive literature review of 433 studies including
90 studies published between 1975 and 2015
Total of 140,444 surgeries
All articles reporting the incidence of urinary tract injury in gynecologic laparoscopy for benign indication
Exclusion criteria comprised malignancy, surgery by urogynecologists, research not in English, and insufficient data
Causes of lower urinary tract injury included the following
Electrosurgery or laser ablation
Forceps or scissor use
Lysis of adhesions or dissection
Suturing or stapling
Veress or trocar insertion
Outcomes of interest were findings that could help enhance patient counseling
Incidence, location, cause, timing, management, and long-term sequelae of lower urinary tract injury in gynecologic laparoscopy for benign indications
458 lower urinary tract injuries were reported with an incidence of 0.33% (95% CI 0.30–0.36)
Bladder injury (0.24%; 95% CI 0.22–0.27) was 3x more frequent than ureteral injury (0.08%; 95% CI 0.07–0.10)
The highest rates of injury were associated with laparoscopic hysterectomy not otherwise specified (1.8%; 95% CI 1.2–2.6) and laparoscopically assisted vaginal hysterectomy (1.0%; 95% CI 0.9–1.2)
Most ureteral injuries resulted from electrosurgery or laser ablation (33.3%; 95% CI 24.3–45.8)
Most bladder injuries resulted from lysis of adhesions or dissection (23.3%; 95% CI 18.7–29.0)
Ureteral injuries were most often
Recognized postoperatively (60%; 95% CI 47–76)
Repaired by open ureteral anastomosis (47.4%; 95% CI 36.3–61.9)
Bladder injuries were most often
Recognized intraoperatively (85%; 95% CI 75–95)
Repaired by laparoscopic suturing (34.9%; 95% CI 29.2–41.7)
No significant difference was found with use of cystoscopy (P=.28)
38% of ureteral injuries were recognized intraoperatively and 84% of bladder injuries
With routine cystoscopy
53% of ureteral injuries were recognized intraoperatively and 94% of bladder injuries
The likelihood of lower urinary tract injury during laparoscopy for benign conditions is 0.33%
Laparoscopic hysterectomy and vaginal hysterectomy are associated with the highest injury risk
The authors state that
Given the recent endorsement of routine cystoscopy by professional gynecologic societies and the incorporation of cystoscopy training into obstetrics and gynecology residency programs, it is likely that the ability of gynecologic surgeons to detect lower urinary tract injuries through cystoscopy will continue to improve and contribute to the promotion of universal cystoscopy.
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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