Archives of Gynecology and Obstetrics

https://doi.org/10.1007/s00404-022-06800-0

GENERAL GYNECOLOGY

Iatrogenic bladder and ureteral injuries following gynecological

and obstetric surgery
Ann‑Sophie Jensen1 · Martin Rudnicki1 

Received: 1 August 2022 / Accepted: 19 September 2022

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022

Abstract
Key message  Ureteral injuries are often associated with complications and risk of fistula especially in case of malig-
nancy. Length of catheterization should be reconsidered according to the injury.
Abstract  Purpose  Iatrogenic urinary tract injuries are potential complications of gynecologic and obstetric surgery. Our aim
was to describe suture type and size, length of urethral catheterization, length of hospitalization, reoperation rate, follow-up,
and impact on quality of life following iatrogenic bladder and ureteral injury.
Methods  In total, 81 women met inclusion criteria. Bladder injuries included 55 women, ureteral injuries in 23 women, and
three women had bladder and ureteral injuries.
Results  Most bladder injuries were managed by a two-layer suture followed by transurethral catheterization for 11.4 days
(95% CI 9.1–13.6). The most frequent suture type was 3.0 Vicryl in all subgroups. In total, 30.4% of ureteral injuries were
managed by neoimplantation followed by ureteral stenting for 38.0 days (95% CI 22.0–54.0) and transurethral catheterization
for 16.9 days (95% CI 5.3–28.4), or by ureteral stenting for 46.7 days (95% CI 31.5–61.2) and transurethral catheterization
for 6.25 days (95% CI 1.0–13.5).
Altogether, 25 (30.9%) women underwent a reoperation mostly due to ureteral injury (68%). In total six women developed
a fistula, of whom five had malignant surgery.
Multiple linear regression showed a statistically significant increased median length of urethral catheterization when the
duration of surgery increased.
Conclusions  Our study demonstrates a high reoperation rate, and a high fistula rate in case of malignancy. Length of cath-
eterization was high even in case of benign surgery, however, only one woman developed a fistula in the benign group, sug-
gesting a reduction in catheterization length.

Keywords  Gynecology · Iatrogenic · Obstetrics · Urinary tract injury

What does this study add to the clinical work 

Bladder and ureter injuries following malignant
gynecological surgery is associated with a high rate
of reoperation and fistula formation. The length of
catheterization should be reduced in benign cases
due to the low risk of complication and especially
following cesarean section.
* Martin Rudnicki
mr@rsyd.dk
1
Department of Obstetrics and Gynecology, University
of Southern Denmark, Odense University Hospital, Region
of Southern Denmark, Odense, Denmark
Introduction
Iatrogenic urinary tract injuries are potential complications
of gynecologic and obstetric surgery due to the proximity
to the female internal genitals [1, 2]. A recent systematic
review demonstrated an incidence of bladder injuries of
0.24% and on ureteral injuries of 0.08% following laparo-
scopic surgery for benign indication [1]. Oliphant et al. [3]
found an overall lower urinary tract injury rate of 2.72 per
1000 cesarean deliveries.
Early recognition of a urinary tract injury is of great
importance and has been associated with a more suc-
cessful outcome. Delayed recognition and diagnosis can
cause increased morbidity such as risk of ureterovaginal
and vesicovaginal fistula formation and impact on quality
of life [1, 4–7].

13
Vol.:(0123456789)

Most bladder injuries are recognized intraoperatively
[8]. Intraoperative signs are observation of the catheter in
the operative field, macroscopic hematuria, and fluid in the
abdominal cavity [1, 8].
Typically, bladder injuries are repaired by a two-layer
suture followed by transurethral catheter drainage [5, 9],
but great differences exist. There is no consensus regarding
suture type and size, number of layers, and use of continu-
ous or interrupted suture. Thus, Sahai et al. [8] using either
interrupted or continuous absorbable sutures in one or two
layers suggested that urethral catheterization should last for
2–3 weeks. Yossepowitch et al. [5] used a two-layer, run-
ning, absorbable suture followed by postoperatively blad-
der drainage for an average of 6.3 days. On the other hand,
Aydin et al. [2] reported successful repair in all cases by
use of a two-layer, interrupted suture with 3.0 Vicryl or 4.0
Polyglactin and catheter removal after 5–7 days. In addition,
another study used barbed sutures in either one or two layers
followed by 10 days of Foley catheterization and observed
no major complications following repair [10].
Ureteral injuries are often recognized postoperatively
[8], with symptoms such as urosepsis, flank pain, abdominal
distension, hematuria, dysuria, anuria/oliguria, and elevated
creatinine [6]. Management of a ureteral injury depends on
the cause, location, and time of recognition [8, 11]. Sahai
et al. [8] suggested that small lesions due to electrocoagula-
tion intraoperatively should be managed by stenting alone
for 4–6 weeks in agreement with Chan et al. [11] who rec-
ommended removal after 6 weeks. Other injuries require
reconstruction [8]. Injuries to the mid and proximal part
of the ureter are managed by neoimplantation, Boari flap,
transureteroureterostomy, or ureteroureterostomy [8, 11, 12].
Injuries to the distal part of the ureter are managed by uret-
eroneocystostomy with or without psoas hitch.
The aim of this descriptive study was to describe the
management and outcome of iatrogenic bladder or ure-
teral injuries following gynecologic and obstetric surgery
in a Danish University hospital undertaken between 2015
and 2021. Specifically, we evaluated the suture type and
suture size, length of urethral catheterization, length of
hospitalization, length of follow-up, reoperation rate, and
impact on quality of life.
Materials and methods
In this descriptive study, 91 women were retrospectively
identified with an iatrogenic urinary tract injury at the
Department of Obstetrics and Gynecology, Odense Uni-
versity Hospital, Denmark, between January 2015 and
May 2021. The department is a tertiary referral hospital for
13
Archives of Gynecology and Obstetrics
gynecological cancer and endometriosis as well as compli-
cated obstetric cases.
ICD-10 codes were utilized to identify women. Women
included were ≥18 years with a bladder or ureteral injury
following obstetric or gynecologic surgery independent from
surgical procedure. Both women with benign and malignant
surgery were included. We excluded women with a tempo-
rary ureteral stent in cases, where the stent was prophylacti-
cally placed, and no urinary tract injury was observed. In
total, 91 women were identified using ICD-10 codes. Among
those, 10 women were excluded since no urinary tract inju-
ries were identified. In all these cases a temporary placement
of a ureter stent was confirmed, leaving 81 women to be
included in the study.
Information was obtained from the women’s medical
records. Demographics included age at the time of primary
surgery, body mass index, smoking history, prior abdominal
surgery, and comorbidities. Furthermore, information was
collected regarding surgical procedure, indication of surgery,
management of injury, type and size of suture, complica-
tions, catheterization time, length of follow-up, and length
of hospitalization.
A questionnaire was sent to the women, at inclusion,
through an online secure digital mail [13]. The self-reported
questionnaire included questions on urinary tract symptoms
and their impact on quality of life. Questions on urinary
tract symptoms were obtained from The Danish Urogyneco-
logical Database (DugaBase), which is a nationwide clinical
database that seeks to monitor and improve the quality of
urogynecological surgery [14], and included International
Consultation on Incontinence Questionnaire—Urinary
Incontinence Short form (ICIQ-UI SF). The questionnaire
has been validated previously [15]. The questionnaire was
sent up to three times over the course of 2 months to increase
the response rate. Women not understanding Danish or
women with mental illness or similar disease, and death did
not receive a questionnaire.
By answering the questionnaire, the women gave
informed consent for the use of the answers in this study.
Approval to record information from the medical records
was obtained from the Region of Southern Denmark (No.
20/43272). Data were registered and stored in OPEN, Open
Patient data Explorative Network, Odense University Hospi-
tal, Region of Southern Denmark (OPEN (OP_1257)). The
present study was carried out in accordance with the Dec-
laration of Helsinki.
Our study was in accordance with the Strengthening
the Reporting of Observational Studies in Epidemiology
(STROBE) reporting guideline [16].
Archives of Gynecology and Obstetrics

Statistical analyses death (N = 10, 66.7%)), mental or similar illnesses (N = 3,

STATA version 17.0 for Mac was used for statistical analy-
sis. Numerical data are presented as means and 95% confi-
dence intervals. Categorical data are presented as numbers
and percentages. Multiple linear regression adjusting for
age, body mass index, prior abdominal/pelvic surgery, smok-
ing history, and operation time was used to assess numerical
outcomes. Assumptions of multiple linear regression analy-
sis were evaluated by plots of residuals. The multiple linear
regression analysis was done on a logarithmic scale due to
the results of the model validation, where a right-skewed
distribution occurred. The results were back-transformed
into median ratios as an outcome is numerical data. A two-
sided P-value <0.05 was considered a statistically significant
result.
Results
In total, 81 women fulfilled inclusion criteria and were sub-
sequently included in the study. Of these, 66 women received
a questionnaire of whom 53 women (80.3%) answered. In
total, 15 women did not receive the questionnaire due to
20.0%) or were not able to receive the digital questionnaire
(N = 2, 13.3%).
Among the included women, 55 women had a bladder
injury, 23 women had a ureteral injury, and three women had
both bladder and ureteral injuries. The women were divided
into two subgroups: Group 1: Women undergoing surgery
for benign indication including cesarean section (N = 48)
and Group 2: Women undergoing surgery for the malignant
indication (N = 33). Baseline characteristics, operation indi-
cation, and localization of injury are shown in Table 1.
In group 1, 38 women had a bladder injury (11 due to
cesarean section), nine women had a ureteral injury, and
one woman had both injuries. The most frequent operation
indication was the removal of the fibroma (32.4%) followed
by incontinence surgery (16.2%). In group 2, 16 women had
a bladder injury, 15 women had a ureteric injury, and two
women had both bladder and ureteral lesions. The most com-
mon operation indication in this group was ovarian cancer
(66.7%) followed by cervix cancer (21.2%), and corpus can-
cer (9.1%). The number of ureteral injuries was highest in
the malignant group (68.0%), whereas most bladder injuries
occurred in the benign group (50.0%). Overall, most injuries

Table 1  Baseline characteristics Group 1: Benign Group 3: Malignant

on women in the three n = 47 (59.3%) n = 33 (40.7%)
subgroups, surgery indication,
and localization of injury Age, mean (95% CI) 49.0 (44.8–53.0) 59.9 (55.9–63.9)
BMI, mean (95% CI) 23.6 (24.4–26.8) 26.9 (24.6–29.2)
Prior abdominal/pelvic surgery, N (%) 32 (66.7) 23 (69.7)
Surgical procedure, N (%)
 Transabdominal hysterectomy 2 (4.2) 0 (0)
 Other open surgery 0 (0) 24 (72.7)
 Laparoscopic assisted vaginal hysterectomy 2 (4.2) 0 (0)
 Total laparoscopic hysterectomy 11 (22.9) 3 (9.1)
 Other laparoscopic surgery 8 (16.7) 1 (3.0)
 TVT 7 (14.6) 0 (0)
 Colpopexi 4 (8.3) 0 (0)
 Other vaginal surgery 1 (2.1) 0 (0)
 Robot assisted total laparoscopic hysterectomy 2 (4.2) 5 (15.2)
 Cesarean section 11 (22.9) 0 (0)
Localization of lesion, N (%)
 Fundus/trigonum of bladder 12 (25.0) 6 (18.2)
 Apex of bladder 0 (0) 0 (0)
 Corpus of bladder 8 (16.67) 3 (9.1)
 Bladder neck 0 (0) 0 (0)
 Bladder, no more specified 19 (39.58) 9 (27.3)
 Ureter 10 (20.83) 17 (51.5)
 Unknown 0 (0) 0 (0)
Duration of operation (minutes), mean (95% CI) 126.6 (107.9–145.3) 268.4 (225.6–311.2)

BMI Body mass index, CI  Confidence interval

13

were recognized intraoperatively (77.8%) and the remaining
postoperatively (22.2%) (Table 2).
Most bladder injuries (63.6%) were managed by a two-
layer suture followed by transurethral catheterization for
an average 11.4  days (95% CI 9.1–13.6) (Table  2). The
most frequent suture type was 3.0 Vicryl in all subgroups
(Table 2).
Of all ureteral injuries, 15 were localized to the right
ureter (60.0%), six to the left ureter (24.0%), two were bilat-
eral (8.0%), and two women had an unknown localization
(8.0%). In seven women (26.9%) the lesion was managed by
neoimplantation followed by ureteral stenting for 38.0 days
(95% CI 22.0–54.0) and transurethral catheterization for an
average of 16.9 days (95% CI 5.3–28.4). Fourteen lesions
(51.9%) were managed by ureteral stenting for 46.7 days
(95% CI 31.5–61.2) and transurethral catheterization for
6.25 days (95% CI 1.02–13.51). Three women (11.5%) had
both a nephrostomy catheter and ureteral stenting for 36 days
(95% CI 28.5–45.5) and transurethral catheterization for an
average of 6.7 days (95% CI −11.6 to 25.0). One ureteral
injury, in group 3, was managed by a nephrostomy catheter
alone in an unknown period of days.
Mean hospitalization in group 1 was 3.3 days (95% CI
1.5–4.8) in women with a bladder injury and 2.9 days (95%
CI 0.5–5.3) in women with a ureteral injury. Overall, 14
(29.1%) women underwent reoperation in group 1. Women
with cesarean section (N = 11) disclosed a mean hospitali-
zation stay of 6.7 days (95% CI 1.4–12.1) and one woman
(9.1%) underwent reoperation. In group 2, the mean hospi-
talization was 4.9 days (95% CI 2.5–7.2) for those with a
bladder injury and 10.8 days (95% CI 4.7–16.8) for those
with a ureteral injury. In group 2, ten women had a reopera-
tion (30.3%), of whom three had a bladder injury and seven
had a ureteral injury (Table 2). A urologist was consulted
in 60.0% of cases. A urologist was more often consulted in
case of malignancy (68.8%) compared to benign operation
indication (48.7%).
The most frequent postoperative symptom was hema-
turia followed by anuria/oliguria and flank pain. In total,
six women (7.4%) developed a fistula of whom one woman
(16.7%) was in group 1 compared to five women (83.3%)
in group 2. Of these, four were vesicovaginal, one was ure-
terorectal, and one was ureterovaginal. In total, 32 women
(39.5%) had a urinary tract infection, which required anti-
biotic treatment. Furthermore, six women (7.4%) had renal
complications including hydronephrosis and dilatation of
the proximal ureter. In total, three women from the benign
group, one woman from the cesarean section group, and two
women from the malignant group presented with urinary
retention ≥300 ml (Table 3).
In total, 53 women answered the questionnaire and
were subsequently divided into the benign group (N = 35;
13
Archives of Gynecology and Obstetrics
cesarean group N = 7), and the malignant group (N = 18).
The questionnaires demonstrated that 28 (52.8%) of all
women reported urinary incontinence symptoms after the
injury (19 in the benign group and nine in the malignant
group) (Table 4). Altogether, 11 (20.8%) women reported
to have had urinary tract symptoms before the iatrogenic
lesion, but only two women reported having more symptoms
after surgery compared to prior to the injury. Regarding the
impact on quality of life, 21 (39.6%) women reported not at
all, and three (5.6%) women reported very much.
Multiple linear regression analysis was used to estimate
the relationship between multiple variables and the length of
catheterization (Table 5). When comparing women who had
undergone cesarean section to the remaining patients in the
benign group, we observed that the median length of cath-
eterization was statistically significant 159% longer in the
cesarean group (median ratio 2.59 (95% CI 1.10–6.09)) com-
pared to the benign group, when adjusting for confounders.
When comparing the malignant group to the benign group,
we found that the median length of catheterization was 1%
shorter in the malignant group compared to the benign group
when adjusting for confounders (median ratio: 0.99 (95% CI
0.52–1.89)).
The median length of catheterization was 60% longer in
case of prior surgery compared to no prior surgery (median
ratio: 1.60, 0.95–2.70). Furthermore, the length of cath-
eterization was statistically significantly associated with
increased duration of surgery (median ratio 1.004 (95% CI
1.001–1.007)). Results on age, body mass index, and cur-
rently smoking history were not statistically significant.
Discussion
Although injuries to the bladder and ureter are frequently
recognized complications in relation to gynecological and
obstetric surgery, limited data are still present in relation
to the most optimal repair and follow-up, including length
of catheterization. Recently, Chamsy et al. [10] demon-
strated barbed sutures as an option in case of bladder
injury, although barbed sutures have not been routinely
used so far. Most others use absorbable sutures like Vic-
ryl [2, 5]. The latter is in keeping with our observations,
demonstrating that most bladder injuries were repaired
promptly without any sequelae using a 3.0 Vicryl two-layer
technique. Aydin et al. [2] reported transurethral catheter
drainage for 5–7 days, however, Sahai et al. [8] suggested
catheterization may last 2–3 weeks. In our study, women
with a bladder injury had a transurethral catheter for an
average of 11.4 days, of whom two women developed a
fistula (3.5%). This may suggest that 2 weeks of transure-
thral catheterization is sufficient for healing, but a shorter
period may be sufficient as suggested by Aydin et al. [2].
Archives of Gynecology and Obstetrics

Table 2  Management of Group 1: Benign n = 48 Group 3:

bladder injury and ureteral (59.3%) Malignant n = 33
injury including length of (40.7%)
catheterization, length of
hospitalization, and length of Recognition, N (%)
follow-up on women with a
 Intraoperative 36 (75.0) 27 (81.8)
urinary tract injury
 Postoperative 12 (25.0) 6 (18.2)
 Conferred with urologist (%) 26 (54.2) 22 (68.8)
Methylene blue, N (%) 23 (63.9) 14 (51.9)
Cystoscopy, N (%) 11 (30.6) 0 (0)
Length of bladder lesion (mm), mean (95% CI) 26.3 (16.1–36.4) 21.8 (7.2–36.4)
Suture type for bladder lesion, N (%)
 Barbed suture (V-loc) 4 (8.3) 0 (0)
 Vicryl 17 (35.4) 11 (33.3)
 Monocryl 6 (12.5) 9 (27.3)
 Other reabsorbable suture 3 (6.3) 1 (3.0)
 Unknown 9 (18.8) 3 (9.1)
Suture size for bladder lesion, N (%)
 2.0 5 (13.2) 1 (4.8)
 3.0 16 (42.1) 10 (47.6)
 4.0 1 (2.6) 4 (19.1)
 Unknown 16 (42.1) 6 (28.6)
Suture technique for bladder lesion, N (%)
 Interrupted 3 (7.9) 3 (15.0)
 Continuous 10 (26.3) 8 (40.0)
 Unknown 25 (65.8) 9 (45.0)
Layers of suture, N (%)
 1 layer 1 (2.6) 1 (5.0)
 2 layers 23 (60.5) 12 (60.0)
 Unknown 14 (36.8) 7 (35.0)
Neoimplantation, N (%) 0 (0) 7 (21.21)
Nephrostomy, N (%) 2 (4.2) 2 (6.06)
Intraoperative stent, N (%) 12 (25.0) 16 (50.0)
Length of hospitalization (days), mean (95% CI) 3.0 (1.7–4.4) 8 (4.6–11.4)
 Bladder injury 3.3 (1.5–4.8) 4.9 (2.5–7.2)
 Ureteral injury 2.9 (0.5–5.3) 10.8 (4.7–16.8)
Length of catheterization (days), mean (95% CI) 9.5 (7.2–11.7) 13.0 (8.7–17.3)
 Bladder injury 10.2 (7.9–12.4) 12.2 (6.3–21.3)
 Ureteral injury 3.7 (−0.5 to 7.8) 13.8 (6.3–21.3)
Reoperation, N (%)
 Bladder injury 5 (13.2) 3 (18.8)
 Ureteral injury 9 (100.0) 7 (41.2)
Days until follow-up, mean (95% CI) 115.5 (66.3–164.7) 76.5 (38.9–114.1)
 Bladder injury 70.1 (41.6–98.6) 40.6 (8.6–72.6)
 Ureteral injury 299 (74.3–523.7) 110.2 (44.0–176.3)

CI Confidence interval

Surprisingly, the median length was highest in women
undergoing cesarean section (14.6 days). The length of cath-
eterization was in agreement with Gungorduk et al. [17] who
suggested catheterization for 10–14 days in case of blad-
der injury during cesarean delivery. Considering that these
women were healthy young women without fistula formation
and a lower range of complication, this suggests the need for
further studies regarding the length of catheterization in case
of cesarean section bladder injuries.
Ureteric injuries are a possible complication of intraab-
dominal, retroperitoneal, and pelvic surgery, and should be
repaired promptly [12]. In our study, most ureteral injuries

13
 Archives of Gynecology and Obstetrics

Table 3  Postoperative symptoms and complications following iatro- Early detection of an injury has previously been asso-
genic urinary tract injuries ciated with decreased morbidity including shorter hospital
Group 1: Group 3: stay, urinary tract infections, and fistula formation [5, 6, 12].
Benign n = 48 Malignant n = 33 The dominating long-term complications in our study were
(59.3%) (40.7%) urinary tract injury and fistula formation. In total, seven
Postoperative symptoms, N (%) women (8.6%) developed a fistula, and 32 women (39.5%)
 Anuria/oliguria 10 (20.8) 9 (27.3) had a urinary tract infection.
 Dysuria 1 (2.1) 1 (3.0) In accordance with the literature, the intraoperative
 Hematuria 28 (58.3) 20 (60.6) detection rate was 77.8% in our study [6]. In some cases,
 Flank pain 13 (27.1) 4 (12.1) intravesical instillation of methylene blue was used intraop-
 Fever >38° 5 (10.4) 5 (15.2) eratively (58.7%), as well as cystoscopy. Gilmour et al. and
 Abdominal distension 4 (8.3) 3 (9.1) Sahai et al. [4, 8] suggested that the use of cystoscopy can
 Peritonitis 0 (0) 2 (6.1) improve the detection of urinary tract injuries. However, in
Postoperative complications, N (%) our study only 17.5% of the women had a cystoscopy. This
 Sepsis 1 (2.1) 3 (9.1) may reflect the fact that usage of cystoscopies in our depart-
 DVT 0 (0) 1 (3.0) ment, in general, are low. Furthermore, the use of cystoscopy
 Renal 4 (8.3) 2 (6.1) may be useful to increase the detection rate.
 Cardiac 0 (0) 2 (6.1) Length of follow-up was defined as the number of days
 Wound infection 0 (0) 1 (3.0) from primary surgery until the end of control regarding
 Urinary tract infection 16 (33.3) 16 (48.5) urinary tract symptoms and function due to the bladder or
 Fistula formation 1 (2.1) 5 (15.2) ureteral injury. Data were missing due to death before the
 ICU-management 1 (2.1) 1 (3.0) end of follow-up in two cases. They were excluded from
 Urinary retention ≥300 mL 4 (8.3) 2 (6.1) follow-up calculations because of the risk of an underestima-
tion. In our study, we observed a longer follow-up among
DVT Deep venous thrombosis, ICU Intensive care unit
women with a ureteral injury compared to women with a
bladder injury. This may not surprise since ureteral injuries
were either repaired by ureteral stenting and transurethral are more complicated and most ureteral injuries were in the
catheter drainage or by neoimplantation, ureteral stenting, malignant group.
and transurethral catheterization. This has been described in One strength of our study is that both benign and malig-
other studies as well [8]. Sahai et al. [8] suggested removal nant cases are included. Furthermore, we used the national
of the ureteric stent after 4–6 weeks. On the other hand, email to make it easier to respond [20], and ended up with
Chan et al. [11] recommended removal after 6 weeks. In a response rate of 74.5% of all invited women, which may
our study, the ureteral stent was kept for an average of reduce bias. The questionnaire was re-sent to the women up
42.2 days, which is approximately 6 weeks. Of these women, to three times over the course of 2 months. This may contrib-
five developed a fistula, suggesting that the ureteral stent ute to reduce selection bias as this allows as many women
should not be removed before 6 weeks, especially in case as possible to respond. In addition, the questionnaire sent to
of malignancy. the women was validated previously [15].
Identified risk factors for iatrogenic urinary tract injuries The main limitation of our study is the single center setup
are adhesions, prior pelvic/abdominal surgery, urinary tract with a low number of patients. Secondly, we did not have a
abnormalities, fibroids, and endometriosis [2, 6, 9, 18, 19] control group to compare the length of follow-up and length
which is similar to our findings of 67.9% of the women having of hospitalization.
a history of prior abdominal or pelvic surgery. Lack of data The questionnaire is sensitive to information bias because
in the literature on the management of urinary tract injuries it contains questions regarding the women’s conditions and
renders decision-making inconsistent and is based on the sur- quality of life prior to surgery.
geons’ biases and experiences [12]. Thus, the success of repair During our study there were 10 instances of exclusion
may be associated with surgical experience. A prevention to because of no urinary tract injury. Should the opposite apply,
decrease the incidence of iatrogenic urinary tract injuries is there may be some women missing from the initial partici-
sufficient knowledge of pelvic and abdominal anatomy [12]. pant pool, as they would not have seemed eligible for inclu-
In our study, the surgeon was a medical specialist in 86.4% sion. The ICD-10 codes were selected wisely, but wrong
of primary surgery, and a urologist was consulted in 60.0% coding may be a risk, and we cannot preclude that miscoding
of all cases to repair the injury. Our study corroborates other may have occurred, resulting in lower inclusion rates.
studies, where a urologist is consulted in most cases [2]. In conclusion our study demonstrates a high reopera-
tion rate, and a high rate of fistula development in case of

13
Archives of Gynecology and Obstetrics

Table 4  Demonstrates the answers to the questionnaire sent to the women. In total, 53 women answered the questionnaire, and were divided into
the three subgroups

Group 1: Benign Group 3: Malignant

n = 28 (52.8%) n = 18 (34.0%)

How often do you leak urine? N (%)

 Never 16 (45.7) 9 (50.0)
 Once a week or less 8 (22.9) 2 (11.11)
 2–3 times a week 6 (17.1) 2 (11.11)
 Once a day 2 (5.7) 1 (5.56)
 More times at a day 3 (8.6) 3 (16.67)
 All the time 0 (0) 1 (5.56)
Quantity of urine when you leak, N (%)
 I don’t leak 15 (42.9) 9 (50.0)
 A small amount 17 (48.6) 4 (22.22)
 A moderate amount 2 (5.7) 5 (27.28)
 A great amount 1 (2.9) 0 (0)
Did you have urinary tract symptoms before the urinary tract lesion? N (%)
 Yes 9 (25.7) 2 (11.11)
 No 26 (74.3) 16 (88.89)
In which extend do you think that the injury to your urinary tract or bladder plays a role in your cumulative quality of life? 1 is not at all, and 7
is very much. N (%)
 1 14 (40.0) 7 (38.89)
 2 9 (25.7) 3 (16.67)
 3 1 (2.9) 0 (0)
 4 4 (11.4) 2 (11.11)
 5 0 (0) 2 (11.11)
 6 5 (14.3) 3 (16.67)
 7 2 (5.7) 1 (5.56)

Table 5  Multiple linear Multiple linear regression on Unadjusted esti- P value Adjusted coefficient (95% CI) P value
regression on length of length of catheterization mate (95% CI)
catheterization (days).
Presenting unadjusted and Risk factors/confounders
adjusted median ratios for risk
 Group 1: Benign 2.88 (1.40–5.95) 0.005 2.59 (1.10–6.09) 0.030
factors/confounders
 Group 3: Malignant 1.62 (0.97–2.73) 0.066 0.99 (0.52–1.89) 0.976
Age 0.99 (0.97–1.01) 0.538
Body mass index 0.98 (0.94–1.03) 0.461
Currently smoking 0.81 (0.38–1.73) 0.576
Prior abdominal/pelvic surgery 1.60 (0.95–2.70) 0.075
Operation duration (minutes) 1.004 (1.001–1.007) 0.005

CI  Confidence interval

malignancy. Length of catheterization was high even in the
case of benign surgery, however, only two women developed
a fistula in the benign group, suggesting a reduction in cath-
eterization length.
Authors contribution:  AJ: Project development, data collection, data
analysis, and manuscript writing; MR: Protocol/Project development,
manuscript writing.
Funding  No financial support was given to the study.

Acknowledgements  The authors would like to thank Open Patient data

Explorative Network for the possibility to register and store data in the
database. Furthermore, for statistical advice.

13
 Archives of Gynecology and Obstetrics

Declarations  gynaecology and obstetrics operation. Arch Gynecol Obstet

28:763–765
13. eBoks. e-boks.com. https://​www.e-​boks.​com/​danma​rk/​en/​what-​
Conflicts of interest  The authors declare that they have no conflicts
is-e-​boks/ Accessed 11.10.2021.
of interest.
14. Guldberg R, Brostrøm S, Hansen JK, Kærlev L, Gradel KO,
Nørgård BM et al (2013) The Danish urogynaecological data-
base: establishment, completeness and validity. Int Urogynecol J
References 24:983–990
15. Clausen J, Gimbel H, Arenholt LTS, Løwenstein E (2021) Valid-
ity and reliability of two Danish versions of the ICIQ-UI SF. Int
1. Wong JMK, Bortoletto P, Tolentino J, Jung MJ, Milad MP (2018)
Urogynecol J 32:3223–3233
Urinary tract injury in gynecologic laparoscopy for benign indica-
16. von Elm E AD, Egger M, Pocock SJ, Gotzsche PC, Vandenb-
tion: a systematic review. Obstet Gynecol 131:100–108
roucke JP (2021) The Strengthening the Reporting of Observa-
2. Aydin C, Mercimek MN (2020) Laparoscopic management of
tional Studies in Epidemiology (STROBE) Statement: guidelines
bladder injury during total laparoscopic hysterectomy. Int J Clin
for reporting observational studies. equator-network. https://w ​ ww.​
Pract 74:e13507
equat​or-​netwo​rk.​org/​repor ​ting-​guide​lines/​strobe/. Accessed 27
3. Oliphant SS, Bochenska K, Tolge ME, Catov JM, Zyczynski HM
Sep 2021.
(2014) Maternal lower urinary tract injury at the time of cesarean
17. Gungorduk K, Asicioglu O, Celikkol O, Sudolmus S, Ark C
delivery. Int Urogynecol J 25:1709–1714
(2010) Iatrogenic bladder injuries during caesarean delivery: a
4. Gilmour DT, Das S, Flowerdew G (2006) Rates of urinary tract
case control study. J Obstet Gynaecol 30:667–670
injury from gynecologic surgery and the role of intraoperative
18. Phipps MG, Watabe B, Clemons JL, Weitzen S, Myers DL (2005)
cystoscopy. Obstet Gynecol 107:1366–1372
Risk factors for bladder injury during cesarean delivery. Obstet
5. Yossepowitch O, Baniel J, Livne PM (2004) Urological injuries
Gynecol 105:156–160
during cesarean section: intraoperative diagnosis and manage-
19. Naicker S, Naidoo TD, Moodley J (2020) Obstetric-associated
ment. J Urol 172:196–199
lower urinary tract injuries: a case series from a tertiary centre in
6. Esparaz AM, Pearl JA, Herts BR, LeBlanc J, Kapoor B (2015)
a low-resource setting. Case Rep Womens Health 27:e00218
Iatrogenic urinary tract injuries: etiology, diagnosis, and manage-
20. Ebert JF, Huibers L, Christensen B, Christensen MB (2018)
ment. Semin Intervent Radiol 32:195–208
Paper- or web-based questionnaire invitations as a method for
7. Adelman MR, Bardsley TR, Sharp HT (2014) Urinary tract inju-
data collection: cross-sectional comparative study of differences
ries in laparoscopic hysterectomy: a systematic review. J Minim
in response rate, completeness of data, and financial cost. J Med
Invasive Gynecol 21:558–566
Internet Res 20:e24
8. Sahai A, Ali A, Barratt R, Belal M, Biers S, Hamid R et al (2021)
British Association of Urological Surgeons (BAUS) consensus
document: management of bladder and ureteric injury. BJU Int Publisher's Note Springer Nature remains neutral with regard to
128:539–547 jurisdictional claims in published maps and institutional affiliations.
9. Rahman MS, Gasem T, Al Suleiman SA, Al Jama FE, Burshaid
S, Rahman J (2009) Bladder injuries during cesarean section in Springer Nature or its licensor holds exclusive rights to this article under
a University Hospital: a 25-year review. Arch Gynecol Obstet a publishing agreement with the author(s) or other rightsholder(s);
279:349–352 author self-archiving of the accepted manuscript version of this article
10. Chamsy D, King C, Lee T (2015) The use of barbed suture for is solely governed by the terms of such publishing agreement and
bladder and bowel repair. J Minim Invasive Gynecol 22:648–652 applicable law.
11. Chan JK, Morrow J, Manetta A (2003) Prevention of ureteral inju-
ries in gynecologic surgery. Am J Obstet Gynecol 188:1273–1277
12. Rao D, Yu H, Zhu H, Duan P (2012) The diagnosis and treatment
of iatrogenic ureteral and bladder injury caused by traditional

13