Prophylactic ureteric catheterisation during complex gynaecological surgery: A systematic review and meta-analysis

BACKGROUND

There is a lack of robust evidence to recommend the use of perioperative ureteric catheterisation or stenting in complex gynaecological surgery.

OBJECTIVES

To evaluate the evidence on the benefits and risks of perioperative ureteric catheterisation or stenting in complex gynaecological surgery.

SEARCH STRATEGY

A literature search was performed in CINAHL, the Cochrane Library, Embase and MEDLINE, from 1946 to January 2024, using a combination of keywords and Medical Subject Headings (MeSH) terminology.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and observational studies were included.

DATA COLLECTION AND ANALYSIS

Meta-analysis of the RCTs and observational studies were performed separately. Cochrane RevMan 6.5.1 was used to undertake meta-analysis. Risk ratios with 95% CIs were calculated for the outcome measures.

MAIN RESULTS

Ten studies were included: three RCTs and seven observational studies, comprising 8661 patients. The three RCTs, comprising a total of 3277 patients, showed no difference in the risk of immediate complications in the form of ureteric injury between the ureteric stent and the control groups (RR 0.9, 95% CI 0.49-1.65). The observational studies included 5384 patients. Four studies that explored the ureteric injury as an outcome did not show any difference between the two groups (RR 0.76, 95% CI 0.27-2.16). One case-control study with 862 participants found that the rate of ureteric injury was higher in the non-stented group, although this was observed in only three patients. The risk of urinary tract infection (UTI) was increased in the stent group, although not with statistical significance (RR 1.84, 95% CI 0.47-7.17). There was no significant difference in the risk of ureteric fistulae (RR 1.91, 95% CI 0.62-5.83), although the number of studies was limited.

CONCLUSIONS

Prophylactic ureteric catheterisation or stenting for complex gynaecological surgery is not associated with a lower risk of ureteric injury.

A delayed diagnosis of iatrogenic ureteral injury results in increased morbidity

This study aimed to register and analyse outcomes after iatrogenic ureteral injuries (IUI) with special emphasis on potential consequences of a delayed diagnosis, and further to analyse if the incidence of IUI has changed during the study period. 108 patients treated for an IUI during 2001-2021 were included. Injuries due to endourological procedures, planned tumour resection and traumatic injuries were excluded. All relevant information to answer the research questions were entered into a database. Chi-square and t-tests were used for categorical and continuous variables respectively. Regression analysis was used to evaluate potential change of incidence in IUIs over time. Our results showed that most IUIs (74, 69%) were caused by gynaecological surgery. 49 (45%) had a delayed diagnosis (not diagnosed intraoperatively). Younger age (mean 50 vs 62 years, p < 0.001) and benign indication for laparoscopic hysterectomy (OR 8.0, p < 0.001) predisposed for a delayed diagnosis. Patients with a delayed diagnosis had a higher number of secondary injury related procedures (mean 4.6 vs 1.7, p < 0.001), hospital admissions (mean 3.0 vs 0.8, p < 0.001) and longer hospital stays (mean 20.6 vs 3.9 days p < 0.001) compared to patients with an intraoperative diagnosis. There was complete recovery for 91% of the patients. We did not observe any changes in IUI incidence during the study period. In conclusion, our study underlines that IUI can cause major morbidity for the patient affected if not diagnosed intraoperatively. Benign indication and younger age are predictors for a delayed diagnosis. The prognosis is good, with 91% full recovery. No significant changes in incidence of IUIs were observed.

Uterine allograft removal by total laparoscopic hysterectomy after successful cesarean delivery in a living-donor uterus recipient with uterovaginal agenesis (MRKHS)

PURPOSE

To limit the burden of long-term immunosuppression (IS) after uterus transplantation (UTx), removal of the uterine allograft is indicated after maximum two pregnancies. Hitherto this has required graft hysterectomy by laparotomy. Our objective was to demonstrate, as a proof of concept, the feasibility of less traumatic transplantectomy by total laparoscopic hysterectomy (TLH).

PATIENT

A 37-year-old woman with uterovaginal agenesis due to Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) who had undergone neovaginoplasty at age 19 years prior to living-donor (LD) UTx in 10/2019 at age 35 years gave birth to a healthy boy by primary cesarean section in 06/2021. During pregnancy, she developed impaired renal function, with bilateral hydronephrosis, necessitating early allograft removal in 09/2021 to prevent chronic kidney disease, particularly during a potential second pregnancy.

METHODS

Transplantectomy by TLH essentially followed standard TLH procedures. We paid meticulous attention to removing as much donor tissue as possible to prevent postoperative complications from residual donor tissue after stopping IS, as well as long-term vascular damage.

RESULTS

TLH was performed successfully without the need to convert to open surgery. Surgical time was 90 min with minimal blood loss. No major complications occurred intra- or postoperatively and during the subsequent 9-month follow-up period. Kidney function normalized.

CONCLUSIONS

To our knowledge, we report the first successful TLH-based removal of a uterine allograft in a primipara after LD UTx, thus demonstrating the feasibility of TLH in uterus recipients with MRKHS.

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.

Uterine Artery Embolization and Double-J (DJ) Stenting in a Case of Urinary Retention Due to a Massive Cervical Fibroid: A Case Report

In women, the most common solid tumor of the pelvis is a uterine fibroid. A large cervical fibroid can also cause urinary incontinence in women. We report a case of a 45-year-old woman with urinary retention that was initially diagnosed as an anterior wall uterine fibroid in the peripheral health center but turned out to be a massive cervical fibroid. After the initial evaluation, it was determined that the cervical fibroid was huge and impacted the pelvis, and there was a possibility of a torrential operative hemorrhage. Thus, preoperative uterine artery embolization (UAE) was performed to prevent intraoperative blood loss, and Double-J (DJ) stenting was performed to avoid ureteric injury. This was followed by a total abdominal hysterectomy, without facing any intraoperative complications. This case demonstrates the importance of proper clinical assessment and the use of skilled interventional radiology procedures such as UAE and DJ stenting in the treatment of a massive cervical fibroid.

Does prophylactic ureteral catheter placement offer any advantage for laparoscopic gynecological surgery? A urologist' perspective from a systematic review and meta-analysis

Our aim is to assess the efficacy of prophylactic ureteral catheter placement on patients undergoing laparoscopic gynecological surgery. We searched the electronic database including PubMed, Cochrane Library, Embase, Web of Science, WANFANG and CNKI in January 2020 to identify possible studies without languages limitations. A manual search was also conducted. The trials that compared catheterized group (CG) to non-catheterized group (NCG) were included. This meta-analysis was accomplished by RevMan5 (version 5.3). Initial search yield 997 studies and 5 randomized control trials were included in the final meta-analysis. Pooling data of five studies showed that patients in the CG had a lower risk of ureteral injury than those in NCG (RR: 0.44, 95% CI: 0.20–0.97, P=0.04) without significant between-study heterogeneity (P=0.23, I²=29%). The pooled data analysis showed a statistically significant difference in favor of prophylactic ureter catheter placement (MD: −40.51, 95% CI: −58.65 to −22.36, P<0.0001). Random-effects model meta-analysis found that patients in the CG experienced higher EBL compared to NCG (SMD: −5.78, 95% CI: −10.51 to −1.04, P=0.02). There was no statistically significant difference between CG group and NCG group (P=0.23) with regard to LOS. Current evidence indicates that prophylactic ureteral catheter placement has the advantages of reducing ureteral injury, shortening the operative time, and reducing the amount of bleeding. It might serve as a routine preoperative preparation choice for laparoscopic gynecological surgery, especially with pelvic adhesion. Further large volume, multicenter well-designed trials are warranted before making the final clinical guidelines.

Evaluation of Strategies to Prevent Urinary Tract Injury in Minimally Invasive Gynecologic Surgery: A Systematic Review

OBJECTIVE

To systematically review tools for the prevention of urinary tract injury in adult women undergoing minimally invasive gynecologic surgery.

DATA SOURCES

A medical librarian (M.P.H.) searched Ovid Medline 1946 to, Ovid Embase 1929 to, CINAHL 1965 to, Cochrane Library 1974 to, Web of Science 1926 to, and SCOPUS 1974 to present on April 2 and April 3, 2020.

METHODS OF STUDY SELECTION

Articles evaluating strategies for the prevention of urinary tract injury at the time of minimally invasive gynecologic surgery were included. Articles that were nongynecologic, nonhuman, and nonadult were excluded. If a study did not describe the surgical approach or type of surgical procedures performed, it was excluded. If the study population was <50% gynecologic or <50% minimally invasive, it was excluded. Articles evaluating techniques for the diagnosis or management of injury, rather than prevention, were excluded.

TABULATION, INTEGRATION, AND RESULTS

The search yielded 2344 citations; duplicates were removed, inclusion criteria were applied, and 9 studies remained for analysis. Three studies evaluated bladder catheters, and 6 evaluated ureteral catheters. In the 3 studies evaluating bladder catheters, there were no urinary tract injuries. Urinary tract infection was greater in women who received a bladder catheter. In the studies evaluating the use of ureteral catheters, we found inconsistent reporting and heterogeneity that precluded meta-analysis. The results of the available studies do not indicate that ureteral catheters decrease the risk of injury, and indicate that they increase morbidity.

CONCLUSION

The evidence is insufficient to support the routine use of bladder catheters or ureteral catheters for the prevention of urinary tract injury at the time of minimally invasive gynecologic surgery.

Robot-assisted gynaecological cancer surgery-complications and prevention

Ever since the US Food and Drug Administration approval of the use of da Vinci surgical systems (Intuitive Surgical Inc., Sunnyvale, California) in gynaecology in 2005, robot-assisted surgery has been widely adopted in different countries. Some of the applications in benign and oncological gynaecology include myomectomy, sacrocolpopexy, tubal anastomosis, simple hysterectomy, radical hysterectomy, radical trachelectomy, pelvic and/or para-aortic lymphadenectomy and even debulking surgery for ovarian cancer and pelvic exenteration for recurrent cervical and vaginal cancer. Although there is robust evidence on the safety and treatment outcomes in robot-assisted surgery, complications still rarely occur. Team approach is particularly important in robotic surgery and thorough communication between the bedside assistant and the console surgeon cannot be stressed any more. Thus, complications can be due to miscommunication between the console surgeon and bedside assistant, positioning of the patients, the length of the operations, the malfunction of the instrument and the risks specific to the types of anaesthesia and surgery per se, leading to thromboembolism, haemorrhage, organ damage, and so on. The most important strategies that can prevent complications are to have thorough preoperative assessment of the patients' fitness, good communication between surgical team members, caution regarding the positioning, a good knowledge of the pelvic and abdominal anatomy, careful and meticulous manipulation of the instrument and early recognition of the complications. In this article, different types of complications and the preventive measures are described.