Rate of Urologic Injury with Robotic Hysterectomy

Intraoperative Fluorescent Ureter Visualization in Complex Laparoscopic or Robotic-Assisted Gynecologic Surgery

This study aimed to demonstrate the feasibility of ureteral navigation using intraoperative indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during complex laparoscopic or robot-assisted gynecologic surgery (LRAGS). Twenty-six patients at high risk of ureteral injury with complex pelvic pathology (CPP) due to pelvic organ prolapse (POP), multiple myomas, large intraligamentary or cervical myoma, severe pelvic adhesions, or cervical atresia underwent LRAGS. All patients underwent cystoscopic intraureteral ICG instillation before LRAGS and ureteral navigation under NIRF imaging intraoperatively. Both ureteral pathways were identified from the pelvic brim downwards through NIRF imaging in all patients, even though some were not visualized under the white light mode. The fluorescent ureters were visualized immediately after the beginning of surgery and typically lasted for >5 h during surgery. There were no cases of iatrogenic ureteral injury. The hemoglobin decrement was 1.47 ± 1.13 g/dL, and no transfusion was required. In our study, both ureters in all patients were identified with ICG-NIRF imaging during LRAGS, and these techniques made surgeries easier and safer. Despite the CPP, there was no ureteral injury or transfusion following surgery. Further prospective studies are needed to introduce intraoperative ureteral guidelines for ICG-NIRF imaging during LRAGS with CPP.

Systematic review of urological injury during caesarean section and hysterectomy

INTRODUCTION AND HYPOTHESIS

We aim to review iatrogenic bladder and ureteric injuries sustained during caesarean section and hysterectomy.

METHODS

A search of Cochrane, Embase, Medline and grey literature was performed using methods pre-published on PROSPERO. Eligible studies described iatrogenic bladder or ureter injury rates during caesarean section or hysterectomy. The 15 largest studies were included for each procedure sub-type and meta-analyses performed. The primary outcome was injury incidence. Secondary outcomes were risk factors and preventative measures.

RESULTS

Ninety-six eligible studies were identified, representing 1,741,894 women. Amongst women undergoing caesarean section, weighted pooled rates of bladder or ureteric injury per 100,000 procedures were 267 or 9 events respectively. Injury rates during hysterectomy varied by approach and pathological condition. Weighted pooled mean rates for bladder injury were 212-997 events per 100,000 procedures for all approaches (open, vaginal, laparoscopic, laparoscopically assisted vaginal and robot assisted) and all pathological conditions (benign, malignant, any), except for open peripartum hysterectomy (6,279 events) and laparoscopic hysterectomy for malignancy (1,553 events). Similarly, weighted pooled mean rates for ureteric injury were 9-577 events per 100,000 procedures for all hysterectomy approaches and pathologies, except for open peripartum hysterectomy (666 events) and laparoscopic hysterectomy for malignancy (814 events). Surgeon inexperience was the prime risk factor for injury, and improved anatomical knowledge the leading preventative strategy.

CONCLUSIONS

Caesarean section and most types of hysterectomy carry low rates of urological injury. Obstetricians and gynaecologists should counsel the patient for her individual risk of injury, prospectively establish risk factors and implement preventative strategies.

Ureteric injuries during hysterectomy-A Norwegian retrospective study of occurrence and claims for compensation over an 11-year period

INTRODUCTION

Ureteric injury is a rare but serious, iatrogenic complication of hysterectomy. The risk depends on indication for surgery, predisposing risk factors, and peroperative conditions. Our aims were to evaluate and learn from compensation claims to The Norwegian System of Patient Injury Compensation (NPE) for ureteric injury occurring during hysterectomies to predict risk factors, time of identification, symptoms, and consequences, and to relate these cases to injuries registered in The Norwegian Patient Registry.

MATERIAL AND METHODS

A retrospective study of ureteric injuries occurring during hysterectomies, reported to NPE and the Norwegian Patient Registry from 2009 through 2019.

RESULTS

During the study period, 53 096 hysterectomies were registered in The Norwegian Patient Registry, of which ureteric injury was documented in 643 (1.2%). More ureteric injuries were registered in large hospital trusts than in small trusts (1.3% vs. 0.7%, p < 0.05). NPE received 69 claims due to ureteric injury occurring during hysterectomy, comprising 11% of all injuries in the study period. Compensation was approved for 15%. Women who claimed compensation were younger (48.1 ± 8.9 years vs. 55.1 ± 13.6 years, p < 0.01), more likely to have had a benign diagnosis (89.9% vs. 52.1%, p < 0.01), and more likely to have had the ureteric injury recognized after discharge (58.0% vs. 33.0%, p < 0.001) compared with non-complainants. Identification of the ureters during the hysterectomy was documented in 30% of the NPE patient files. Additional information for the NPE cases included the following. The most common symptoms of unidentified injury were pain (77%), fever (12%), urinary leakage (13%), and anuria (8%). Re-operation was necessary in 77% of the cases, and 10% of the women lost one kidney. Long-term consequences after repair, such as loss of a kidney or persistent pain, were seen in 17%. No women died because of the injury.

CONCLUSIONS

The incidence of ureteric injury occurring during hysterectomy in Norway was 1.2%; 11% involved a claim for compensation, and 15% of these had their case approved. Most ureteric injuries were not recognized during the hysterectomy. Documentation of peroperative identification of the ureters during hysterectomy was often missing. Vigilance to pain as a postoperative symptom of peroperative unrecognized ureteric injury may result in earlier diagnosis and treatment.

Risk Factors for Urologic Injury in Women Undergoing Hysterectomy for Benign Indication

OBJECTIVE

To investigate risk factors associated with urologic injury in women undergoing hysterectomy for benign indication.

METHODS

A retrospective cohort study for the period of 2011-2018 was conducted using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Women without urologic injury were compared with women with injury. A pre-specified multivariable logistic regression model, controlling for key patient demographic factors and intraoperative variables, was used to assess for surgical factors associated with urologic injury.

RESULTS

Among 262 117 women who underwent hysterectomy for benign indication, 1539 (0.6%) sustained urologic injury. On average, patients with urologic injury were younger, had lower body mass index (BMI), and more frequently underwent a transabdominal surgical approach. Patients who underwent total hysterectomy had increased odds of urologic injury than those who underwent subtotal hysterectomy (adjusted OR [aOR] 1.49; 95% confidence interval [CI] 1.21-1.84). Patients with class III obesity had lower odds of injury than patients with normal BMI (aOR 0.64; 95% CI 0.51-0.80). For risk of urologic injury, an interaction was observed between surgical approach and surgical indication. Abdominal compared with laparoscopic approach was associated with urologic injury for women with endometriosis (aOR 2.98; 95% CI 1.99-4.47), pelvic pain (aOR 3.51; 95% CI 1.74-7.08), menstrual disorders (aOR 4.33; 95% CI 1.68-11.1), and fibroids (aOR 2.28; 95% CI 1.72-3.03). Vaginal compared with laparoscopic approach was associated with increased odds of injury for women with menstrual disorders (aOR 7.62; 95% CI 1.37-42.5).

CONCLUSION

While the risk of urologic injury during hysterectomy for benign indication is low, the risk is dependent on patient disease factors and surgical approach.

Post-Hysterectomy Transient Hydronephrosis: A Prospective Study

Objective: To determine the incidence and importance of transient asymptomatic hydronephrosis following total hysterectomy.

Materials and methods: In a prospective study over 4 year, 368 women were studied who had undergone a total abdominal or vaginal hysterectomy. Totally, 95% of operations were done for benign diseases (abnormal uterine bleeding, chronic pelvic pain, uterine prolapse, etc.) and 5% were performed for uterine malignancy. Renal ultrasonography was performed before and 3, 7 and 28 days after the surgery for diagnosing hydronephrosis. Intravenous urography was performed in patients with either persistent/progressive or symptomatic hydronephrosis.

Results: There was no intraoperative identifiable ureteral injury. Hydronephrosis was seen in 35 (9.5%), 21 (5.7%), and 1 (0.27%) patients at days 3, 7 and 28 after the operation, respectively. The degree of hydronephrosis was graded I, II or III. Considering the frequency and severity of hydronephrosis, the right kidney was affected more. Hydronephrosis correlated significantly with indication, duration and route of surgery as well as patient's age. All kidneys improved spontaneously, except one case which needed ureteral stenting with no surgical intervention (p=0.05).

Conclusion: Transient hydronephrosis could occur after simple total hysterectomy despite the absence of any obvious intraoperative ureteral injury. It is noted in 9.5% of the patients within three days after the non-complicated surgery. The clinical course may be continued until one month.

Robotic-Assisted Hysterectomy for Benign Indications of Uteri Less Than Fourteen Weeks Size Versus More Than Fourteen Weeks Size: A Comparative Study

Objectives

This study was conducted to evaluate the feasibility of robotic hysterectomy for benign indications in patients with small size (<14 weeks) versus large size (>14 weeks) uterus.

Methods

This prospective study was conducted in a single centre from August 2018 to January 2020 in the Department of Obstetrics and Gynecology at All India Institute of Medical Sciences, Rishikesh (Uttarakhand). Surgical outcomes of 216 patients who underwent a robotic hysterectomy in our institution for benign indications were analysed. Women opting for definitive surgical management by minimally invasive technique were divided into two groups according to the size of the uterus less than 14 weeks (group 1) versus more than equal to 14 weeks (group 2). Data collected in both groups included intra-operative and post-operative parameters, length of hospital stay and morbidity if any.

Results

The demographic profile was comparable in both groups. The mean estimated blood loss was 180.78 ±68.0 ml (range, 10-340 ml) in group 1 and 253.49 ±57ml (range, 60-360 ml) in group 2 (p-value < 0.0001). However, the fall in haemoglobin level after 24 hours of surgery was not statistically significantly different between the two groups. The total duration of surgery in group 1 was 97.86 ± 12.0 minutes (range, 78-132 minutes) and in group 2 was 116.60 ± 15.4 minutes (range, 97-156 minutes), the difference being statically significant (p-value < 0.0001, 95% CI 103±2.1). Console time in group 1 was 43.84 ±6.0 minutes (range, 34-57 minutes) and in group 2 53.22 ±5.5 minutes (range, 44-66 minutes), the difference being statistically significant (p-value < 0.0001, 95% CI 46.57±0.97). There was no difference observed in terms of intra-operative and post-operative complications between the two groups.

Conclusion

The total duration of surgery and estimated blood loss were directly proportional to the size of the uterus. However, complication rate, hospital stay and requirement of post-op analgesia were comparable in both groups. Robotic surgery in a larger uterus is a feasible option in terms of better surgical outcomes and postoperative course. Thus, robotic hysterectomy in women with a large uterus is a suitable approach in the narrow region of the pelvis.

Use of a Novel Fluorescent Catheter to Locate the Ureters during Total Laparoscopic Hysterectomy

Ureteral injury can occur during total laparoscopic hysterectomy. This report documents our experience in using the near-infrared ray catheter (NIRC), a newly developed fluorescent ureteral catheter made of material that contains a fluorescent dye to improve visualization of the ureters. We have used the device in 3 patients between 40 and 50 years of age (mean, 46.3 ± 4.5 years) undergoing total laparoscopic hysterectomy and bilateral salpingectomy for uterine myomas. The time of catheter insertion ranged from 4 minutes and 9 seconds to 10 minutes and 57 seconds. A number of intraoperative procedures were performed near the ureters, namely, identification and ligation of the uterine arteries, dissection of the cardinal ligament, incision of the vaginal canal, and suturing of the vaginal stump. The abovementioned fluorescent ureteral catheter appears green on a monitor when illuminated by near-infrared light, and this facilitated real-time confirmation of the ureter positions, increasing surgical safety. The patients were followed up for 6 months postoperatively, and no urinary tract infection or injury was found. Prophylactic use of the fluorescent ureteral catheter may improve visualization of the ureters in patients considered to be at high risk of ureteral injury, such as those expected to exhibit ureteral deviation due to severe adhesions or an enlarged uterus and when the surgeon has little experience in laparoscopic surgery.

Urinary System Iatrogenic Injuries: Problem Review

INTRODUCTION

From May to December 2019, a literature review of the urinary system iatrogenic injury problem was performed. The most cited, representative articles in PubMed, Scopus, and WoS databases dedicated to this problem were selected. Urinary system iatrogenic injuries include ureter, bladder, urethra, and kidney traumas. It is widely thought that the main causes of such injuries are urological, obstetric, gynecological, and surgical operations on the retroperitoneal space, pelvis, or perineum.

METHODS

The purpose of the study is to describe all aspects of the iatrogenic injure problem, under the established scheme and for each of the most damaged organs: the urethra, bladder, kidney, and ureter. The treatment of confirmed iatrogenic injuries largely depends on the period of its detection. Modern medical procedures provide conservative or minimally invasive treatment. An untimely diagnosis worsens the treatment prognosis. "Overlooked" urinary system trauma is a serious threat to society and a particular patient. Thus, incorrect or traumatic catheterization can lead to infection (RR 95%) and urethral stricture (RR ≥11-36%), and percutaneous puncture nephrostomy can cause the risk of functional renal parenchyma loss (median 5%), urinary congestion (7%), or sepsis (0.6-1.5%).

RESULTS

Lost gain, profits, long-term and expensive, possibly multistage treatment, stress and depression, and the risks of suicide put a heavy financial, moral, and ethical burden on a person and society. Also, iatrogenic injury might have legal consequences.

DISCUSSION/CONCLUSION

Thus, the significant problem of urinary tract iatrogenic injuries is still difficult to solve. There is a need to implement mandatory examining algorithms for patients at risk, as well as the multidisciplinary principle for all pelvic surgery.

Iatrogenic ureteral injury during retroperitoneal laparoscopy for large renal cysts: What we learned and a review of the literature

PURPOSE

To avoid Iatrogenic ureteral injury during retroperitoneal laparoscopy for large renal cyst (diameter > 70 mm), we present two cases of iatrogenic ureteral injury and discuss their clinical courses and final outcomes.

PATIENTS AND METHODS

Two male patients (47 years old and 74 years old) with large left simple renal cysts underwent a retroperitoneal laparoscopic operation to treat the cysts. In the first patient, the left proximal ureter was partially transected (Grade 3) during the operation. The injury was identified intraoperatively. The transection was managed with a primary ureteroureterostomy (end to end) along with a double J ureteral stent. In the second patient, the left proximalureter was partially transected (Grade 4). However, the injury was unrecognized postoperatively for two days. After recognition of the complication, the injury was managed with an early primary ureteroureterostomy, which followed a failed attempt to place ureteral stent endoscopically.

RESULTS

In the first patient, a postoperative urinary leakage developed and lasted for 13 days. During long term follow-up of the first patient after the urine leak resolved, there were no reports of pain in the lumbar region or other discomfort. No recurrence of the renal cyst occurred, which was confirmed with an ultrasound at one year postoperatively. In the second patient a ureteral fistula and severe perirenal infection occurred and lasted for 86 days. The patient ultimately underwent a left nephrectomy after conservative management for this surgical complication failed. This patient developed a chronic wound infection that lasted for 3.14 months following the nephrectomy. During follow-up post nephrectomy, the patient developed stage 3B moderate chronic kidney disease (CKD) (GFR = 30 -44 ml/min).

CONCLUSIONS

For single large (diameter > 70 mm) renal cysts located at the lower pole of the kidney, it is recommended to not completely dissect out and mobilize the entire renal cyst for cyst decortication in order to avoid injuring the ureter. Iatrogenic ureteral injury increases the risk of readmission and serious life-threatening complications. The immediate diagnosis and proper management ureteric injury can reduce complications and long term sequalae.

The current state and the future of robotic surgery in female pelvic medicine and reconstructive surgery

In this article, we review the current uses and future directions of robotic surgery in the field of female pelvic medicine and reconstructive surgery. Pelvic surgery is ideal for the use of surgical robots, which provide improved visualization and ease of suturing deep within the pelvis. Robots have been successfully used for the treatment of pelvic organ prolapse, in procedures such as sacrocolpopexy, sacrohysteropexy, and uterosacral ligament plication. Surgeons have used the robotic successfully to treat various etiologies of female pelvic pain including fibroids, endometriosis, and nerve entrapment. Robotic repair of iatrogenic injury has been described with excellent outcomes and avoidance of conversion to open surgery in the event of an injury caused using the robotic platform. While more data is needed on this topic, there has been increasing interest in using the robot for urologic reconstruction including repair of vesico-vaginal fistula, cystectomy, augmentation cystoplasty, and continent and non-continent diversions. Recently the use of the robot has been described in the treatment of stress urinary incontinence in females, with robotic placement of an artificial urinary sphincter. While robotic surgery is associated with increased cost, the outcomes of robotic surgery in female urology are promising. More studies that properly evaluate the benefits of robotic surgery as compared to open and laparoscopic approaches are needed.

Bladder and ureteral injuries during benign hysterectomy: an observational cohort analysis in New York State

PURPOSE

Hysterectomy (Hys) is the most common non-urologic surgery associated with iatrogenic genitourinary (GU) injury. We present the largest known population-based evaluation of GU injury related to benign Hys.

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) was queried by ICD-9 and CPT codes. SPARCS for women from 1995 to 2014, who underwent laparoscopic or robotic Hys (minimally invasive surgery = MIS), abdominal Hys (AH), and vaginal Hys (VH) for benign diagnoses. Bladder and ureteral repairs were captured based on the procedure codes. Codes for ureteroneocystotomy (UNC) were compared to any other ureteral repairs, to elucidate injury patterns. Statistical analysis was conducted using Chi squared test, ANOVA, Mann-Whitney test and Poisson Regression and multivariable analysis were performed.

RESULTS

516,340 women underwent Hys for a benign etiology. 69% were AH, 25% VH, and 6% were MIS. 7490 patients (1.45%) had a concomitant GU injury. Compared to VH, MIS and AH were associated with greater odds of bladder and ureteral injury (p < 0.001). MIS and AH, compared to VH, were associated with reduced odds of UNC compared to complex reconstruction (OR 0.27, p < 0.001 and OR 0.12, p < 0.00, respectively). The injured cohort had higher total mean charges ($29,889 vs $15,808) and length of hospitalization (6.32 vs 3.56 days) (p < 0.001).

CONCLUSIONS

Bladder and ureteral injuries during hysterectomy are uncommon in contemporary practice and are lower than historical rates. GU injury increases hospitalization cost. VH is associated with the lowest rate of GU injury, and thus appears to be a valuable approach, when feasible.