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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 29  |  Issue : 1  |  Page : 12-19

Management of urinary tract injuries following total hysterectomy: A single-hospital experience


1 Divisions of Urology, Department of Surgery, Tungs' Taichung Metro Harbor Hospital, Taichung, Taiwan
2 Department of Obstetrics and Gynecology, Tungs' Taichung Metro Harbor Hospital, Taichung, Taiwan

Date of Web Publication23-Feb-2018

Correspondence Address:
Chao-Yu Hsu
Tungs' Taichung MetroHarbor Hospital, Taichung
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_11_17

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  Abstract 


Objective: This study elaborated on the clinical experience of patients who underwent urologic management due to urologic complications after receiving a total hysterectomy at a regional hospital. Materials and methods: A total of 696 female patients received the four types of total hysterectomy including total abdominal hysterectomy, transvaginal hysterectomy, lapaparoscopic hysterectomy or robotic hysterectomy for variant gynecologic pathologies. Only 22 cases (3.2%) had urologic procedures performed during or after the operations from 2012/1/1 to 2016/6/30. Results: Of the 22 cases, thirteen (1.9%) received a series of conservative managements only, including cystoscopy, ureteroscopy, endoscopic ureterotomy, ureteral catheterization or double J stenting during the follow-up period. Nine more complicated cases (1.3%) eventually had definitive management, including repair of the urinary bladder rupture, repair of the vesicovaginal fistula, ureteroureterostomy or ureteroneocystostomy. However, five of these nine cases had both conservative and definitive management. The mean delay interval between the initial management and gynecologic procedure was 19.3 days. For definitive management and the gynecologic procedure, the period was 52.8 days. Conclusions: Compared to previous studies, the incidence of urologic injuries following a total hysterectomy in our hospital was similar. From the paper review, it seems early recognition does not improve the outcome but we found a 100% good outcome in patients with definitive management. Copyright © 2017, Taiwan Urological Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Conservative management, definitive management, hysterectomy, urologic injuries


How to cite this article:
Hsu CY, Law KS, Tai HP, Chen HL, Tse SS, Huang ZM, Weng WC, Huang LH, Lee IY, Tung MC. Management of urinary tract injuries following total hysterectomy: A single-hospital experience. Urol Sci 2018;29:12-9

How to cite this URL:
Hsu CY, Law KS, Tai HP, Chen HL, Tse SS, Huang ZM, Weng WC, Huang LH, Lee IY, Tung MC. Management of urinary tract injuries following total hysterectomy: A single-hospital experience. Urol Sci [serial online] 2018 [cited 2018 Sep 23];29:12-9. Available from: http://www.e-urol-sci.com/text.asp?2018/29/1/12/226025


  Introduction Top


The hysterectomy is the most common major gynecologic surgery worldwide.[1] Owing to the female uterus and the urinary tracts being closely related, the potential risk of urologic tract injury is always of concern when undergoing gynecologic surgery such as a hysterectomy. Although improvements in surgical techniques have decreased the incidence rate of urinary tract injury and occurrence of complications, urologic injuries remain a common event in gynecologic surgery. According to previous reports, the incidence rates of urinary tract injury in all gynecologic procedures and pelvic surgery range from 0.2% to 1%.[2],[3] Another 10-year review study based on a community hospital showed a 0.4% incidence rate of urinary tract injury after undergoing gynecologic surgical procedures.[4] A systematic review of urinary tract injuries in laparoscopic hysterectomy also shows the urinary tract injury rate for laparoscopic hysterectomy was 0.73%, with the rate ranging from 0.05% to 0.66% and 0.02% to 0.4% for bladder injury and ureteral injury, respectively.[5] A 20-year review study in Asia shows similar results with a 0.7% and 0.6% prevalence of urinary bladder and ureteral injuries in gynecological surgeries.[6] In Europe, a large retrospective study reported the incidence of bladder injury during laparoscopic hysterectomy, abdominal hysterectomy, and vaginal hysterectomy ranged from 0.6% to 1.0%.[7] Routine cystoscopy has become a trend in postgynecological surgery management because previous studies demonstrated <25% of bladder injuries and <50% of ureteral injuries are disclosed without the use of cystoscopy, but there is up to a 100% detection rate of ureteral injuries and 80% detection rate of urinary bladder injuries following performance of an intraoperative cystoscopy.[8] However, a retrospective cohort study showed 14 patients (0.71%) with bladder injury and 5 patients (0.25%) with ureteral injury at the time of hysterectomy not detected by cystoscopy indicated cystoscopy was selective rather than universal procedure at the time of hysterectomy.[9] Routine intraoperative cystoscopy has been suggested as the reason for the decreased incidence of urinary tract injury during gynecological surgery.[10],[11],[12] However, potential considerations related to routine cystoscopy such as the false-positive findings, insignificant injuries, increased cost of training and instruments, and lack of verifiable benefit in the postsurgery period may be reasons for the lack of demonstrable reports. To the best of our knowledge, less comprehensive reports of urologic treatment experiences and management in posttotal hysterectomy have been presented in Taiwan. The aim of this study is to show the treatment experience for those who received urologic treatment and management due to urologic complications after undergoing a total hysterectomy in a community hospital. This may provide an appropriate strategy to prevent future occurrences of urinary tract injuries in gynecological surgeries.


  Materials and Methods Top


Sudy subjects

A total of 696 female patients who received surgery, including a total abdominal hysterectomy, transvaginal hysterectomy, laparoscopic hysterectomy, or robotic hysterectomy in Tungs' Taichung MetroHarbor Hospital during 2012–2016. Those who underwent conservative management (cystoscopy, ureteroscopy, endoscopic ureterotomy, or double-J stenting) or definitive management (repair of urinary bladder rupture, repair of vesicovaginal fistula (VVF), ureteroureterostomy, or ureteroneocystostomy) due to urologic injuries during or after hysterectomies by gynecologists were enrolled in this study. The characteristics, clinical measures, and the period and bleeding amount of the surgical procedures for these patients were also collected in this study. Conservative or definitive management was performed including diagnosis, operation, and postsurgery evaluation for these patients with urologic injuries based on the experience of the urologists in the hospital. The observational period of urologic treatment and management was between January 1, 2012 and June 30, 2016.

Statistical analysis

We computed the distribution of demographics, clinical measures, and surgical period including age (<40, 40–49, 50–59, and ≥60), surgery period (<3, 3–3.9, 4–4.9, 5–5.9, and ≥6 h), bleeding amount (<100, 100–199, 200–299, 300–999, and ≥1000 ml), hemoglobin level (<12, 12–14 and ≥14), creatinine level (<0.5, 0.5–0.9 and ≥1 mg/dl), blood urea nitrogen (BUN)(8–12 and 13–17 mg/dl), and urine protein (positive, negative, and unknown). The series of conservative managements of the urologic injuries were individually computed as cystoscopy, diagnostic ureteroscopy, endoscopic ureterotomy, and double-J stenting. The definitive management encompassed four procedures, including repair of urinary bladder rupture and VVF repair, ureteroureterostomy, and ureteroneocystostomy. The final treatments, including operation and diagnosis, were divided into eight (ureteroscopic procedures such as bilateral/unilateral ureteroscopy with double-J stent implantation or endoscopic ureterotomy with double-J implantation, cystoscopy, removal of tension-free vaginal tape-obturator (TVT-O) mesh, laparoscopic urinary bladder repair, open repair of urinary bladder, repair of VVF, ureteroneocystostomy, and ureteroureterostomy) types and nine (ureteral swelling-immediately following gynecology surgery or narrowing of the lumen without fibrotic change, ureteral stricture – visualized fibrotic change tissue, ureteral severance, TVT-O mesh erosion, urinary bladder minor injury – mucosal injury only, urinary bladder scarring – visualized fibrotic change tissue on urinary bladder mucosa, urinary bladder rupture, ureter–vaginal fistula, and VVF) types, respectively. The evaluation of final treatments included the severity of injuries (minor or major) and prognosis (good, loss follow-up, or stricture). The definition of major injuries included those who received major repair operations of urinary bladder rupture, repair of VVF, ureteroureterostomy, and ureteroneocystostomy. Otherwise, they were defined as minor injuries. The definition of multiple procedures includes those having at least two urologic operations following gynecology operations but not including removal of the double-J stent, and the first urologic management could be the same day or the other day of the gynecologic operation. The definition of one procedure includes those who only have a one-step urologic operation following the gynecologic operation, perhaps on the same day or the other day of gynecologic surgeries, and maybe including those lost to follow-up after gynecologic surgeries and having only one urologic operation. Lag time of recognition denotes the interval between the day of the total hysterectomy and the 1st day of recognition of urologic complications, possibly at the same time, and is also the day of first conservative management or even combined with a definitive operation. Lag time of final operation denotes the interval between the day of the total hysterectomy and definitive operations, including repair of the urinary bladder rupture, repair of VVF, ureteroneocystostomy, and ureteroureterostomy. The definition of a good prognosis is effective reconstruction of the urinary tract without functional abnormality and departure of urologic follow-up. The categorical variables of the baseline demographics and clinical measures were summarized as percentages, and continuous variables were calculated as means with standard deviations (SDs). Differences between the conservative management and definitive management for continuous variables and categorical valuables used the t-test and Fisher's exact test. All analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC, USA).


  Results Top


Twenty-two patients who underwent urologic treatment and management after total hysterectomy were selected in this study. All 22 cases underwent laparoscopically-assisted vaginal hysterectomy (LAVH). The baseline characteristics between the minor injury and major injury study participants are shown in [Table 1]. The minor injury study participants had a higher mean age, presurgery hemoglobin level, bleeding amount, presurgery creatinine level, post-BUN, postcreatinine, but less surgery period of total hysterectomy, and negative pre- and posturine protein events then major injure study participants. However, there were no significant differences between minor and major injuries among all of the baseline characteristics (all P > 0.05). [Table 2] showed the differences in final operations for the treatment of urologic complication following total hysterectomy between managements, multiple-/one-stage procedure, and lag time of recognition. A significant difference between conservative management and definitive management was found for the final operation (P < 0.001). There were three categories of conservative management. The first was ureteroscopic procedures (n = 8, 61.5%) including ureteroscopy and double-J stenting (n = 5, 38.5%), bilateral ureteroscopy and double-J stenting (n = 1, 7.7%), endoscopic ureterotomy, and double-J stenting (n = 2, 15.4%). The second was cystoscopy (n = 4, 30.8%) and the third was removal of the TVT-O mesh (n = 1, 7.7%). The definitive managements were ureteroneocystostomy (n = 3, 33.3%), ureteroureterostomy (n = 2, 22.2%), repair of the urinary bladder (n = 2, 22.2%), laparoscopic urinary bladder repair (n = 1, 11.1%), and repair of VVF (n = 1, 11.1%), respectively. The four categories of final operation completed within the one-stage procedure included cystoscopy, laparoscopic urinary bladder repair, repair of urinary bladder and ureteroureterostomy, and the others were multiple-stage procedures with/without one-stage procedure. Lag time of recognition was day 0 when repair of urinary bladder were required on the same day of hysterectomy in 3 cases. Mean ± SD of lag time of recognition for ureteroureterostomy was 5.5 ± 7.8 days. Mean ± SD of lag time of recognition for ureteroneocystostomy was as long as 11.7 ± 6.7 days. For most of the others, the mean lag time of recognition was between 2 and 3 weeks to identify the particular gynecologic complication. [Table 3] shows the characteristics of the final diagnosis following the total hysterectomy. For conservative management, the top four causes of final diagnosis were ureteral swelling (n = 3, 23.1%), ureteral severance (n = 2, 15.4%), ureteral stricture (n = 2, 15.4%), and urinary bladder minor injury (n = 2, 15.4%). There were four categories of diagnosis in definitive management, including ureteral severance (n = 3, 33.3%), ureteral stricture (n = 2, 22.2%), urinary bladder rupture (n = 3, 33.3%), and VVF (n = 1, 11.1%). Urinary bladder complications including urinary bladder minor injury, scarring, or rupture were all managed by a one-stage procedure. The others were multiple-stage procedures of conservative management with/without definitive management. The lag time of recognition was 0 days for urinary bladder rupture in 3 cases, 7.8 ± 4.7 days (mean ± SD) for ureteral severance in 5 cases, 9.5 ± 13.4 days (mean ± SD) of urinary bladder minor injury in 2 cases, and the longest 38 days delay was for 1 case of TVT-O mesh erosion. The mean lag time of recognition of the others to identify gynecologic complications was more than 2 weeks. The urologic management, lag time of recognition, lag time of final operation, severity of injury, and prognosis following the total hysterectomy are shown in [Table 4]. Significant differences between conservative management and definitive management were observed among the lag time of recognition (P = 0.012) and severity of injury (P < 0.001). Thirteen cases (59.1%) performed conservative management only, with 19.0 ± 11.6 days (mean ± SD) of lag time between the first recognition of the injury and gynecologic operation, 33.5 ± 37.8 days (mean ± SD) of the lag time for the final operation as the definitive treatment. For those having good prognosis, the loss to follow-up and ureteral stricture in the prognosis were 69.2% (n = 9), 23.1% (n = 3), and 7.7% (n = 1), respectively. Of the others with definitive management, the means ± SD for lag time of recognition and lag time of final operation were 6.9 ± 7.5 and 52.8 ± 109.2 days, respectively. All of whom were classified as major injuries due to a subsequent major definitive management, including repair of the urinary bladder rupture, repair of VVF, ureteroneocystostomy, and ureteroureterostomy. However, all had good prognosis without subsequent urologic adverse events.
Table 1: Comparison of baseline demographics and clinical characteristics between the minor injury and major injury study participants (n=22)

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Table 2: The differences in final operations for treatment of urologic complication following a total hysterectomy between managements, multiple-/one-stage procedure, and lag time of recognition

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Table 3: The characteristics of final diagnosis of urologic complication following a total hysterectomy

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Table 4: The urologic management, lag time of recognition, lag time of final operation, severity of injury, and prognosis following a total hysterectomy

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  Discussion Top


The incidence rates of urinary bladder and ureteral injuries receiving total hysterectomy at our institute were 1.1% (8/696) and 1.9% (13/696), respectively. The results are similar to the reporting range from recent guidelines. The summarized incidence rates of urinary bladder injuries following abdominal hysterectomy, vaginal hysterectomy, and laparoscopic hysterectomy ranged from 0.37% to 2.5%, 0.44% to 6.3%, and 0.5% to 2.0%, respectively. The summarized incidence rates of ureteral injuries following abdominal hysterectomy, vaginal hysterectomy, and laparoscopic hysterectomy ranged from 0.03 to 2.0%, 0.02% to 0.5%, and 0.2% to 6.0%, respectively.[13] The chance of urinary tract injuries with a total hysterectomy by gynecologists is rare but unavoidable. Some clinical strategies are helpful in reducing the impact of adverse events. Delicate explanation of possible events to the patient and her family is mandatory before the operation. The surgeon obviously must be highly aware of the urinary tract and gynecologic organs relationship, especially during the operation. The surgeon must be alert during the history taking and physical examination, especially if there is a history of cesarean delivery or abdominal surgery/laparotomy, adhesions, and gynecology diseases of endometriosis or broad ligament fibrosis are high-risk situations. Low-volume surgeons commonly mentioned risk factors in urinary tract injuries.[14] High-risk patients had more intraoperative blood loss and a longer operation time during the operation.[15] Ibeanu et al. showed the below factors were also statistically correlated with increased risk of urinary tract injury, including blood loss of more than 800 mL, lower body mass index, duration of surgery, and increased uterine size.[10] We attempted to compare the risk of major or minor injury in [Table 1], but the P value is of no significance.

Prevention of ureteral injuries by ureteral catheterization before the hysterectomy used to be suggested in high-risk patients and has been surveyed as a generalized preoperative prophylaxis based on the retrospective study [16] and randomized trial [17] both showing no significant difference in the incidence of ureteral injuries. In contrast, some studies reached different conclusions. Cohen et al. suggested prophylactic ureteral catheterization should not supplant meticulous dissection, but it may improve the ability to identify the ureter either visually or by palpation among appropriately selected patients. The decision concerning the use of catheterization should be left to the surgeon's discretion.[18]

Early recognition of complications during or immediately after hysterectomy will improve the outcome and reduce morbidity after such complications of gynecologic surgery,[19] and perhaps it will decrease the lag time of the final operation for gynecologic complication and also reduce the possibility of eventual loss of kidney or legal problems. Most previous studies suggest almost all bladder injuries are detected and about 80%–90% of ureteral injuries are detected by intraoperative cystoscopy.[8],[20] The American Association of Gynecologic Laparoscopists (AAGL) proposed the sources of injuries “missed” by intraoperative cystoscopy are related to postoperative swelling of nonocclusive suture ligatures and thermal injuries that initially do not cause mechanical obstruction. AAGL also advised that the current evidence supports the conclusion cystoscopic evaluation of the lower urinary tract should be readily available to gynecologic surgeons performing laparoscopic hysterectomy. However, not all ureteral injuries are detected by intraoperative cystoscopy, even under the use of intravenous indigo Carmine injection.[21] Cystoscopy is a good tool but not a fail-safe method of intraoperative assessment of ureteral integrity, and might increase the number of injuries recognized, possibly preventing many of the subsequent complications.[22]

Intraoperative recognition of urinary bladder injuries may directly identify by obvious cystostomy, urine leakage, hematuria, or distended catheter bag due to leakage of gas through the urinary bladder defect during LAVH. In highly suspect cases, cystoscopy with/without instillation of urinary bladder with 200–300 ml colored saline (methyl blue or indigo carmine) could be chosen. Postoperative recognition of urinary bladder injuries may present suprapubic pain, hematuria, and leakage of urine from the vagina and oliguria. If uroperitoneum develops, it will present diffuse abdominal pain, distension, and ileus. Intraoperative recognition of ureteral injuries is challenging due to the seven types of ureteral injuries, including transection, resection, laceration, thermal, ligation, crush, and angulation. Only a third of these injuries are recognized during the operation. In highly suspicious cases, it is advised using a cystoscopy to identify presentation of urine jets or hematuria from ureteral orifice or not, and ureteral catheterization to differentiate a possible ureteral injury or the ureteroscope is located at the site of the ureteral injury. Postoperative recognition of ureteral injuries following major pelvic surgery may present as flank pain with tenderness, hematuria, oliguria or watery vaginal loss, which may be present in the first 48 h after the injury. Urinoma, extensive cellulitis, and even abscesses may develop if the above are obscure or misleading. Thermal injury to the ureter may lead to delayed necrosis and fistula formation between 10 and 14 days postoperatively. If the ureteral injuries are left unrecognized, the consequences will be spontaneous healing to fistula and/or stricture formation.[23] Of importance, up to 25% of unrecognized ureteral injuries lead to eventual loss of the kidney (ipsilateral nephrectomy).[24]

Hove et al. reported the number of ureteral injuries discovered intraoperatively amounted to 17 cases, within a week of the operation in 50 cases and 47 patients whose injuries were discovered within a month, where 17 patients were found to have urologic injuries more than 1 month later. In five cases, the damage was not noted until more than 2 years after the operation.[22] This will lead to eventual loss of the kidney.[23] In our experience, three patients with urinary bladder rupture having definitive management and three patients of ureteral severances having definitive management [Table 3] all achieved a 100% good outcome, and their injury were all classified as major severity [Table 4]. The lag time of recognition of the urinary bladder ruptures and ureteral severances was within 1 week, and most of these injuries were a one-stage procedure. On the other hand, the lag time of recognition of the other injuries was more than 2 weeks and most of these injuries were a multiple-stage procedure [Table 3]. Timing of the first recognition and repair of the injury may be related to the outcome and multiple procedures or not. Regardless, it means more aggressive management leads to a better outcome. In contrast to definitive management, our patients received a series of conservative managements. Four of the 13 (4/13, 30.8%) patients either had ureteral stricture (n = 3) or were lost to follow-up (n = 1, perhaps requesting a second opinion from another hospital). Among the nine definitive managements, four cases had immediate reconstruction of the urinary bladder (n = 3) or ureter (n = 1) during gynecologic surgery, five cases had initial conservative management before the final definitive management and all achieved a good prognosis. The mean interval of the five cases between the first recognition and definite operation was 87 days (data not shown). Contrarily, only conservative endoscopic procedures are not always good choices following several similar efforts. Our cases showed 23.2% (n = 3) loss to follow-up and 7.7% (n = 1) eventual stricture without further management. Definitive management should be considered for these patients.

Our study shows the lag time between the first recognition of injury and gynecologic operation was 19.0 ± 11.6 days (mean ± SD) in only conservative management cases and a shorter interval of 6.9 ± 7.5 days (mean ± SD) in definitive management cases. The difference was significant (P = 0.012). However, it did not shorten the lag time for the final operation in definitive management cases; the lag time of the final operation was 33.5 ± 37.8 days (mean ± SD) in only conservative management cases and 52.8 ± 109.2 days (mean ± SD) in definitive management cases. It showed no difference (P = 0.386 for t-test) due to some of our definitive management patients trying conservative endoscopic double-J stenting before final definitive management, with the wide variant range being 0–335 days.

As to the location of the ureteral injuries, the majority (71%) occurred at the level of the vaginal cuff, approximately 2–4 cm from the ureteral orifice. The majority of urinary bladder injuries occurred along the posterior bladder wall.[25] Our cases are compatible with the paper review (data not shown). The management of different locations of the urinary bladder is only primary repair, but different locations of ureteral injuries are related to different repairs. The choices for middle-third ureteral injury are ureteroureterostomy, transureteroureterostomy, or ureteral reimplantation with a Boari flap. The choices for lower-third ureteral injuries are ureteral reimplantation or ureteral reimplantation with a psoas hitch.[25] Upper-third ureteral injury or complete loss of the ureter from a gynecologic surgery complication is rare.

Only one patient received LAVH for uterine myoma and TVT-O for genuine stress urinary incontinence. As proven by the paper review, concomitant placement of TVT-O during a LAVH surgery is an efficacious and safe procedure. However, the study was designed for a benign gynecological disease coexisting with stress urinary incontinence.[26] Our case displayed an erosive tape between the lumen of the middle urethra 1 month after the operation. Eventually, her right groin area pain persisted in spite of partial removal of the tape.

There are some limitations to this study. First, the small sample size of the retrospective study makes it difficult to evaluate the relationship between management and prognosis, so we only conducted descriptive research. Nevertheless, all patients with major injuries that received definitive management clearly showed a better prognosis (100% good prognosis) than with a series of conservative managements.


  Conclusion Top


Compared to previous studies, the incidence of urologic injuries following a total hysterectomy in our hospital was similar. From the paper review, it seems early recognition does not improve the outcome but we found a 100% good outcome in patients with definitive management. We look forward to conducting this study over a wider area of hospitals in Taiwan and collecting nationwide data to conduct a more precise analysis of the exact Taiwanese experience.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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