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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