What is the prevalence of ureteral injury during gynecologic surgery?

Updated: Nov 12, 2020
  • Author: Sandip P Vasavada, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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The frequency of ureteral injury following gynecologic surgery is approximately 1%, with a higher percentage of injuries occurring during abdominal hysterectomies and partial vaginectomies. Patients who have received pelvic radiation or who have advanced pelvic cancers requiring extensive surgical procedures are more likely to experience a ureteral injury. In addition, ureteral injury is an extremely rare complication of transvaginal oocyte retrieval for in vitro fertilization. [1]

The rate of ureteral injuries in laparoscopic procedures varies. While some physicians report that laparoscopic procedures have an equivalent rate of ureteral stricture formation secondary to ureteral injury, other authors argue that the rate of ureteral strictures is significantly higher. [2, 3]

A systematic review of 79 studies of gynecologic surgery for benign conditions found an adjusted ureteric injury rate of 0.3%.Postoperative ureteric injury detection rates per 1,000 surgeries were estimated at 1.6 without routine cystoscopy and 0.7 with routine cystoscopy. [4]

A review of a California inpatient database for 2007 to 2011 by Blackwell et al found that ureteral injury occurred in 1,753 of 223,872 patients (0.78%) undergoing hysterectomy and was unrecognized in 1,094 (62.4%). The 90-day readmission rate increased from a baseline of 5.7% to 13.4% after recognized injury and 67.3% after unrecognized injury. Ureteral injuries independently increased the risk of sepsis and urinary fistula, while unrecognized ureteral injury increased the odds of acute renal insufficiency and death. [5]

A systematic review of 37 studies by Adelman et al found that laparoscopic hysterectomy had an overall urinary tract injury rate of 0.73% and a ureteral injury rate that ranged from 0.2% to 0.4%, depending on procedure type. These investigators concluded that contrary to earlier published findings citing unacceptably high urinary tract injury rates, laparoscopic hysterectomy was a safe procedure in terms of the bladder and ureter. [6]

A review of 45,139 patients who underwent hysterectomy for benign gynecologic indications found that the incidence of any lower urinary tract complication was 0.2%; ureteral obstruction was the most commonly reported complication, accounting for 0.1% of cases; ureteral fistulae comprised 0.07% of cases. Factors significantly associated with the occurrence of any lower urinary tract complication recognized in the first 30 days postoperatively were endometriosis (adjusted odds ratio [OR] 2.29), black race (adjusted OR 1.90), and prior abdominal surgery (adjusted OR 1.53). [7]

A review of 208 uterosacral ligament suspension procedures by Barbier et al found that ureteral compromises occurred in six of the 60 patients in whom a vaginal approach was used, but in none of the 148 patients in whom a laparoscopic approach was used. Although some of the cases of ureteral compromise in the vaginal group required only suture removal and replacement, a number required stent placement. [8]

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