Hysterectomy

Because hysterectomy is one of the most commonly performed gynecologic procedures in the United States, it is no surprise that the majority of urologic injuries occur with this procedure. Most injuries to the ureter occur while attempting to clamp the uterine vessels near their path alongside the uterine cervix.

Efforts should be made to avoid lateral deviation into the parametrium, while isolating the uterine vessels. This oftentimes kinks the ureter, resulting in obstruction. It may also lead to ureterovaginal fistula. The second common site of injury to the ureter occurs when clamping the ovarian vessels as they pass through the infundibulopelvic ligament. The close approximation of the ureter medially and inferiorly as it enters the true pelvis often results in damage at this point. This may involve inadvertent clamping or thermal injury to complete transection. The most common site of injury to the bladder during hysterectomy occurs when separating the uterus and bladder anteriorly. Injury above the trigone may occur in this area.

In 1999, Gilmour et al. reviewed reports of lower urinary tract injury from 1966 to 1998 (7). Listed in Tables 1 and 2 are the frequencies of ureteral and bladder injuries after major gynecologic surgery.

The overall frequency of ureteral injury was 1.6/1000. The overall frequency of bladder injury was 2.6/1000. In 2004, the evaluate study included two parallel randomized trials of laparoscopic versus abdominal hysterectomy and laparoscopic versus vaginal hysterectomy (8). The primary outcome was rate of complications. In the laparoscopic versus abdominal trial, laparoscopy was associated with higher complications (11.1% vs. 6.2%, p = 0.02; difference, 4.9%, 95% confidence interval, 0.9-9.1). The number needed to treat to harm was 20. The rate of bladder and ureteral injuries was 2.1% and 0.9%, respectively, in the laparoscopic group versus 1% and 0% in the abdominal group. In the laparoscopic versus vaginal study, there was no difference in the rate of major complications (9.8% vs. 9.5%, p = 0.92; difference, 0.3%, —5.2% to 5.8%), and the number needed to treat to harm was 333.

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