Urological Science xxx (2017) 1e6

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Urological Science
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Original article

Management of urinary tract injuries following total

hysterectomydA single hospital experience
Chao-Yu Hsu a, *, Kim-Seng Law b, Hao-Ping Tai a, Hsiang-Lai Chen a, Siu-San Tse a,
Zhon-Min Huang a, Wei-Chun Weng a, Li-Hua Huang a, I-Yen Lee a, Min-Che Tung a
a
Divisions of Urology, Department of Surgery, Tungs' Taichung Metro Harbor Hospital, Taichung, Taiwan
b
Department of Obstetrics and Gynecology, Tungs' Taichung Metro Harbor Hospital, Taichung, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Objective: This study elaborated on the clinical experience of patients who underwent urologic man-
Received 14 March 2017 agement due to urologic complications after receiving a total hysterectomy at a regional hospital.
Received in revised form Materials and methods: A total of 696 female patients received the four types of total hysterectomy
22 May 2017
including total abdominal hysterectomy, transvaginal hysterectomy, lapaparoscopic hysterectomy or
Accepted 28 June 2017
robotic hysterectomy for variant gynecologic pathologies. Only 22 cases (3.2%) had urologic procedures
Available online xxx
performed during or after the operations from 2012/1/1 to 2016/6/30.
Results: Of the 22 cases, thirteen (1.9%) received a series of conservative managements only, including
Keywords:
Hysterectomy cystoscopy, ureteroscopy, endoscopic ureterotomy, ureteral catheterization or double J stenting during
Urologic injuries the follow-up period. Nine more complicated cases (1.3%) eventually had definitive management,
Conservative management including repair of the urinary bladder rupture, repair of the vesicovaginal fistula, ureteroureterostomy
Definitive management or ureteroneocystostomy. However, five of these nine cases had both conservative and definitive man-
agement. The mean delay interval between the initial management and gynecologic procedure was 19.3
days. For definitive management and the gynecologic procedure, the period was 52.8 days.
Conclusions: Compared to previous studies, the incidence of urologic injuries following a total hyster-
ectomy in our hospital was similar. From the paper review, it seems early recognition does not improve
the outcome but we found a 100% good outcome in patients with definitive management.
Copyright © 2017, Taiwan Urological Association. Published by Elsevier Taiwan LLC. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
The hysterectomy is the most common major gynecologic sur-
gery worldwide.1 Owing to the female uterus and the urinary tracts
being closely related, the potential risk of urologic tract injury is
always of concern when undergoing gynecologic surgery such as a
hysterectomy. Although improvements in surgical techniques have
decreased the incidence rate of urinary tract injury and occurrence
of complications, urologic injuries remain a common event in gy-
necologic surgery. According to previous reports, the incidence
rates of urinary tract injury in all gynecologic procedures and pelvic
surgery range from 0.2 to 1%.2,3 Another ten-year review study
based on a community hospital showed a 0.4% incidence rate of
urinary tract injury after undergoing gynecologic surgical proced-
ures.4 A systematic review of urinary tract injuries in laparoscopic
hysterectomy also shows the urinary tract injury rate for
* Corresponding author.
E-mail addresses: t4361@ms.sltung.com.tw, jowyu@msn.com (C.-Y. Hsu).
laparoscopic hysterectomy was 0.73%, with the rate ranging from
0.05% to 0.66% and 0.02% to 0.4% for bladder injury and ureteral
injury, respectively.5 A 20 year review study in Asia shows similar
results with a 0.7 and 0.6% prevalence of urinary bladder and
ureteral injuries in gynecological surgeries.6 In Europe, a large
retrospective study reported the incidence of bladder injury during
laparoscopic hysterectomy, abdominal hysterectomy and vaginal
hysterectomy ranged from 0.6 to 1.0%.7 Routine cystoscopy has
become a trend in post-gynecological surgery management
because previous studies demonstrated less than 25% of bladder
injuries and less than 50% of ureteral injuries are disclosed without
the use of cystoscopy, but there is up to a 100% detection rate of
ureteral injuries and 80% detection rate of urinary bladder injuries
following performance of an intraoperative cystoscopy.8 However,
a retrospective cohort study showed 14 patients (0.71%) with
bladder injury and 5 patients (0.25%) with ureteral injury at the
time of hysterectomy not detected by cystoscopy indicated
cystoscopy was a selective rather than universal procedure at the
time of hysterectomy.9 Routine intraoperative cystoscopy has been

http://dx.doi.org/10.1016/j.urols.2017.06.002
1879-5226/Copyright © 2017, Taiwan Urological Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Hsu C-Y, et al., Management of urinary tract injuries following total hysterectomydA single hospital
experience, Urological Science (2017), http://dx.doi.org/10.1016/j.urols.2017.06.002
2 C.-Y. Hsu et al. / Urological Science xxx (2017) 1e6
suggested as the reason for the decreased incidence of urinary tract
injury during gynecological surgery.10e12 However, potential con-
siderations related to routine cystoscopy such as the false positive
findings, insignificant injuries, increased cost of training and in-
struments and lack of verifiable benefit in the post-surgery period
may be reasons for the lack of demonstrable reports. To our
knowledge, less comprehensive reports of urologic treatment ex-
periences and management in post-total hysterectomy have been
presented in Taiwan. The aim of this study is to show the treatment
experience for those who received urologic treatment and man-
agement due to urologic complications after undergoing a total
hysterectomy in a community hospital. This may provide an
appropriate strategy to prevent future occurrences of urinary tract
injuries in gynecological surgeries.
2. Materials and methods
2.1. Study subjects
A total of 696 female patients who received surgery, including
a total abdominal hysterectomy, transvaginal hysterectomy,
laparoscopic hysterectomy or robotic hysterectomy in Tungs'
Taichung Metro Harbor Hospital during 2012e2016. Those who
underwent conservative management (cystoscopy, ureteroscopy,
endoscopic ureterotomy or double J stenting) or definitive man-
agement (repair of urinary bladder rupture, repair of ves-
icovaginal fistula, ureteroureterostomy or ureteroneocystomy)
due to urologic injuries during or after hysterectomies by gyne-
cologists were enrolled in this study. The characteristics, clinical
measures and the period and bleeding amount of the surgical
procedures for these patients were also collected in this study.
Conservative or definitive management was performed including
diagnosis, operation and post-surgery evaluation for these pa-
tients with urologic injuries based on the experience of the
urologists in the hospital. The observational period of urologic
treatment and management was between January 1, 2012 and
June 30, 2016.
2.2. Statistical analysis
We computed the distribution of demographics, clinical mea-
sures and surgical period including age (<40, 40e49, 50e59 and
S60), surgery period (<3, 3e3.9, 4e4.9, 5e5.9 and S6 h), bleeding
amount (<100, 100e199, 200e299, 300e999 and S1000 ml),
hemoglobin level (<12, 12e14 and S14), creatinine level (<0.5,
0.5e0.9 and S1 mg/dl), blood urea nitrogen (BUN) (8e12 and
13e17 mg/dl), urine protein (positive, negative and unknown). The
series of conservative managements of the urologic injuries were
individually computed as cystoscopy, diagnostic ureteroscopy,
endoscopic ureterotomy and double J stenting. The definitive
management encompassed four procedures, including repair of
urinary bladder rupture and vesicovaginal fistula (VVF) repair,
ureteroureterostomy and ureteroneocystostomy. The final treat-
ments, including operation and diagnosis, were divided into eight
(Ureteroscopic procedures such as bilateral/unilateral uretero-
scopy with double J stent implantation or endoscopic ureterotomy
with double J implantation, cystoscopy, removal of TVT-O mesh,
laparoscopic urinary bladder repair, open repair of urinary bladder,
repair of VVF, ureteroneocystostomy and ureteroureterostomy)
types and nine (ureteral swelling e immediately following gyne-
cology surgery or narrowing of the lumen without fibrotic change,
ureteral stricture e visualized fibrotic change tissue, ureteral
severance, tension-free vaginal tape-obturator [TVT-O] mesh
erosion, urinary bladder minor injury e mucosal injury only, uri-
nary bladder scarring e visualized fibrotic change tissue on urinary
Please cite this article in press as: Hsu C-Y, et al., Management of urinary tract injuries following total hysterectomydA single hospital
experience, Urological Science (2017), http://dx.doi.org/10.1016/j.urols.2017.06.002
bladder mucosa, urinary bladder rupture, ureter-vaginal fistula
and vesicovaginal fistula) types, respectively. The evaluation of
final treatments included the severity of injuries (minor or major)
and prognosis (good, loss follow-up or stricture). The definition of
major injuries included those who received major repair opera-
tions of urinary bladder rupture, repair of VVF, ureter-
oureterostomy and ureteroneocystomy. Otherwise, they were
defined as minor injuries. The definition of multiple procedures
includes those having at least two urologic operations following
gynecology operations but not including removal of the double J
stent and the first urologic management could be the same day or
the other day of the gynecologic operation. The definition of one
procedure includes those who only have a one-step urologic
operation following the gynecologic operation, perhaps on the
same day or the other day of gynecologic surgeries, and may be
including those lost to follow-up after gynecologic surgeries and
having only one urologic operation. Lag time of recognition de-
notes the interval between the day of the total hysterectomy and
the first day of recognition of urologic complications, possibly at
the same time, and is also the day of first conservative manage-
ment or even combined with a definitive operation. Lag time of
final operation denotes the interval between the day of the total
hysterectomy and definitive operations, including repair of the
urinary bladder rupture, repair of VVF, ureteroneocystostomy and
ureteroureterostomy. The definition of a good prognosis is effective
reconstruction of the urinary tract without functional abnormality
and departure of urologic follow-up. The categorical variables of
the baseline demographics and clinical measures were summa-
rized as percentages and continuous variables were calculated as
means with standard deviations. Differences between the con-
servative management and definitive management for continuous
variables and categorical valuables used the t test and Fisher's
exact test. All analysis was performed using SAS version 9.4 (SAS
Institute, Cary, NC).
3. Results
Twenty-two patients who underwent urologic treatment and
management after total hysterectomy were selected in this study.
All 22 cases underwent laparoscopically assisted vaginal hyster-
ectomy (LAVH). The baseline characteristics between the minor
injury and major injury study subjects are shown in Table 1. The
minor injury study subjects had a higher mean age, pre-surgery
hemoglobin level, bleeding amount, pre-surgery creatinine level,
post-BUN, post-creatinine, but less surgery period of total hyster-
ectomy, negative pre- and post-urine protein events then major
injure study subjects. However, there were no significant differ-
ences between minor and major injuries among all of the baseline
characteristics (all p > 0.05). Table 2 showed the differences in final
operations for treatment of urologic complication following total
hysterectomy between managements, multiple/one-stage pro-
cedure and lag time of recognition. A significant difference be-
tween conservative management and definitive management was
found for the final operation (p < 0.001). There were three cate-
gories of conservative management. The first was ureteroscopic
procedures (n ¼ 8, 61.5%) including ureteroscopy and double J
stenting (n ¼ 5, 38.5%), bilateral ureteroscopy and double J stenting
(n ¼ 1, 7.7%), endoscopic ureterotomy and double J stenting (n ¼ 2,
15.4%). The second was cystoscopy (n ¼ 4, 30.8%), and the third was
removal of the TVT-O mesh (n ¼ 1, 7.7%). The definitive manage-
ments were ureteroneocystostomy (n ¼ 3, 33.3%), ureter-
oureterostomy (n ¼ 2, 22.2%), repair of the urinary bladder (n ¼ 2,
22.2%), laparoscopic urinary bladder repair (n ¼ 1, 11.1%) and repair
of VVF (n ¼ 1, 11.1%), respectively. The four categories of final
operation completed within the one-stage procedure included
 C.-Y. Hsu et al. / Urological Science xxx (2017) 1e6 3

Table 1

p Value

<0.001
Comparison of baseline demographics and clinical characteristics between the mi-

0.022
0.105
nor injury and major injury study subjects (n ¼ 22).

Characteristics Minor injure Major injure p Value

Ureteroureterostomy
n (%) n (%)

Total 22 (100) 13 (100) 9 (100)

Age 0.050
<40 4 (18.2) 4 (30.8) 0 (0)

5.5 ± 7.8
2 (22.2)

2 (9.1)
40e49 14 (63.6) 8 (61.5) 6 (66.7)
50e59 3 (13.6) 0 (0) 3 (33.3)

0/2
0
60þ 1 (4.6) 1 (14.3) 0 (0)

The differences in final operations for treatment of urologic complication following a total hysterectomy between managements, multiple/one-stage procedure and lag time of recognition.
Mean ± SD 46.6 ± 8.3 46.8 ± 10.3 46.5 ± 4.6 0.954

Ureteroneocystostomy
Range 37.1e77.8 37.1e77.8 40.5e53.5
Surgery period of 0.882
total hysterectomy
(h)

11.7 ± 6.7
<3 5 (22.7) 4 (30.8) 1 (11.1)

3 (33.3)

3 (13.6)
3e3.9 7 (31.8) 4 (30.8) 3 (33.3)
4e4.9 3 (13.6) 2 (15.4) 1 (11.1)

3/0
0
5e5.9 2 (9.1) 1 (7.7) 1 (11.1)
6þ 5 (22.7) 2 (15.4) 3 (33.3)

Repair of VVF
Mean ± SD 4.9 ± 3.8 5.0 ± 4.8 4.7 ± 1.8 0.831
Range 2.3e20.8 2.8e20.8 2.3e7.6

1 (11.1)

1 (4.6)
Pre-surgery 0.674

16.0
hemoglobin

1/0
0
level (g/dl)

D-J ¼ double J stent; UB ¼ urinary bladder; URS ¼ ureteroscopic procedures including ureteroscopy and ureterotomy; VVF ¼ vesicovaginal fistula.
<12 13 (59.1) 7 (53.9) 6 (66.7)

Repair of UB
12þ 9 (40.9) 6 (46.2) 3 (33.3)
Mean ± SD 11.6 ± 1.9 11.9 ± 2.0 11.1 ± 1.6 0.359

2 (22.2)
Final operation

2 (9.1)
Range 8.1e14.4 8.4e14.4 8.1e12.9

0/2
Bleeding amount (ml) 0.433

0
<100 9 (40.9) 6 (46.2) 3 (33.3)

Laparoscopic UB repair
100e199 6 (27.3) 3 (23.1) 3 (33.3)
200e299 1 (4.6) 1 (7.7) 0 (0)

Including patients with both conservative and definitive management, and patients with only definitive management.
300e999 4 (18.2) 1 (7.7) 3 (33.3)
1000þ 2 (9.1) 2 (15.4) 0 (0)
Mean ± SD 628.7 ± 2109.4 954.0 ± 3737.9 158.9 ± 124.3 0.316
Range 2e10,000 2e10,000 30e350

1 (11.1)

1 (4.6)
Pre-surgery creatinine 0.774

0/1
level (mg/dl)

0
<0.5 3 (13.6) 2 (15.4) 1 (11.1)
0.5e1.0 19 (86.4) 11 (84.6) 8 (88.9)
Removal of mesh

Mean ± SD 0.6 ± 0.1 0.6 ± 0.1 0.6 ± 0.2 0.745

Range 0.4e1.0 0.4e0.8 0.4e1.0
Post-BUN 0.567
1 (7.7)

8e12 6 (50.0) 2 (33.3) 4 (66.7) 1 (4.6)

38.0

13e17 6 (50.0) 4 (66.7) 2 (33.3)

1/0
0

Mean ± SD 12.3 ± 2.7 12.5 ± 2.1 12.1 ± 3.3 0.825

Range 8e17 10e15 8e17
16.5 ± 11.2
Cystoscopy

Post-creatinine 0.515
4 (30.8)

4 (18.2)

level (mg/dl)
0.5e0.9 11 (50.0) 6 (85.7) 5 (71.4)
0/4
0

1þ 3 (13.6) 1 (14.3) 2 (28.6)

Mean ± SD 0.8 ± 0.2 0.8 ± 0.1 0.8 ± 0.2 0.431
17.9 ± 11.0
URS þ D-J

Range 0.55e1.1 0.6e1.0 0.55e1.1

8 (61.5)

8 (36.4)

Pre-urine protein 0.619

Positive 2 (10) 2 (16.7) 0 (0)
4/4
0

Negative 14 (70) 8 (66.7) 6 (75.0)

unknown 4 (20) 2 (16.7) 2 (25.0)
14.0 ± 11.6

Post-urine protein 0.765

13 (59.1)

22 (100)
9 (40.9)

Positive 4 (18.2) 3 (23.1) 1 (11.1)

9/13

Negative 17 (77.3) 9 (69.2) 8 (88.9)

unknown 1 (4.6) 1 (7.7) 0 (0)
Lag time of recognition (Mean ± SD)
Conservative management (only)

cystoscopy, laparoscopic urinary bladder repair, repair of urinary

Multiple/one-stage procedure

bladder and ureteroureterostomy, and the others were multiple-

Definitive managementa

stage procedures with/without one-stage procedure. Lag time of

recognition was day zero when repair of urinary bladder were
required on the same day of hysterectomy in 3 cases. Mean ± SD of
lag time of recognition for ureteroureterostomy was 5.5 ± 7.8 days.
Managements

Mean ± SD of lag time of recognition for ureteroneocystomy was as

Variables

Total (%)

long as 11.7 ± 6.7 days. For most of the others, the mean lag
Table 2

time of recognition was between two to three weeks to identify

a

the particular gynecologic complication. Table 3 shows the

Please cite this article in press as: Hsu C-Y, et al., Management of urinary tract injuries following total hysterectomydA single hospital
experience, Urological Science (2017), http://dx.doi.org/10.1016/j.urols.2017.06.002
4 C.-Y. Hsu et al. / Urological Science xxx (2017) 1e6

Table 3
The characteristics of final diagnosis of urologic complication following a total hysterectomy.

Variables Final diagnosis

Ureteral Ureteral Ureteral Ureter-vaginal TVT-O mesh UB minor UB UB Vesicovaginal p

swelling stricture severance fistula erosion injury scarring rupture fistula Value

Managements
Conservative management (only) 13 (59.1) 3 (23.1) 2 (15.4) 2 (15.4) 1 (7.7) 1 (7.7) 2 (15.4) 1 (7.7) 0 1 (7.7) 0.232
Definitive managementa 9 (40.9) 0 2 (22.2) 3 (33.3) 0 0 0 0 3 (33.3) 1 (11.1)
Multiple/one procedure 9/13 1/2 3/1 2/3 1/0 1/0 0/2 0/1 0/3 1/1 0.367
Lag time of recognition (Mean ± SD) 14.0 ± 11.6 18.0 ± 15.9 19.5 ± 10.1 7.8 ± 4.7 18.0 38.0 9.5 ± 13.4 24.0 0 19.5 ± 4.9 0.063
Total (%) 22 (100) 3 (13.6) 4 (18.2) 5 (22.7) 1 (4.6) 1 (4.6) 2 (9.1) 1 (4.6) 3 (13.6) 2 (9.1)

UB ¼ urinary bladder; TVT-O ¼ tension-free vaginal tape-obturator.

a
Including patients with both conservative and definitive management, and patients with only definitive management.

characteristics of the final diagnosis following the total hysterec- 4. Discussion

tomy. For conservative management, the top four causes of final
diagnosis were ureteral swelling (n ¼ 3, 23.1%), ureteral severance
(n ¼ 2, 15.4%) ureteral stricture (n ¼ 2, 15.4%) and urinary bladder
minor injury (n ¼ 2, 15.4%). There were four categories of diagnosis
in definitive management, including ureteral severance (n ¼ 3,
33.3%), ureteral stricture (n ¼ 2, 22.2%), urinary bladder rupture
(n ¼ 3, 33.3%) and vesicovaginal fistula (n ¼ 1, 11.1%). Urinary
bladder complications including urinary bladder minor injury,
scarring or rupture were all managed by a one-stage procedure.
The others were multiple-stage procedures of conservative man-
agement with/without definitive management. The lag time of
recognition was zero days for urinary bladder rupture in 3 cases,
7.8 ± 4.7 days (mean ± SD) for ureteral severance in 5 cases,
9.5 ± 13.4 days (mean ± SD) of urinary bladder minor injury in 2
cases, and the longest 38 days delay was for 1 case of TVT-O mesh
erosion. The mean lag time of recognition of the others to identify
gynecologic complications was more than two weeks. The urologic
management, lag time of recognition, lag time of final operation,
severity of injury and prognosis following the total hysterectomy
are shown in Table 4. Significant differences between conservative
management and definitive management were observed among
the lag time of recognition (p ¼ 0.012) and severity of injury
(p < 0.001). Thirteen cases (59.1%) performed conservative man-
agement only, with 19.0 ± 11.6 days (mean ± SD) of lag time be-
tween the first recognition of the injury and gynecologic
operation, 33.5 ± 37.8 days (mean ± SD) of the lag time for final
operation as the definitive treatment. For those having good
prognosis, the loss to follow-up and ureteral stricture in the
prognosis were 69.2(n ¼ 9), 23.1(n ¼ 3) and 7.7 (n ¼ 1)%, respec-
tively. Of the others with definitive management, the means ± SD
for lag time of recognition and lag time of final operation were
6.9 ± 7.5 and 52.8 ± 109.2 days, respectively. All of whom were
classified as major injuries due to a subsequent major definitive
management, including repair of the urinary bladder rupture,
repair of VVF, ureteroneocystostomy and ureteroureterostomy.
However, all had good prognosis without subsequent urologic
adverse events.
The incidence rates of urinary bladder and ureteral injuries
receiving total hysterectomy at our institute were 1.1% (8/696) and
1.9% (13/696) respectively. The results are similar to the reporting
range from recent guidelines. The summarized incidence rates of
urinary bladder injuries following abdominal hysterectomy, vaginal
hysterectomy and laparoscopic hysterectomy ranged from 0.37 to
2.5%, 0.44 to 6.3% and 0.5 to 2.0% respectively. The summarized
incidence rates of ureteral injuries following abdominal hysterec-
tomy, vaginal hysterectomy and laparoscopic hysterectomy ranged
from 0.03 to 2.0%, 0.02 to 0.5% and 0.2 to 6.0% respectively.13 The
chance of urinary tract injuries with a total hysterectomy by gy-
necologists is rare but unavoidable. Some clinical strategies are
helpful in reducing the impact of adverse events. Delicate expla-
nation of possible events to the patient and her family is mandatory
before the operation. The surgeon obviously must be highly aware
of the urinary tract and gynecologic organs relationship, especially
during the operation. The surgeon must be alert during the history
taking and physical examination, especially if there is a history of
cesarean delivery or abdominal surgery/laparotomy, adhesions and
gynecology diseases of endometriosis or broad ligament fibrosis are
high-risk situations. Low-volume surgeons commonly mentioned
risk factors in urinary tract injuries.14 High-risk patients had more
intraoperative blood loss and a longer operation time during the
operation.15 Ibeanu OA et al. showed the below factors were also
statistically correlated with increased risk of urinary tract injury,
including blood loss of more than 800 ml, lower body mass index,
duration of surgery, and increased uterine size.10 We attempted to
compare the risk of major or minor injury in Table 1, but the p value
is of no significance.
Prevention of ureteral injuries by ureteral catheterization before
the hysterectomy used to be suggested in high-risk patients and has
been surveyed as a generalized preoperative prophylaxis based on
the retrospective study16 and randomized trial,17 both showing no
significant difference in the incidence of ureteral injuries. In
contrast, some studies reached different conclusions. Cohen SJ
suggested prophylactic ureteral catheterization should not supplant

Table 4
The urologic management, lag time of recognition, lag time of final operation, severity of injury and prognosis following a total hysterectomy.

Managements Lag time of recognition Lag time of final operation Severity of injury Prognosis

n (%) Mean ± SD Range p value Mean ± SD Range p value Minor Major p value Good Loss FU Stricture p Value

n (%) n (%) n (%) n (%) n (%)

Conservative management 13 (59.1) 19.0 ± 11.6 0e38 0.012 33.5 ± 37.8 0e126 0.386 13 (100) 0 <0.001 9 (69.2) 3 (23.1) 1 (7.7) 0.240
(only)
Definitive managementa 9 (40.9) 6.9 ± 7.5 0e19 52.8 ± 109.2 0e335 0 9 (100) 9 (100) 0 0
Total 22 (100) 14.0 ± 11.6 0e38 41.4 ± 73.8 0e335 7 (31.8) 15 (68.2) 18 (81.8) 3 (13.6) 1 (4.6)

FU ¼ follow-up.
a
Including patients with both conservative and definitive management, and patients with only definitive management.

Please cite this article in press as: Hsu C-Y, et al., Management of urinary tract injuries following total hysterectomydA single hospital
experience, Urological Science (2017), http://dx.doi.org/10.1016/j.urols.2017.06.002
 C.-Y. Hsu et al. / Urological Science xxx (2017) 1e6
meticulous dissection, but it may improve the ability to identify the
ureter either visually or by palpation among appropriately selected
patients. The decision concerning the use of catheterization should
be left to the surgeon's discretion.18
Early recognition of complications during or immediately after
hysterectomy will improve the outcome and reduce morbidity after
such complications of gynecologic surgery,19 and perhaps it will
decrease the lag time of the final operation for gynecologic
complication and also reduce the possibility of eventual loss of
kidney or legal problems. Most previous studies suggest almost all
bladder injuries are detected and about 80%e90% of ureteral in-
juries are detected by intraoperative cystoscopy.8,20 The American
Association of Gynecologic Laparoscopists (AAGL) proposed the
sources of injuries “missed” by intraoperative cystoscopy are
related to postoperative swelling of non-occlusive suture ligatures
and thermal injuries that initially do not cause mechanical
obstruction. AAGL also advised current evidence supports the
conclusion cystoscopic evaluation of the lower urinary tract should
be readily available to gynecologic surgeons performing laparo-
scopic hysterectomy. However, not all ureteral injuries are detected
by intraoperative cystoscopy, even under the use of intravenous
indigo carmine injection.21 Cystoscopy is a good tool but not a fail-
safe method of intraoperative assessment of ureteral integrity, and
might increase the number of injuries recognized, possibly pre-
venting many of the subsequent complications.22
Intraoperative recognition of urinary bladder injuries may
directly identify by obvious cystomy, urine leakage, hematuria or
distended catheter bag due to leakage of gas through the urinary
bladder defect during LAVH. In highly suspect cases, cystoscopy
with/without instillation of urinary bladder with 200e300 ml
colored saline (methyl blue or indigo carmine) could be chosen.
Postoperative recognition of urinary bladder injuries may present
suprapubic pain, hematuria, and leakage of urine from the vagina
and oliguria. If uroperitoneum develops, it will present diffuse
abdominal pain, distension and ileus. Intraoperative recognition of
ureteral injuries is challenging due to the seven types of ureteral
injuries, including transection, resection, laceration, thermal, liga-
tion, crush and angulation. Only a third of these injuries are
recognized during the operation. In highly suspicious cases, it is
advised using a cystoscopy to identify presentation of urine jets or
hematuria from ureteral orifice or not, and ureteral catheterization
to differentiate a possible ureteral injury or the ureteroscope is
located at the site of the ureteral injury. Postoperative recognition
of ureteral injuries following major pelvic surgery may present as
flank pain with tenderness, hematuria, oliguria or watery vaginal
loss, which may be present in the first 48 h after the injury. Uri-
noma, extensive cellulitis and even abscesses may develop if the
above are obscure or misleading. Thermal injury to the ureter may
lead to delayed necrosis and fistula formation between 10 and 14
days postoperatively. If the ureteral injuries are left unrecognized,
the consequences will be spontaneous healing to fistula and/or
stricture formation.23 Of importance, up to 25% of unrecognized
ureteral injuries lead to eventual loss of the kidney (ipsilateral
nephrectomy).24
Hove LD reported the number of ureteral injuries discovered
intra-operatively amounted to 17 cases, within a week of the
operation in 50 cases and 47 patients whose injuries were discov-
ered within a month, where 17 patients were found to have uro-
logic injuries more than one month later. In five cases, the damage
was not noted until more than two years after the operation.22 This
will lead to eventual loss of the kidney.23 In our experience, three
patients with urinary bladder rupture having definitive manage-
ment and three patients of ureteral severances having definitive
management (Table 3) all achieved a one hundred percent good
outcome, and their injury were all classified as major severity
Please cite this article in press as: Hsu C-Y, et al., Management of urinary tract injuries following total hysterectomydA single hospital
experience, Urological Science (2017), http://dx.doi.org/10.1016/j.urols.2017.06.002
5
(Table 4). The lag time of recognition of the urinary bladder rup-
tures and ureteral severances was within one week, and most of
these injuries were a one-stage procedure. On the other hand, the
lag time of recognition of the other injuries was more than 2 weeks
and most of these injuries were a multiple-stage procedure
(Table 3). Timing of the first recognition and repair of the injury
may be related to the outcome and multiple procedures or not.
Regardless, it means more aggressive management leads to a better
outcome. In contrast to definitive management, our patients
received a series of conservative managements. Four of the thirteen
(4/13, 30.8%) patients either had ureteral stricture (n ¼ 3) or were
lost to follow-up (n ¼ 1, perhaps requesting a second opinion from
another hospital). Among the nine definitive managements, four
cases had immediate reconstruction of the urinary bladder (n ¼ 3)
or ureter (n ¼ 1) during gynecologic surgery, five cases had initial
conservative management before final definitive management and
all achieved a good prognosis. The mean interval of the five cases
between the first recognition and definite operation was 87 days
(data not shown). Contrarily, only conservative endoscopic pro-
cedures are not always good choices following several similar ef-
forts. Our cases showed 23.2% (n ¼ 3) loss to follow-up and 7.7%
(n  1) eventual stricture without further management. Definitive
management should be considered for these patients.
Our study shows the lag time between the first recognition of
injury and gynecologic operation was 19.0 ± 11.6 days (mean ± SD)
in only conservative management cases and a shorter interval of
6.9 ± 7.5 days (mean ± SD) in definitive management cases. The
difference was significant (p ¼ 0.012). However, it did not shorten
the lag time for the final operation in definitive management cases;
the lag time of the final operation was 33.5 ± 37.8 days (mean ± SD)
in only conservative management cases and 52.8 ± 109.2 days
(mean ± SD) in definitive management cases. It showed no differ-
ence (p ¼ 0.386 for t test) due to some of our definitive manage-
ment patients trying conservative endoscopic double J stenting
before final definitive management, with the wide variant range
being 0e335 days.
As to the location of the ureteral injuries, the majority (71%)
occurred at the level of the vaginal cuff, approximately 2e4 cm
from the ureteral orifice. The majority of urinary bladder injuries
occurred along the posterior bladder wall.25 Our cases are
compatible with the paper review (data not shown). The manage-
ment of different locations of the urinary bladder is only primary
repair but different locations of ureteral injuries are related to
different repairs. The choices for middle third ureteral injury are
ureteroureterostomy, transureteroureterostomy or ureteral reim-
plantation with a Boari flap. The choices for lower third ureteral
injuries are ureteral reimplantation or ureteral reimplantation with
a psoas hitch.25 Upper third ureteral injury or complete loss of the
ureter from a gynecologic surgery complication is rare.
Only one patient received LAVH for uterine myoma and TVT-O
for genuine stress urinary incontinence. As proven by the paper
review, concomitant placement of TVT-O during a LAVH surgery is
an efficacious and safe procedure. However, the study was designed
for a benign gynecological disease coexisting with stress urinary
incontinence.26 Our case displayed an erosive tape between the
lumen of the middle urethra one month after the operation.
Eventually, her right groin area pain persisted in spite of partial
removal of the tape.
There are some limitations to this study. First, the small sample
size of the retrospective study makes it difficult to evaluate the
relationship between management and prognosis, so we only
conducted descriptive research. Nevertheless, all patients with
major injuries that received definitive management clearly showed
a better prognosis (100% good prognosis) than with a series of
conservative managements.
6 C.-Y. Hsu et al. / Urological Science xxx (2017) 1e6
We look forward to conducting this study over a wider area of
hospitals in Taiwan and collecting nationwide data to conduct a
more precise analysis of the exact Taiwanese experience.
Conflicts of interest
The authors have no conflicts of interest to declare.
Sources of funding
No funding was received for the work described in the article.
References
1. Ma €kinen J, Johansson J, Tomas C, Tomas E, Heinonen PK, Laatikinen T, et al.
Morbidity of 10100 hysterectomy by type of approach. Hum Reprod 2001;16:
1473e8.
2. Gilmour DT, Dwyer PL, Carey MP. Lower urinary tract injury during gynecologic
surgery and its detection by intraoperative cystoscopy. Obstet Gynecol 1999;94:
883e9.
3. Messaoudi F, Ben Jemaa S, Yazidi M, El Housseini S, Basly M, Sbai N, et al. Lower
urinary trauma complicating gyneacologic and obstetrical surgery. Tunis Med
2008;86:740e4.
4. Goodno Jr JA, Powers TW, Harris VD. Ureteral injury in gynecologic surgery: a
ten-year review in a community hospital. Am J Obstet Gynecol 1995;172:
1817e20.
5. Adelman MR, Bardsley TR, Sharp HT. Urinary tract injuries in laparoscopic
hysterectomy: a systematic review. J Minim Invasive Gynecol 2014;21:558e66.
6. Nawaz FH, Khan ZE, Rizvi J. Urinary tract injuries during obstetrics and
gynaecological surgical procedures at the Aga Khan University Hospital Kar-
achi, Pakistan: a 20-year review. Urol Int 2007;78:106e11.
7. Brummer TH, Jalkanen J, Fraser J, Heikkinen AM, Kauko M, Ma €kinen J, et al.
FINHYST, a prospective study of 5279 hysterectomies: complications and their
risk factors. Hum Reprod 2011;26:1741e51.
8. Gimour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic
surgery and the role of intraoperative cystoscopy. Obstet Gynecol 2006;107:
1366e72.
9. Sandberg EM, Cohen SL, Hurwitz S, Einarsson JI. Utility of cystoscopy during
hysterectomy. Obstet Gynecol 2012 Dec;120(6):1363e70.
10. Ibeanu OA, Chesson RR, Echols KT, Nieves M, Busangu F, Nolan TE. Urinary tract
injury during hysterectomy based on universal cystoscopy. Obstet Gynecol
2009;113:6e10.
Please cite this article in press as: Hsu C-Y, et al., Management of urinary tract injuries following total hysterectomydA single hospital
experience, Urological Science (2017), http://dx.doi.org/10.1016/j.urols.2017.06.002
11. Sakellariou P, Protopapas AG, Voulgaris Z, Kyritsis N, Rodolakis A, Vlachos G,
et al. Management of ureteric injuries during gynecological operations: 10
years experience. Eur J Obstet Gynecol Reprod Biol 2002;101:179e84.
12. Chi AM, Curran DS, Morgan DM, Fenner DE, Swenson CW. Universal cystoscopy
after benign hysterectomy: examining the effects of an institutional policy.
Obstet Gynecol 2016;127:369e75.
13. Summerton DJ, Djakovic N, Kitrey ND, Kuehhas FE, Lumen N, Serafetinides E,
et al. Guidelines on urological trauma. March 2015. Available at: http://uroweb.
org/guideline/urological-trauma/. Accessed March 2015.
14. Adelman MR, Bardsley TR, Sharp HT. Urinary tract injuries in laparoscopic
hysterectomy: a systematic review. J Minim Invasive Gynecol 2008;15:440e5.
15. Tu YP, Chen J, Chueh SC, Chiu TY, Tsai TC, Lai MK. Urologic complications of
obstetrico-gynecologic surgery: experience from national Taiwan university
hospital. J Urol ROC 1999;10:62e7.
16. Kuno K, Menzin A, Kauder HH, Sison C, Gal D. Prophylactic ureteral catheter-
ization in gynecologic surgery. Urology 1998;52:1004e8.
17. Chou MT, Wang CJ, Lien RC. Prophylactic ureteral catheterization in gyneco-
logic surgery: a 12-year randomized trial in a community hospital. Int Urogy-
necol J Pelvic Floor Dysfunct 2009;20:689e93.
18. Cohen SJ, Moculder JK. Preventing urinary tract injury at the time of hysterec-
tomy. Four strategies success. February 02, 2013. By Sarah L. Cohen MD MPH,
Janelle K. Moulder MD.
19. Utrie Jr JW. Bladder and ureteral injury: prevention and management. Clin
Obstet Gynecol 1998;41:755e63.
20. Gustilo-Ashby AM, Jelovsek JE, Barber MD, Yoo EH, Paraiso MF, Walters MD.
The incidence of ureteral obstruction and the value of intraoperative cystos-
copy during vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol
2006;194:1478e85.
21. American Association of Gynecologic Laparoscopists (AAGL). AAGL practice
report: practice guidelines for intraoperative cystoscopy in laparoscopic hys-
terectomy. J Minim Invasive Gynecol 2012;19:407e11.
22. Hove LD, Bock J, Christoffersen JK, Andreasson B. Analysis of 136 ureteral in-
juries in gynecological and obstetrical surgery from completed insurance
claims. Acta Obstet Gynecol Scand 2010;89:82e6.
23. Minas V, Gul N, Aust T, Doyle M, Rowlands D. Urinary tract injuries in lapa-
roscopic gynaecological surgery; prevention, recognition and management.
TOG 2014;16:19e28.
24. Liu CY. Laparoscopic ureteral surgery. In: Wetter PA, Kavic MS, Levinson CJ,
Kelley WE, McDougall EM, Nezhat C, editors. Prevention & management of
laparoendoscopic surgical complications. 2nd ed. Miami, FL: Society of Lapa-
roendoscopic Surgeons; 2005.
25. Tan-Kim J, Menefee SA, Reinsch CS, O'day CH, Bebchuk J, Kennedy JS, et al.
Laparoscopic hysterectomy and urinary tract injury: experience in a health
maintenance organization. J Minim Invasive Gynecol 2015;22:1278e86.
26. Lin YH, Liang CC, Lo TS, Soong YK, Chang SD, Chang YL. Concomitant tension-
free vaginal tape for urinary incontinence during laparoscopic hysterectomy.
Aust N Z J Obstet Gynaecol 2005;45:304e7.