Female Pelvic Medicine & Reconstructive Surgery:
1Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA; 2Department of Obstetrics and Gynecology, University of Mississippi School of Medicine, Jackson, MS
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: None.
To evaluate factors associated with the development of vesicovaginal fistula following a cystotomy during benign hysterectomy at two large university settings.
MATERIALS AND METHODS
Charts from all hysterectomies performed for benign indications at Grady Memorial Hospital and the University of Mississippi Medical Center between January 1, 2000 and December 31, 2008 were reviewed. Demographic and operative data were abstracted. Cystotomies were scored using the American Association for the Surgery of Trauma (AAST) grading system for iatrogenic bladder injuries. Cases were patients who developed a vesicovaginal fistula (VVF) following cystotomy while patients who had a bladder injury without development of a VVF served as the controls. The Fisher's exact test was used to analyze categorical variables while the Student's t-test was used for continuous variables. Odds ratios with 95% confidence intervals were calculated for risk factors.
During the study period, 5786 hysterectomies were performed for benign indications at the two study centers. Of these, 59% were abdominal, 34% vaginal and 7% were laparoscopic assisted hysterectomies. A total of 90 (1.6%) cystotomies occurred. Vesicovaginal fistulas developed in seven (7.8%) patients. No significant differences in age, parity, weight or ethnicity were identified between those developing a VVF and those who did not. No significant differences in the rate of tobacco use, hypertension, diabetes, prior Cesarean delivery, prior sexually transmitted infections, pelvic adhesive disease or prior pelvic surgeries were seen. The route or indication for hysterectomy did not differ between the groups. The mean uterine weight and operative blood loss did not differ between the groups, however, patients who developed a VVF were more likely to have a uterus that weighed more than 250 g (83% vs 36%, P = 0.03) and a trend towards an operative blood loss of greater than 1000 mL (67% vs 27%, P = 0.06). Patients who developed a VVF had longer operative time (317 ± 82 vs 206 ± 10 minutes, P = 0.02) and were more likely to have an associated ureteral injury (29% vs 1%, P = 0.02). An AAST Grade V bladder injury (OR: 30.80, 95% CI: 4.50–210.79) and one layer repair of the bladder (OR: 7.20, 95% CI: 1.05–49.32) were associated with VVF formation.
Patients with an AAST Grade V bladder injury or those whose bladder is repaired in a single layer are at increased risk for developing a vesicovaginal fistula following a cystotomy during a hysterectomy performed for benign indications.