Review
Urinary Tract Injury in Gynecologic
Laparoscopy for Benign Indication
A Systematic Review
Jacqueline M. K. Wong, MD, Pietro Bortoletto, MD, Jocelyn Tolentino, MD, MPH, Michael J. Jung, MD, MBA,
and Magdy P. Milad, MD, MS
OBJECTIVE: To perform a comprehensive literature
review of the incidence, location, etiology, timing,
management, and long-term sequelae of urinary tract
injury in gynecologic laparoscopy for benign indication.
DATA SOURCES: A systematic review of PubMed,
EMBASE, Cochrane Library, and ClinicalTrials.gov was
conducted.
METHODS OF STUDY SELECTION: Four hundred thirty-
three studies were screened for inclusion with 136 full-
text articles reviewed. Ninety studies published between
1975 and 2015 met inclusion criteria, representing
140,444 surgeries. Articles reporting the incidence of
urinary tract injury in gynecologic laparoscopy for benign
indication were included. Exclusion criteria comprised
malignancy, surgery by urogynecologists, research not in
English, and insufficient data.
TABULATION, INTEGRATION, AND RESULTS: A total
of 458 lower urinary tract injuries were reported with an
incidence of 0.33% (95% CI 0.30–0.36). Bladder injury
(0.24%, 95% CI 0.22–0.27) was overall three times more
frequent than ureteral injury (0.08%, 95% CI 0.07–0.10).
Laparoscopic hysterectomy not otherwise specified
(1.8%, 95% CI 1.2–2.6) and laparoscopically assisted vag-
From the Department of Obstetrics and Gynecology, Northwestern University
Feinberg School of Medicine, Chicago, Illinois; and the Department of Obstetrics
and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts.
Presented at the American Society for Reproductive Medicine meeting, October
15–19, 2016, Salt Lake City, Utah; and at the American Association of Gyne-
cologic Laparoscopists meeting, November 14–18, 2016, Orlando, Florida.
Each author has indicated that he or she has met the journal’s requirements for
authorship.
Corresponding author: Jacqueline M. K. Wong, MD, Department of Obstetrics
and Gynecology, 250 East Superior Street, Suite 5-2177, Chicago, IL 60611;
email: Jacqueline-wong@northwestern.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2017 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/18
VOL. 131, NO. 1, JANUARY 2018
Copyright Ó by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
inal hysterectomy (1.0%, 95% CI 0.9–1.2) had the highest
rates of injury. Most ureteral injuries resulted from electro-
surgery (33.3%, 95% CI 24.3–45.8), whereas most bladder
injuries resulted from lysis of adhesions (23.3%, 95% CI
18.7–29.0). Ureteral injuries were most often recognized
postoperatively (60%, 95% CI 47–76) and were repaired
by open ureteral anastomosis (47.4%, 95% CI 36.3–61.9).
In contrast, bladder injuries were most often recognized
intraoperatively (85%, 95% CI 75–95) and were repaired
by laparoscopic suturing (34.9%, 95% CI 29.2–41.7).
CONCLUSION: The incidence of lower urinary tract
injury in gynecologic laparoscopy for benign indication
remains low at 0.33%. Bladder injury was three times
more common than ureteral injury, although ureteral
injuries were more often unrecognized intraoperatively
and underwent open surgical repair. These risk estimates
can assist gynecologic surgeons in effectively counseling
their patients preoperatively concerning the risks of
lower urinary tract injury.
(Obstet Gynecol 2018;131:1–9)
DOI: 10.1097/AOG.0000000000002414
A dvancements in minimally invasive surgery,
including gynecologic laparoscopy, have yielded
benefits such as smaller incisions, shorter hospital
stays, and reduced blood loss.1–3 However, the risk
of injury to the lower urinary tract, consisting of the
bladder and ureters, is inherent to gynecologic sur-
gery regardless of operative technique, because the
bladder and ureters lie adjacent to and resemble other
critical structures.4,5 Lower urinary tract injury carries
an increased morbidity including infection, fistula for-
mation, and renal failure.4–6 Injuries with primary or
delayed repair may also require reoperation and may
significantly affect patients’ quality of life, hospital
costs, and emotional well-being.6
Many previous studies have reported varied
incidences of lower urinary tract injury in gynecologic
OBSTETRICS & GYNECOLOGY 1
laparoscopy, from 0.2% to 1.6%.3,7–10 The exact inci- abstract was then evaluated for final inclusion. Data
dence, however, has been difficult to determine. Re- were obtained and extracted by two reviewers in dupli-
ported rates vary greatly as a result of factors such as cate ( J.M.K.W. and P.B.). The quality of the enrolled
patient characteristics, approach to injury diagnosis, studies was evaluated using the Newcastle-Ottawa Qual-
type of surgery, surgeon volume and experience, ity Assessment Scale.
and study design.4,5,11–13 Further complicating this Data were pooled to obtain crude incidence rates.
discussion has been the emergence of cystoscopy as As a result of the rarity of the injuries and the
a tool to intraoperatively detect lower urinary tract limitations of inverse weighting with up to 99.7% of
injuries through the observation of bladder defects the sample noted to be inestimable, the data were
or absent or sluggish efflux from the ureteral orifi- aggregated without any inverse weighting or meta-
ces.11,12,14 Although cystoscopy may be a useful analysis. Poisson distribution was used to obtain 95%
adjunct for gynecologic surgery, the data concerning CIs. Tests were considered statistically significant
its utility have also been conflicting. The objective of when the P value was ,.05. Pearson correlation coef-
this study was therefore to conduct a comprehensive ficient and linear regression weighted by the size of
systematic review of the incidence, location, cause, the study were used to test the relationship between
timing, management, and long-term sequelae of lower the type of injury and the year of diagnosis. RevMan
urinary tract injury in gynecologic laparoscopy for 5.3 and SAS 9.4 were used for analyses.
benign indication to improve understanding of and
subsequent patient counseling on the risks of injury. RESULTS
SOURCES Study selection is outlined in Figure 1. Four hundred
thirty-three abstracts were initially identified with 136
The PubMed Central, EMBASE, Cochrane Library,
full-text articles then assessed for eligibility. A total of
and ClinicalTrials.gov databases were searched in
90 studies were included in the final analysis, involv-
duplicate by two reviewers (J.M.K.W. and P.B.). The
ing 140,444 patient surgeries between the years 1975
PubMed Central search was conducted using the fol-
and 201510,13,16–55,56–90,91–103 (Appendix 1, available
lowing MeSH headings: 1) “laparoscopy,” “gyneco-
online at http://links.lww.com/AOG/B43). These
logic surgical procedures,” and “ureter/injuries ” or
studies comprised four randomized controlled trials,
“bladder/injuries”; and 2) “ureter or ureteral or ure-
19 prospective studies, 62 retrospective studies, three
thra or urethral or bladder,” “injury,” “gynecology,”
combined prospective and retrospective studies, one
and “laparoscopy.” A similar search strategy was used
case-controlled study, and one unspecified retrospec-
for EMBASE, Cochrane Library, and ClinicalTrials.
tive or prospective study. Forty-two of these studies
gov. The databases were searched without restriction
reported ureteral injuries, and 59 reported bladder
on date of publication or study design.
injuries.
STUDY SELECTION The overall incidence of lower urinary tract injury
was found to be 0.33% (95% CI 0.30–0.36), which
This systematic review was conducted in accordance
included a 0.08% (95% CI 0.07–0.10) incidence of
with the Guidelines for Meta-Analyses and Systematic
ureter injury and a 0.24% (95% CI 0.22–0.27)
Reviews of Observational Studies.15 Eligibility for inclu-
sion was limited to papers written in English that re-
ported the incidence of laparoscopic injury of the
lower urinary tract. Studies were excluded if they were
case reports, presented insufficient data, did not reflect
original research, involved gynecologic malignancy, or
were performed by urogynecologists. Patients with
gynecologic malignancy or who were operated on by
urogynecologists were excluded because they represent
different populations of risk as a result of the heightened
need for a subspecialist surgeon to perform dissection
close to the bladder and ureters. Lower urinary tract
injury comprised ureteral or bladder trauma secondary
to any damage during the surgical procedure. Each Fig. 1. Systematic review selection process.
abstract identified through the electronic databases was Wong. Gynecologic Laparoscopy Urinary Injury. Obstet Gynecol
evaluated for relevance, and the full text of each relevant 2018.

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incidence of bladder injury. This represents a three
times higher incidence of bladder injury than ureter
injury. Rates of injury were then calculated according
to the type of procedure in which the injury occurred
(Table 1). The highest incidence of ureteral injury was
found in endometriosis resection (0.4%, 95% CI 0.3–
0.6) followed by laparoscopically assisted vaginal hys-
terectomy (0.2%, 95% CI 0.2–0.3) and laparoscopic
hysterectomy not otherwise specified (0.2%, 95% CI
0.1–0.6). Bladder injuries were found to be most com-
mon in laparoscopic hysterectomy not otherwise spec-
ified (1.6%, 95% CI 1.1–2.3) followed by
laparoscopically assisted vaginal hysterectomy (0.8%,
95% CI 0.7–0.9), major surgery not otherwise speci-
fied (0.5%, 95% CI 0.2–1.0), and laparoscopic supra-
cervical hysterectomy (0.2%, 95% CI 0.1–0.4). There
were no lower urinary tract injuries found for the
1,004 robotic surgeries included in the analysis.
Causes of lower urinary tract injury were
separated into electrosurgery or laser ablation,
forceps or scissor use, lysis of adhesions or dissec-
tion, suturing or stapling, vaginal surgery, Veress or
trocar insertion, or an unspecified cause (Table 2).
An unspecified cause of injury accounted for 39.5%
of ureteral injuries (95% CI 29.5–52.9) and 53.5% of
bladder injuries (95% CI 46.3–61.8). When speci-
fied, ureteral injuries were most often the result of
electrosurgery or laser ablation (33.3%, 95% CI
24.3–45.8) followed by lysis of adhesions or dissec-
tion (11.4%, 95% CI 6.6–19.6). Bladder injuries
were most often the result of lysis of adhesions or
dissection (23.3%, 95% CI 18.7–29.0) and vaginal
surgery (18.9%, 95% CI 14.8–24.1).
Timing of diagnosis of lower urinary tract injury
was separated into two time periods: intraoperative
and postoperative (Appendix 2, available online at
http://links.lww.com/AOG/B43). Most ureteral inju-
ries were recognized postoperatively (60%, 95% CI
47–76), whereas most bladder injuries were recog-
nized intraoperatively (85%, 95% CI 75–95). The
value of routine cystoscopy during surgery was then
assessed for each time period to determine if routine
use could increase intraoperative rather than delayed
postoperative injury recognition. We found that only
38% (95% CI 28–53) of ureteral injuries were recog-
nized intraoperatively in the absence of routine cys-
toscopy. This rate increased to 53% (95% CI 27–100)
when cystoscopy was routinely used; however, this
was not found to be significant (P5.28). Bladder in-
juries were recognized intraoperatively at a rate of
84% (95% CI 75–95) without routine cystoscopy com-
pared with 94% (95% CI 59–100) with routine cystos-
copy. Again, this difference was not found to be
significant (P5.26).
Ureteral injuries were primarily managed by
open ureteral anastomosis, including ureteroureteros-
tomy and ureteroneocystotomy (47.4%, 95% CI 36.3–
61.9) (Appendix 3, available online at http://links.
lww.com/AOG/B43). Bladder injuries were most
often repaired by laparoscopic suturing (34.9%, 95%
CI 29.2–41.7) followed by transvaginal repair during
vaginal surgery (18.9%, 95% CI 14.8–24.1). In total,
48% of ureteral injuries and 15% of bladder injuries
required conversion to laparotomy to achieve repair.
The incidences of ureterovaginal, ureterosigmoid,
and vesicovaginal fistula formation were used as

Table 1. Incidence of Laparoscopic Lower Urinary Tract Injury by Type of Procedure

Total LUT Injury Ureter Injury Bladder Injury

No. of No. of
Procedure Type Surgeries n % (95% CI) n % (95% CI) n % (95% CI) Studies

TLH 86,683 122 0.1 (0.1–0.2) 31 0.04 (0.03–0.05) 91 0.1 (0.1–0.1) 37

LAVH 24,257 247 1.0 (0.9–1.2) 50 0.2 (0.2–0.3) 197 0.8 (0.7–0.9) 42
LSH 5,452 19 0.4 (0.2–0.6) 6 0.1 (0.1–0.3) 13 0.2 (0.1–0.4) 10
LH NOS 1,590 28 1.8 (1.2–2.6) 3 0.2 (0.1–0.6) 25 1.6 (1.1–2.3) 8
Adnexal surgery 6,905 9 0.1 (0.1–0.3) 6 0.09 (0.04–0.2) 3 0.04 (0.01–0.1) 10
Endometriosis resection 4,275 17 0.4 (0.3–0.6) 17 0.4 (0.3–0.6) 0 — 7
Major surgery NOS* 1,644 8 0.5 (0.2–1.0) 0 — 8 0.5 (0.2–1.0) 4
Minor surgery NOS† 2,257 3 0.1 (0.04–0.4) 0 — 3 0.1 (0.04–0.4) 7
NOS 3,235 5 0.2 (0.1–0.4) 1 0.03 (0.0–0.2) 4 0.1 (0.1–0.3) 4
Total 140,444 458 0.33 114 0.08 344 0.24 90
LUT, lower urinary tract; TLH, total laparoscopic hysterectomy; LAVH, laparoscopically assisted vaginal hysterectomy; LSH, laparoscopic
supracervical hysterectomy; LH NOS, laparoscopic hysterectomy not otherwise specified; NOS, not otherwise specified.
There were no LUT injuries found for the following procedures (no. of surgeries): robotic hysterectomy (1,004), sterilization (1,985),
myomectomy (824), adhesiolysis (248), and uterine suspension (85).
* Major surgery NOS: ectopic pregnancy; appendectomy; undifferentiated hysterectomy, myomectomy, and bladder neck suspension.
†
Minor surgery NOS: diagnostic laparoscopy, nerve ablation, fimbrioplasty.

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Table 2. Causes of Laparoscopic Lower Urinary Tract Injury

Location Cause of Injury No. of Injuries % of Injuries (95% CI) No. of Studies

Ureter Electrosurgery or laser 38 33.3 (24.3–45.8) 19

Forceps or scissors 4 3.5 (1.3–9.4) 3
LOA or dissection 13 11.4 (6.6–19.6) 7
Suturing or stapling 10 8.8 (4.7–16.3) 7
Vaginal surgery 4 3.5 (1.3–9.4) 3
Veress or trocar insertion 0 — 0
Unspecified 45 39.5 (29.5–52.9) 23
Bladder Electrosurgery or laser 8 2.33 (1.2–4.7) 5
Forceps or scissors 3 0.9 (0–2.7) 2
LOA or dissection 80 23.3 (18.7–29.0) 22
Suturing or stapling 0 — 0
Vaginal surgery 65 18.9 (14.8–24.1) 10
Veress or trocar insertion 4 1.2 (0–3.1) 4
Unspecified 184 53.5 (46.3–61.8) 35
LOA, lysis of adhesions.

markers for the long-term sequelae of ureteral and
bladder injury. Ureterovaginal and ureterosigmoid
fistulas were found to have an incidence of 0.02%
(95% CI 0.01–0.03), which was comparable with
the 0.02% incidence of vesicovaginal fistula forma-
tion (95% CI 0.02–0.03). Two deaths were found
among the 140,444 surgeries reviewed with neither
related to urinary tract injury (one myocardial
infarction or pulmonary embolism and one aortic
injury).
The relationships between the year of diagnosis
and the reported rates of ureteral, bladder, and total
lower urinary tract injuries were investigated by
weighted Pearson correlation. This was plotted
along a fitted line with r values of 20.19 (P5.07),
20.25 (P5.02), and 20.28 (P5.01) found for the
rates of ureteral, bladder, and combined injuries,
respectively. Finally, prospective studies were
found to have a significantly higher incidence of
ureteral (0.2%, CI 0.1–0.4, P5.001) and total lower
urinary tract (0.5%, CI 0.3–0.7, P5.01) injuries than
retrospective studies (0.07% and 0.3%, respec-
tively). This comparison was not found to be signif-
icant for the rate of bladder injuries (0.3% compared
with 0.2%, P5.41).
DISCUSSION
Our study confirmed a 0.33% incidence of lower
urinary tract injury in gynecologic laparoscopy for
benign indication from a comprehensive review of the
literature over the past 40 years. Incomplete reporting
of the causes, management, and timing of injuries
among the included papers, however, may limit our
full understanding of the nature of these injuries. An
increased incidence of ureteral injury was noted in
prospective compared with retrospective studies,
highlighting the likely underreporting within retro-
spective research and the need for high-quality pro-
spective data.
Procedural type was found to significantly affect
the location and incidence of lower urinary tract
injury. All combined types of laparoscopic hyster-
ectomies accounted for 95% of reported bladder
injuries—likely a result of the necessary dissection of
the vesicouterine peritoneum involved in the pro-
cedure. The vaginal portion of surgery in laparos-
copically assisted vaginal hysterectomy and
laparoscopic hysterectomy not otherwise specified
accounted for 15% of all injuries, which, in combi-
nation with the reported trend of declining vaginal
surgery over the last decade,104 may reflect a lack of
surgeon comfort with vaginal surgery. For ureteral
injuries, endometriosis resection was responsible for
a twofold higher rate of injury (0.4%) than any other
procedure type. This finding is consistent with pre-
vious research implicating endometriotic lesions
and thickening of the uterosacral ligaments as
causes of anatomic distortion that make identifica-
tion and avoidance of the ureter challenging.105,106
The benefit of universal cystoscopy has been
extensively debated in the literature. Although
multiple studies have demonstrated an increased
rate of intraoperative bladder and ureteral injury
detection from the routine use of cystos-
copy,5,11,13,14 others have reported no increase in
intraoperative injury detection107 and no decrease
in postoperative injury detection.108 We found that
although the use of routine cystoscopy increased the
rates of intraoperative detection of ureteral injury
from 38% to 53% and of bladder injury from 84%

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to 94%, neither was a statistically significant
improvement. In concurrence with data from Visco
et al109 noting that routine cystoscopy becomes
cost-effective only over a ureteral injury incidence
of 2% in laparoscopic hysterectomy, our findings do
not appear to support routine cystoscopy from
a cost-effectiveness viewpoint. The Visco et al analysis,
however, notably excluded the associated costs of lower
urinary tract injury as a leading cause of litigation for
gynecologic surgeons.110 Given the recent endorsement
of routine cystoscopy by professional gynecologic soci-
eties111 and the incorporation of cystoscopy training into
obstetrics and gynecology residency programs, it is
likely that the ability of gynecologic surgeons to detect
lower urinary tract injuries through cystoscopy will con-
tinue to improve and contribute to the promotion of
universal cystoscopy.
Lower urinary tract injury carries the potential for
substantial morbidity. Although ureteral injury occurs
only one third as often as bladder injury, it is
associated with high rates of open conversion (48%)
and delayed recognition (62%). Although minimally
invasive ureteral repair has been increasing over the
past decade, the approach of repair still relies heavily
on physician discretion.3,112 Although delayed injury
recognition has been associated with fistula forma-
tion,113,114 we found that fistulization remained a rare
event with an incidence of 0.02% for both the bladder
and ureter.
Studies from the late 1990s suggested that the
rate of lower urinary tract injury had increased over
threefold since the advent of laparoscopy.10,113,115
This was attributed to surgeon inexperience, a lim-
ited view, the adoption of increasingly difficult tech-
niques, and reduced tactile feedback.4,113,116 Our
results demonstrated significantly decreased rates
of bladder and total lower urinary tract injuries
from 1975 to 2015. We theorize that this decrease
in injuries mirrors an increase in surgeon volume
and experience with laparoscopy. Desai et al104
note, for instance, a 31% increase in the rate of total
laparoscopic hysterectomy in the United States
between 2007 and 2012.
A notable limitation of this study was the
identification of only one paper involving robotic-
assisted gynecologic surgery. This may prevent
extrapolation of this study’s findings to broad phy-
sician practices as robotic assistance has recently
been reported in up to 39.5% of minimally invasive
hysterectomies.104 The applicability of this study to
individual patients may also be limited by an
imprecise characterization of procedural type in
the literature, which could potentially obscure
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underlying surgical complexity and risk. Finally,
this review was unable to evaluate uterine size, sur-
geon volume, and surgeon level of training, all
variables that have been previously documented
to significantly affect the incidence of
injury.3,12,17,117,118
This study represents a comprehensive summary
of the rates of lower urinary tract injury in gyneco-
logic laparoscopy for benign indication. Our hope is
that this review can help promote an improved
understanding of and subsequent patient counseling
on the risks of injury in gynecologic laparoscopy as
the field of minimally invasive gynecologic surgery
continues to expand.
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