#Grand Rounds

CMECNE

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

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

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 March 3 2021, 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.

Read Disclaimer & Fine Print

BACKGROUND AND PURPOSE:

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

METHODS:

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
- Vaginal surgery
- Veress or trocar insertion
- Unspecified cause
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

RESULTS:

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)
Without cystoscopy
- 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

CONCLUSION:

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.

Learn More – Primary Sources:

Urinary Tract Injury in Gynecologic Laparoscopy for Benign Indication: A Systematic Review

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