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Kim E, Wu H, Simpson K, Patzkowsky K, Wang K. Litigations Involving Ureteral Injury Related to Minimally Invasive Gynecologic Surgery: Lessons Learned from a Legal Literature Review. J Minim Invasive Gynecol 2019; 26:608-617. [DOI: 10.1016/j.jmig.2018.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/26/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
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Orhan A, Kasapoglu I, Ocakoglu G, Yuruk O, Uncu G, Ozerkan K. The Comparison of Outcomes between the "Skeleton Uterus Technique" and Conventional Techniques in Laparoscopic Hysterectomies. Gynecol Minim Invasive Ther 2019; 8:67-72. [PMID: 31143626 PMCID: PMC6515746 DOI: 10.4103/gmit.gmit_125_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 01/03/2019] [Accepted: 01/17/2019] [Indexed: 01/06/2023] Open
Abstract
Aim The aim of this study is to compare demographic characteristics, operative data, and complication rates of women who underwent total laparoscopic hysterectomy by the skeleton uterus technique (Skeleton-TLH) with those of women who underwent TLH by the standard technique (Standard-TLH) in a university teaching and research hospital. Materials and Methods This retrospective study included 932 laparoscopic hysterectomies in a university teaching and research hospital between January 1, 2013 and December 31, 2017. Clinical characteristics, operative outcomes, and complications were recorded and compared for the two techniques. Results In total, 932 laparoscopic hysterectomies were performed, 454 by Skeleton-TLH and 478 by Standard-TLH. The general demographic characteristics of the patients were similar; only gravida and parity were statistically significantly different between the groups (P < 0.001). Based on the primary outcomes (the operative data), total anesthesia time and main operation time were similar in the two groups. Estimated blood loss was statistically significantly lower in the Skeleton-TLH group than in the Standard-TLH group. Hospital stay was longer for the Skeleton-TLH group, and specimen weight was heavier. The secondary outcome was the complication rate. There were no differences between the Skeleton-TLH and Standard-TLH groups in the rates of all minor and major complications. Conclusion TLH with the skeleton uterus technique is feasible and safe, especially for advanced pelvic surgeons. This technique not only provides retroperitoneal access to the pelvic spaces and good anatomical visibility; but it also delivers a safer laparoscopic hysterectomy by clamping the uterine arteries and monitoring the ureter throughout the operation.
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Affiliation(s)
- Adnan Orhan
- Department of Obstetrics and Gynecology, Uludag University Teaching Hospital, Bursa, Turkey
| | - Isil Kasapoglu
- Department of Obstetrics and Gynecology, Uludag University Teaching Hospital, Bursa, Turkey
| | - Gokhan Ocakoglu
- Department of Biostatistics, Uludag University Teaching Hospital, Bursa, Turkey
| | - Oguzhan Yuruk
- Department of Obstetrics and Gynecology, Uludag University Teaching Hospital, Bursa, Turkey
| | - Gurkan Uncu
- Department of Obstetrics and Gynecology, Uludag University Teaching Hospital, Bursa, Turkey
| | - Kemal Ozerkan
- Department of Obstetrics and Gynecology, Uludag University Teaching Hospital, Bursa, Turkey
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Cystoscopy at the time of benign hysterectomy: a decision analysis. Am J Obstet Gynecol 2019; 220:369.e1-369.e7. [PMID: 30685289 DOI: 10.1016/j.ajog.2019.01.217] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/17/2019] [Accepted: 01/18/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Gynecologists debate the optimal use for intraoperative cystoscopy at the time of benign hysterectomy. Although adding cystoscopy leads to additional up-front cost, it may also enable intraoperative detection of a urinary tract injury that may otherwise go unnoticed. Prompt injury detection and intraoperative repair decreases morbidity and is less costly than postoperative diagnosis and treatment. Because urinary tract injury is rare and not easily studied in a prospective fashion, decision analysis provides a method for evaluating the cost associated with varying strategies for use of cystoscopy. OBJECTIVE The objective of the study was to quantify costs of routine cystoscopy, selective cystoscopy, or no cystoscopy with benign hysterectomy. STUDY DESIGN We created a decision analysis model using TreeAge Pro. Separate models evaluated cystoscopy following abdominal, laparoscopic/robotic, and vaginal hysterectomy from the perspective of a third-party payer. We modeled bladder and ureteral injuries detected intraoperatively and postoperatively. Ureteral injury detection included false-positive and false-negative results. Potential costs included diagnostics (imaging, repeat cystoscopy) and treatment (office/emergency room visits, readmission, ureteral stenting, cystotomy closure, ureteral reimplantation). Our model included costs of peritonitis, urinoma, and vesicovaginal/ureterovaginal fistula. Complication rates were determined from published literature. Costs were gathered from Medicare reimbursement as well as published literature when procedure codes could not accurately capture additional length of stay or work-up related to complications. RESULTS From prior studies, bladder injury incidence was 1.75%, 0.93%, and 2.91% for abdominal, laparoscopic/robotic, and vaginal hysterectomy, respectively. Ureteral injury incidence was 1.61%, 0.46%, and 0.46%, respectively. Hysterectomy costs without cystoscopy varied from $884.89 to $1121.91. Selective cystoscopy added $13.20-26.13 compared with no cystoscopy. Routine cystoscopy added $51.39-57.86 compared with selective cystoscopy. With the increasing risk of injury, selective cystoscopy becomes cost saving. When bladder injury exceeds 4.48-11.44% (based on surgical route) or ureteral injury exceeds 3.96-8.95%, selective cystoscopy costs less than no cystoscopy. Therefore, if surgeons estimate the risk of injury has exceeded these thresholds, cystoscopy may be cost saving. However, for routine cystoscopy to be cost saving, the risk of bladder injury would need to exceed 20.59-47.24% and ureteral injury 27.22-37.72%. Model robustness was checked with multiple 1-way sensitivity analyses, and no relevant thresholds for model variables other than injury rates were identified. CONCLUSION While routine cystoscopy increased the cost $64.59-83.99, selective cystoscopy had lower increases ($13.20-26.13). These costs are reduced/eliminated with increasing risk of injury. Even a modest increase in suspicion for injury should prompt selective cystoscopy with benign hysterectomy.
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Thurston J, Murji A, Scattolon S, Wolfman W, Kives S, Sanders A, Leyland N. No 377- Indications gynécologiques bénignes de l'hystérectomie. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:558-574. [DOI: 10.1016/j.jogc.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Thurston J, Murji A, Scattolon S, Wolfman W, Kives S, Sanders A, Leyland N. No. 377-Hysterectomy for Benign Gynaecologic Indications. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:543-557. [DOI: 10.1016/j.jogc.2018.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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İnan AH, Budak A, Beyan E, Kanmaz AG. The incidence, causes, and management of lower urinary tract injury during total laparoscopic hysterectomy. J Gynecol Obstet Hum Reprod 2018; 48:45-49. [PMID: 30321609 DOI: 10.1016/j.jogoh.2018.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/09/2018] [Accepted: 10/11/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Determining the incidence and causes of lower urinary tract injury in patients undergoing total laparoscopic hysterectomy and examining the procedures applied for management. METHODS Patients who underwent total laparoscopic hysterectomy in a large referral center between 1 January 2015 and 31 October 2017 for benign gynecological reasons were included in the study. Patients who underwent laparoscopic supracervical hysterectomy, laparoscopy-assisted vaginal hysterectomy and robot-assisted laparoscopic hysterectomy were not included in this study. The hospital records of all patients included in the study were examined and the incidence, causes and management of lower urinary tract injuries were reviewed. RESULTS Total lower urinary tract injury rate was found as 2.01%, and these injuries were evaluated separately as bladder and ureter injuries. All the bladder injuries had occurred on the posterior wall of the bladder during vesicouterine dissection; six cases were intraoperatively detected and one case was detected on the first postoperative day. Most of ureteral injury cases were detected in the early postoperative period (75%). The rates of previous cesarean section and endometriosis were significantly higher in patients with injury to the bladder and ureter than in the control group (p<0,001). There was no significant difference between the patients with lower urinary tract injury and the control group regarding uterine weight, estimated blood loss, bilateral salpingo-oophorectomy, the presence and location of fibroids, and laparoscopic or vaginal closure of the vaginal cuff. CONCLUSION Laparoscopic hysterectomy may be a good option in appropriate patients, but in case of previous cesarean section and endometriosis cases, patients should be informed about the possible complications in detail before the operation and care should be taken during dissection.
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Affiliation(s)
- Abdurrahman Hamdi İnan
- Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital Izmir, Turkey.
| | - Adnan Budak
- Izmir Provincial Health Directorate, Izmir, Turkey.
| | - Emrah Beyan
- Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital Izmir, Turkey.
| | - Ahkam Göksel Kanmaz
- Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital Izmir, Turkey.
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Koroglu N, Cetin BA, Turan G, Yıldırım GY, Akca A, Gedikbasi A. Characteristics of total laparoscopic hysterectomy among women with or without previous cesarean section: retrospective analysis. SAO PAULO MED J 2018; 136:385-389. [PMID: 30570089 PMCID: PMC9907767 DOI: 10.1590/1516-3180.2018.0197030718] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 07/03/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The number of hysterectomized patients with previous cesarean sections (CSs) has increased due to increasing CS rates. A previous history of CS has been demonstrated to be an important risk factor for major complications in total laparoscopic hysterectomy. The aim here was to evaluate the major complications and safety of TLH in patients with previous CS. DESIGN AND SETTING Retrospective analysis in a tertiary-level center. METHODS The medical records of 504 total laparoscopic hysterectomy patients operated between May 2013 and May 2017 were reviewed retrospectively. Data on age, parity, surgical indications, duration of operation, length of hospital stay, histopathological diagnosis and major intra and postoperative complications were gathered. The patients were categorized into two groups according to their CS history, namely those with and those without previous CS. Major complications were defined as the presence of lower urinary tract injury (bladder or ureter injury), enterotomy/colostomy, bowel serosal injury or vascular injury. RESULTS There was no difference between the groups in terms of parity, duration of operation, hospital stay or pre and postoperative hemoglobin levels. The conversion rates to laparotomy in the previous CS and no CS groups were 2% and 1.7%, respectively. The rates of major complications in the previous CS and no CS groups were 5% and 1.3%, respectively, and these results did not differ significantly (P > 0.05). CONCLUSION TLH could be performed safely in the previous CS group, since the complication rate was not different from that of the patients without previous CS.
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Affiliation(s)
- Nadiye Koroglu
- MD. Physician, Department of Obstetrics and Gynecology, Health Sciences University Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey.
| | - Berna Aslan Cetin
- MD. Physician, Department of Obstetrics and Gynecology, Health Sciences University Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey.
| | - Gokce Turan
- MD. Physician, Department of Obstetrics and Gynecology, Kırıkhan State Hospital, Hatay, Turkey.
| | - Gonca Yetkin Yıldırım
- MD. Physician, Department of Obstetrics and Gynecology, Health Sciences University Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey.
| | - Aysu Akca
- MD. Physician, Department of Obstetrics and Gynecology, Health Sciences University Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey.
| | - Ali Gedikbasi
- MD. Associate Professor, Department of Obstetrics and Gynecology, Health Sciences University Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey.
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Oliveira MAP, Raymundo TS, Pereira TRD, Lima FV, da Silva DEA. CO 2 Cystoscopy for Evaluation of Ureteral Patency. J Minim Invasive Gynecol 2018; 26:558-563. [PMID: 30165187 DOI: 10.1016/j.jmig.2018.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/12/2018] [Accepted: 08/15/2018] [Indexed: 10/28/2022]
Abstract
Gynecologic surgery is associated with various perioperative complications, especially urinary tract injuries. Intraoperative cystoscopy plays an important role in allowing assessment of the bladder to ensure the absence of injuries. Verification of the urinary jets from the ureters is a fundamental step that is not always easy to accomplish. Dyes are frequently used, but these are not always available and are associated with adverse effects. The present study aimed to demonstrate the use of CO2 as a medium for distension during cystoscopy. A total of 47 patients underwent CO2 cystoscopy after laparoscopic hysterectomy (n = 26) or bladder endometriosis nodule resection (n = 21). In all patients, the ureteral jets were readily identified, leaving no doubt as to their patency. The median interval between the onset of cystoscopy and the view of jetting from both ureteral ostia was 145 seconds (range, 80-300 seconds). All cystoscopies were normal, and no patient had any signs of accidental urinary tract injury in the follow-up period. Two patients experienced mild urinary tract infection. This cystoscopy technique using CO2 is fast, easy, safe, and efficient. We recommend bladder distension with CO2 as a reasonable alternative technique when cystoscopy is required during gynecologic procedures.
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Affiliation(s)
- Marco Aurelio Pinho Oliveira
- Department of Gynecology, State University of Rio de Janeiro, Rio de Janeiro, Brazil (Drs. Oliveira, Raymundo, and Pereira).
| | - Thiers Soares Raymundo
- Department of Gynecology, State University of Rio de Janeiro, Rio de Janeiro, Brazil (Drs. Oliveira, Raymundo, and Pereira)
| | | | - Felipe Vaz Lima
- Central Aristarcho Pessoa Hospital, Rio de Janeiro, Brazil (Dr. Lima)
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Petersen SS, Doe S, Rubinfeld I, Davydova Y, Buekers T, Sangha R. Rate of Urologic Injury with Robotic Hysterectomy. J Minim Invasive Gynecol 2018; 25:867-871. [DOI: 10.1016/j.jmig.2018.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 01/03/2018] [Accepted: 01/06/2018] [Indexed: 11/17/2022]
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Dextrose Instillation as an Alternative Agent to Observe Ureteral Efflux During Pelvic Reconstructive Surgery. Urology 2018; 120:74-79. [PMID: 29958966 DOI: 10.1016/j.urology.2018.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/04/2018] [Accepted: 05/16/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the use, cost, postoperative urinary tract infection (UTI) rates, and complications of dextrose instillation during cystoscopy. METHODS The medical records of patients who underwent cystoscopy during pelvic reconstructive surgery between June 2016 and June 2017 were reviewed. Patients were divided into two groups: patients who had one ampule of dextrose 50% (D50) directly instilled and patients who did not have D50 instilled during cystoscopy. Preoperative demographics, UTI rates, and postoperative complications were compared. Pharmaceutical cost and availability were reported by the pharmacy at our institution. RESULTS Out of 63 patients identified, dextrose instillation was used in 20 patients and no dextrose was used in 43 patients. Each ampule of D50 cost $2.18 and there were no problems with supply shortage. As D50 was directly instilled into the bladder, there was immediate visualization of ureteral efflux at the time of surgery. Three patients (15%) in the dextrose group and 10 patients (23%) in the nondextrose group developed postoperative UTIs. There was no statistically significant difference in postoperative UTI rates between the two groups (p = 0.43) and there were no differences in postoperative complications. CONCLUSION Dextrose is a safe, cost-effective, readily available agent that provides instantaneous visualization of ureteral efflux without an increased risk of postoperative UTI.
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Ureterolysis for Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2018; 26:401. [PMID: 29908340 DOI: 10.1016/j.jmig.2018.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/29/2018] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To demonstrate techniques of ureterolysis during complex laparoscopic hysterectomy. DESIGN Technical video demonstrating different approaches to ureterolysis for complex benign pathology during laparoscopic hysterectomy (Canadian Task Force classification III). SETTING Benign gynecology department at a university hospital. INTERVENTION Performance of ureterolysis during laparoscopic hysterectomy for benign pathology. CONCLUSION Ureteric injury has significant morbidity and is the most common reason for litigation following hysterectomy, with an estimated risk of 0.02% to 0.4%. [1,2]. Ureterolysis is infrequently practiced by benign gynecologists; however, it may be necessary during complex surgery. Benign pathology requiring hysterectomy, such as endometriosis, myomas, large uteri, and adnexal masses, are recognized risk factors for ureteric injury [3]. Most injuries occur during division of the uterine artery at the level of the internal cervical os. The average distance between the ureter and cervix is 2 cm, but it is only 0.5 cm in 3.2% of the population with a normal pelvis [4]. Preventive strategies, such as the use of a uterine manipulator, may increase this distance, although it still might not be sufficient to prevent injury in women with normal anatomic variants and complex pathology. Visualizing the ureter at the pelvic brim and side wall without retroperitoneal dissection may be inadequate because the segment of ureter between the intersection of the uterine artery and the bladder is not visible. The ureter can be safely dissected up to 15 cm without compromising its viability. In this educational video, we demonstrate various simple, quick, and reproducible techniques to perform ureterolysis for complex benign pathology. These techniques can be used by both expert and novice surgeons to perform and teach ureterolysis. Our method determines the course of the ureter throughout the pelvis and relation to the uterine artery to reduce intraoperative injury. We have performed more than 350 cases with no injuries.
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Barbic M, Telenta K, Noventa M, Blaganje M. Ureteral injuries during different types of hysterecomy: A 7-year series at a single university center. Eur J Obstet Gynecol Reprod Biol 2018; 225:1-4. [DOI: 10.1016/j.ejogrb.2018.03.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/26/2018] [Accepted: 03/21/2018] [Indexed: 10/17/2022]
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Tonolini M. Multidetector CT of expected findings and complications after hysterectomy. Insights Imaging 2018; 9:369-383. [PMID: 29626286 PMCID: PMC5990996 DOI: 10.1007/s13244-018-0610-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/12/2018] [Accepted: 02/12/2018] [Indexed: 12/15/2022] Open
Abstract
Abstract Indicated to manage a variety of disorders affecting the female genital tract, hysterectomy represents the second most common gynaecological operation after caesarean section. Performed via an open, laparoscopic or vaginal approach, hysterectomy is associated with non-negligible morbidity and occasional mortality. Iatrogenic complications represent a growing concern for gynaecologists and may result in prolonged hospitalisation, need for interventional procedures or repeated surgery, renal impairment and malpractice claims. As a result, radiologists are increasingly requested to investigate patients with suspected complications after hysterectomy. In the vast majority of early postoperative situations, multidetector CT represents the ideal modality to comprehensively visualise the surgically altered pelvic anatomy and to consistently triage the varied spectrum of possible injuries. This pictorial review provides an overview of current indications and surgical techniques, illustrates the expected CT appearances after recent hysterectomy, the clinical and imaging features of specific complications such as lymphoceles, surgical site infections, haemorrhages, urinary tract lesions and fistulas, bowel injury and obstruction. Our aim is to increase radiologists’ familiarity with normal post-hysterectomy findings and with post-surgical complications, which is crucial for an appropriate choice between conservative, interventional and surgical management. Teaching points • Hysterectomy via open, laparoscopic or vaginal route is associated with non-negligible morbidity. • Multiplanar CT imaging optimally visualises the surgically altered pelvic anatomy. • Familiarity with early post-hysterectomy CT and expected findings is warranted. • Complications encompass surgical site infections, haemorrhages, bowel injury and obstruction. • Urological complications include ureteral leakage, bladder injury, urinomas and urinary fistulas.
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Affiliation(s)
- Massimo Tonolini
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy.
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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. UROLOGICAL SCIENCE 2018. [DOI: 10.4103/uros.uros_11_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Choi YS, Lee SH, Cho HJ, Lee DH, Kim KS. Outcomes of ureteroscopic double-J ureteral stenting for distal ureteral injury after gynecologic surgery. Int Urogynecol J 2017; 29:1397-1402. [DOI: 10.1007/s00192-017-3478-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/31/2017] [Indexed: 11/24/2022]
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Clancy AA, Hickling D. Thermal Bladder Injury at Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2017; 25:562-564. [PMID: 28803812 DOI: 10.1016/j.jmig.2017.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 08/05/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Aisling A Clancy
- Division of Urogynecology, Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Duane Hickling
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
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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. UROLOGICAL SCIENCE 2017. [DOI: 10.1016/j.urols.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Prevention, Recognition, and Management of Urologic Injuries During Gynecologic Surgery. Obstet Gynecol 2017; 127:1085-1096. [PMID: 27159741 DOI: 10.1097/aog.0000000000001425] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The urethra, bladder, and ureters are particularly susceptible to injury during gynecologic surgery. When preventive measures fail, prompt recognition and management of injury can avoid long-term sequelae such as fistula formation and loss of renal function. Intraoperative identification should be the primary goal when an injury occurs, although this is not always possible. Postoperative injury recognition requires a high level of suspicion and vigilance. In addition to history and physical examination, appropriate radiologic studies can be useful in localizing injury and planning management strategies. Some injuries may require Foley catheter drainage or ureteral stenting alone, whereas others will require operative intervention with ureteral resection and reanastomosis or reimplantation. Prompt restoration of urinary drainage or diversion will avoid further renal compromise.
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Satitniramai S, Manonai J. Urologic injuries during gynecologic surgery, a 10-year review. J Obstet Gynaecol Res 2017; 43:557-563. [DOI: 10.1111/jog.13238] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 09/24/2016] [Accepted: 10/20/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Sikarn Satitniramai
- Department of Obstetrics & Gynaecology; Faculty of Medicine Ramathibodi Hospital; Bangkok Thailand
| | - Jittima Manonai
- Department of Obstetrics & Gynaecology; Faculty of Medicine Ramathibodi Hospital; Bangkok Thailand
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Sandberg EM, Twijnstra AR, Driessen SR, Jansen FW. Total Laparoscopic Hysterectomy Versus Vaginal Hysterectomy: A Systematic Review and Meta-Analysis. J Minim Invasive Gynecol 2017; 24:206-217.e22. [DOI: 10.1016/j.jmig.2016.10.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/19/2016] [Accepted: 10/13/2016] [Indexed: 12/13/2022]
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Occurrence of and Risk Factors for Urological Intervention During Benign Hysterectomy: Analysis of the National Surgical Quality Improvement Program Database. Urology 2016; 97:66-72. [DOI: 10.1016/j.urology.2016.06.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 06/14/2016] [Accepted: 06/23/2016] [Indexed: 11/19/2022]
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73
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Luketic L, Murji A. Options to Evaluate Ureter Patency at Cystoscopy in a World Without Indigo Carmine. J Minim Invasive Gynecol 2016; 23:878-85. [DOI: 10.1016/j.jmig.2016.06.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/10/2016] [Accepted: 06/10/2016] [Indexed: 12/15/2022]
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Total Laparoscopic Hysterectomy and Laparoscopic-Assisted Vaginal Hysterectomy. Obstet Gynecol Clin North Am 2016; 43:463-78. [DOI: 10.1016/j.ogc.2016.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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75
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Krentel H, De Wilde R. Complications in Laparoscopic Supracervical Hysterectomy(LASH), especially the morcellation related. Best Pract Res Clin Obstet Gynaecol 2016; 35:44-50. [DOI: 10.1016/j.bpobgyn.2015.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/05/2015] [Indexed: 01/17/2023]
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Prevention and management of urologic injury during gynecologic laparoscopy. Curr Opin Obstet Gynecol 2016; 28:323-8. [DOI: 10.1097/gco.0000000000000296] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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77
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Packiam VT, Cohen AJ, Pariser JJ, Nottingham CU, Faris SF, Bales GT. The Impact of Minimally Invasive Surgery on Major Iatrogenic Ureteral Injury and Subsequent Ureteral Repair During Hysterectomy: A National Analysis of Risk Factors and Outcomes. Urology 2016; 98:183-188. [PMID: 27392649 DOI: 10.1016/j.urology.2016.06.041] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 06/26/2016] [Accepted: 06/28/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To identify risk factors for ureteral injury during hysterectomy and to assess outcomes of concurrent minimally invasive vs converted to open repairs. METHODS We queried the American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2013 to identify abdominal hysterectomy (AH), minimally invasive hysterectomy (MIH), or vaginal hysterectomy. Ureteral injury was identified based on intraoperative or delayed management. Multivariate logistic regression was performed to assess the effect of hysterectomy approach on risk of ureteral injury while controlling for covariates. For patients with ureteral injury during MIH, we compared 30-day outcomes following minimally invasive vs converted open repairs. RESULTS There were 302 iatrogenic ureteral injuries from 96,538 hysterectomies, with 0.18%, 0.48%, and 0.04% from AH, MIH, and vaginal hysterectomy, respectively. Patients who underwent MIH were younger and had decreased comorbidities compared to patients who underwent AH (all P < .001). MIH resulted in lower overall complications (6.6% vs 14.8%, P < .001) but higher ureteral injury rate (0.48% vs 0.18%, P < .001) compared to AH. On multivariate analysis, the minimally invasive approach was associated with increased risk of ureteral injury (odds ratio 4.2, P < .001). Patients undergoing minimally invasive ureteral repairs (89%) during MIH had shorter operating room time and length of stay but similar overall perioperative complications compared to those with converted open repairs (11%). CONCLUSION Using a large national series, we show that the minimally invasive approach for hysterectomy is an independent risk factor for iatrogenic ureteral injuries. During MIH, concurrent minimally invasive ureteral repairs resulted in comparable 30-day outcomes compared to converted to open repairs.
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Affiliation(s)
| | - Andrew J Cohen
- Section of Urology, The University of Chicago, Chicago, IL
| | | | | | - Sarah F Faris
- Section of Urology, The University of Chicago, Chicago, IL
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Cohen AJ, Packiam VT, Nottingham CU, Pariser JJ, Faris SF, Bales GT. Iatrogenic Bladder Injury: National Analysis of 30-Day Outcomes. Urology 2016; 97:250-256. [PMID: 27181242 DOI: 10.1016/j.urology.2016.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/03/2016] [Accepted: 05/05/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To examine the risk factors and outcomes of BI, a rare complication of abdominopelvic surgery. METHODS We queried the National Surgical Quality Improvement Program database to identify intraoperative bladder injury (BI) defined by the Current Procedural Terminology code for cystorrhaphy from 2005 to 2013. Propensity-score matching balanced the differences between patients with BI and the controls. The factors matched included age, body mass index, race, modified frailty index, and procedure category. RESULTS There were 1685 cases of BI in 1,541,736 surgeries (0.11%). Although 49.5% of surgeries were performed in an open fashion, this approach accounted for 69.3% of BI (P < .001). Prior to matching, mortality rates and morbidity were increased for the BI group (P < .001). Moreover, age, recent chemotherapy or radiation or steroid history, and smoking were among the risk factors for BI (all P < .05). Resident involvement increased the odds of BI and complications after BI, but decreased the risk of readmission (all P < .05). After matching, 30-day mortality was no longer increased for patients with BI (P < .001). Patients with BI requiring repair did have increased median length of stay (6 days [interquartile range {IQR}: 3-11] vs 5 [IQR: 2-9]; P < .001) and operative time (203 min [IQR: 140-278] vs 134 [IQR: 86-199]; P < .001). BI patients were more likely to undergo reoperation (7.7% vs 5.3%; P = .005). Urine infection, sepsis, and bleeding were more likely in the BI group compared with the matched controls (all P < .001). Delayed repair was rare. CONCLUSION We present the largest national series assessing iatrogenic BI and subsequent repair. BI increases 30-day complications, reoperation, and length of stay but does not increase 30-day mortality compared with matched controls. More complex surgical cases and increased baseline comorbidity were risk factors for BI.
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Affiliation(s)
- Andrew J Cohen
- Department of Surgery, Section of Urology, University of Chicago Medicine, Chicago, IL.
| | - Vignesh T Packiam
- Department of Surgery, Section of Urology, University of Chicago Medicine, Chicago, IL
| | - Charles U Nottingham
- Department of Surgery, Section of Urology, University of Chicago Medicine, Chicago, IL
| | - Joseph J Pariser
- Department of Surgery, Section of Urology, University of Chicago Medicine, Chicago, IL
| | - Sarah F Faris
- Department of Surgery, Section of Urology, University of Chicago Medicine, Chicago, IL
| | - Gregory T Bales
- Department of Surgery, Section of Urology, University of Chicago Medicine, Chicago, IL
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Macciò A, Chiappe G, Kotsonis P, Nieddu R, Lavra F, Serra M, Onnis P, Sollai G, Zamboni F, Madeddu C. Surgical outcome and complications of total laparoscopic hysterectomy for very large myomatous uteri in relation to uterine weight: a prospective study in a continuous series of 461 procedures. Arch Gynecol Obstet 2016; 294:525-31. [PMID: 27016346 DOI: 10.1007/s00404-016-4075-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 03/14/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE To analyze whether a large uterine size was associated with increased rate of intraoperative and postoperative surgical complications in patients who underwent total laparoscopic hysterectomy (TLH) for myomatous uteri. METHODS We examined prospectively data from 461 consecutive TLHs performed by a single surgeon between August 2004 and August 2014 at the Department of Obstetrics and Gynecology, Sirai Hospital, Carbonia, and at the Department of Gynecologic Oncology, Businco Hospital, Cagliari, Italy. Demographic and surgical data were stratified by uterine weight (range 90-5500 g) into four groups: <300 g; from 300 to 500 g; from 500 to 800 g; and >800 g. Outcomes examined included blood loss, operative time, intraoperative and postoperative complications, and duration of hospital stay. A linear regression analysis was performed to identify whether uterine weight was an independent predictor affecting these outcomes. In addition, BMI, previous surgery with adhesiolysis, and endometriosis were tested as a predictor of surgical complications and outcomes. RESULTS No significant difference was found in intraoperative and postoperative complications, as well as hospital stay, by uterine weight. Increased uterine size was significantly associated with longer operative time and increased blood loss. Beside uterine weight, prior surgery was predictive of postoperative complications. In contrast, higher BMI was not associated with increased complication rate. Independent predictors of longer operative time included previous surgery, endometriosis, and BMI. CONCLUSIONS Our results showed that in experienced hands, TLH is feasible and safe also in presence of very large uteri. TLH results in a few complications and short hospital stay regardless of uterine weight.
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Affiliation(s)
- Antonio Macciò
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy.
| | - Giacomo Chiappe
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy
| | - Parakevas Kotsonis
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy
| | - Romualdo Nieddu
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy
| | - Fabrizio Lavra
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy
| | - Michele Serra
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy
| | - Paolo Onnis
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy
| | - Giuseppe Sollai
- Department of Oncological Surgery, A. Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Fausto Zamboni
- Department of General Surgery, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Clelia Madeddu
- Department of Medical Sciences M. Aresu, University of Cagliari, Cagliari, Italy
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Total laparoscopic hysterectomy via suture and ligation technique. Obstet Gynecol Sci 2016; 59:39-44. [PMID: 26866034 PMCID: PMC4742474 DOI: 10.5468/ogs.2016.59.1.39] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/03/2015] [Accepted: 08/08/2015] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE The term 'total laparoscopic hysterectomy (TLH) with classical suture method' refers to a surgical procedure performed using only sutures and ligations with intracorporeal or extracorporeal ties, without using any laser or electronic cauterization devices during laparoscopic surgery as in total abdominal hysterectomy. However, the method is not as widely used as electric coagulation equipment for TLH because further advances in technology and surgical technique are required and operative time can take longer. In the current study, we evaluated the benefits of the classical suture method for TLH. METHODS This study retrospectively reviewed patients who received TLH using the classical suture method from August 2005 to April 2014. The patients' baseline characteristics were analyzed, including age, parity, cause of operation, medical and surgical history. Surgical outcomes analyzed included the weight of the uterus, operative time, complications, changes in hemoglobin level, blood transfusion requirements, and postoperative hospital stay. RESULTS Of 746 patients who underwent TLH with the classical suture method, mean operation time was 96.9 minutes. Mean average decline in hemoglobin was 1.6 g/dL and transfusion rate was 6.2%. Urinary tract injuries were reported in 8 patients. Urinary tract injuries comprised 6 cases of bladder injury and 3 cases of ureter injury. There were no cases of vaginal stump infection, hematoma, bowel injury or abdominal wound complication. All cases involving complications occurred before 2010. CONCLUSION The classical suture method for TLH presents tolerable levels of complications and blood loss. Advanced surgical skill is expected to decrease operation time and complications.
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Recognition and Management of Urologic Injuries With Laparoscopic Hysterectomy. Clin Obstet Gynecol 2015; 58:805-11. [DOI: 10.1097/grf.0000000000000159] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bailey CD, Frumovitz M. Preventing Complications in Minimally Invasive Gynecologic Surgery. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-015-0123-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Laparoscopic Hysterectomy and Urinary Tract Injury: Experience in a Health Maintenance Organization. J Minim Invasive Gynecol 2015; 22:1278-86. [PMID: 26241687 DOI: 10.1016/j.jmig.2015.07.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/26/2015] [Accepted: 07/28/2015] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVES To evaluate the incidence, detection, characteristics, and management of urinary tract injury in a cohort undergoing laparoscopic hysterectomy, and to identify potential risk factors for urinary tract injury with laparoscopic hysterectomy. DESIGN Retrospective analysis (Canadian Task Force classification II-2). SETTING Kaiser Permanente San Diego Medical Center, 2001 to 2012. PATIENTS Women who underwent attempted laparoscopic hysterectomy for benign indications. INTERVENTIONS Total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparoscopic supracervical hysterectomy. MEASUREMENTS AND MAIN RESULTS Demographic and clinical characteristics, surgical techniques, and perioperative complications were abstracted from the medical record. Multivariable logistic regression analysis assessed independent risk factors for ureteral or bladder injury. RESULTS A total of 3523 patients (mean age, 45.9 ± 8.0 years; median parity, 2; range, 0-10), with a median body mass index (BMI) of 29 kg/m(2) (range, 16-72 kg/m(2)), underwent laparoscopic hysterectomy; 20% had intraoperative cystoscopy. The incidence of urinary tract injury was 1.3% (46 of 3523); of the 46 patients with injuries, 19 (0.54%) had ureteral injuries, 25 (0.71%) had bladder injuries, and 2 (0.06%) had both types. Of the 21 ureteral injuries, 6 (29%) were diagnosed intraoperatively and 15 (71%) were diagnosed postoperatively, including 4 with normal intraoperative cystoscopy. Of the 27 bladder injuries, 23 (85%) were identified intraoperatively. In multivariable logistic analysis, a BMI of 26 to 30 kg/m(2) (compared with >30 kg/m(2)) was associated with an increased risk of ureteral injury, and a BMI ≤25 kg/m(2) (compared with >30 kg/m(2)) and the presence of endometriosis were associated with an increased risk of bladder injury. CONCLUSION Urinary tract injury occurred in 1.3% of laparoscopic hysterectomies, with ureteral injuries almost as common as bladder injuries. Normal intraoperative cystoscopy findings did not exclude the presence of ureteral injury.
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Esparaz AM, Pearl JA, Herts BR, LeBlanc J, Kapoor B. Iatrogenic urinary tract injuries: etiology, diagnosis, and management. Semin Intervent Radiol 2015; 32:195-208. [PMID: 26038626 PMCID: PMC4447880 DOI: 10.1055/s-0035-1549378] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Iatrogenic injury to the urinary tract, including the kidneys, ureters, bladder, and urethra, is a potential complication of surgical procedures performed in or around the retroperitoneal abdominal space or pelvis. While both diagnostic and interventional radiologists often play a central and decisive role in the identification and initial management of a variety of iatrogenic injuries, discussions of these injuries are often directed toward specialists such as urologists, obstetricians, gynecologists, and general surgeons whose procedures are most often implicated in iatrogenic urinary tract injuries. Interventional radiologic procedures can also be a source of an iatrogenic urinary tract injury. This review describes the clinical presentation, risk factors, imaging findings, and management of iatrogenic renal vascular and urinary tract injuries, as well as the radiologist's role in the diagnosis, treatment, and cause of these injuries.
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Affiliation(s)
- Anthony M. Esparaz
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Brian R. Herts
- Department of Abdominal Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Justin LeBlanc
- Department of Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Baljendra Kapoor
- Department of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
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Graziano A, Lo Monte G, Hanni H, Brugger JG, Engl B, Marci R. Laparoscopic Supracervical Hysterectomy With Transcervical Morcellation: Our Experience. J Minim Invasive Gynecol 2015; 22:212-8. [DOI: 10.1016/j.jmig.2014.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 09/21/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
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