Incidence of Urinary Tract Injury While Performing Total Laparoscopic Hysterectomy and Role of Cystoscopy

Abstract

Introduction: 

Total laparoscopic hysterectomy is a common surgical procedure performed by a gynaecological endoscopic surgeon. Urinary tract injuries, though rare, is a serious complication requiring early detection and management. The aim of this study is to determine the incidence and risk factors for injury to the lower urinary tract during total laparoscopic hysterectomy and the role of cystoscopy in diagnosing the injury.

Materials and Methods: 

All patients who underwent total laparoscopic hysterectomy for benign disease from January 1, 2017, to November 1, 2019, at the Institute of Kidney Diseases and Research Centre were included. Intraoperative cystoscopy with oral Pyridium given before surgery was routinely performed. Relevant data were abstracted to determine the incidence of lower urinary tract injury, predictors of injury and post-operative complications and the role of cystoscopy.

Results: 

Total laparoscopic hysterectomy was performed in 150 consecutive subjects. Out of the encountered 6 cases (4%) of renal injuries in our study, two (1.3%) cystotomies were noted and repaired. An absent ureteral spill of Pyridium was detected in one subject, ureteral injury that was detected and confirmed with retrograde pyelography and managed with percutaneous nephrostomy and ureteric implantation. Three patients had a ureteric injury which was missed initially with a cystoscope. Later on, the patient presented with a urinary leak. The injury was identified and managed surgically. Only 25% (1/4) of injuries were recognised with the use of cystoscopy with Pyridium. All patients recovered with no long-term complications on follow-up.

Conclusions: 

Renal injuries are relatively uncommon during total laparoscopic hysterectomy. Nevertheless, when an injury does occur, quick recognition of the problem and a working knowledge of its location and treatment are essential in providing patients with optimal medical care. Surgeons should consider performing cystoscopy at the time of total laparoscopic hysterectomy.

INTRODUCTION

Although all surgeons intend to 'first no harm', a urological injury is one of the most feared complications for pelvic surgeons. Often injury to urological organs is inevitable because of unmodifiable patient-related factors or pathological processes, in cases of uncontrolled bleeding in the pelvis intraoperatively or due to distorted anatomy from a large uterus, endometriosis or previous surgery.[¹²] One of the major risks with total hysterectomy is that of urological complications, mainly ureteral lesions.[³⁴] Because the ureters are located - 2.3 cm from the lateral edge of the cervix in women with normal pelvic anatomy,[⁵] some authors consider that the risk of ureteral injury is higher after laparoscopic hysterectomy compared with traditional hysterectomy.[⁶⁷] Experience and good knowledge of anatomy should reduce complications. However, urological complications may occur in uncomplicated procedures in experienced hands.[⁸] Urological injuries prolong hospital stay and morbidity. However, long-term outcomes, particularly for injuries identified intraoperatively, are excellent. The role of cystoscopy and ureteric stenting in laparoscopic procedures is questionable but can be useful in difficult cases.[⁹¹⁰]

MATERIALS AND METHODS

Patient selection

A total of 150 patients who underwent total laparoscopic hysterectomy for indicated pathology from 1^st January 2017 to 1^st November 2019, at the Institute of Kidney Diseases and Research Centre were included in the study. The ethical clearance was obtained from the institutional review board (IKDRC-ITS EC/APP/01OCT20/25).

Surgical procedure

All the operations were carried out according to a technique described. The total hysterectomy was indicated for a benign pathology in every case. Laparoscopic hysterectomy performed from the conservative or radical adnexal phase right up to the time of colpotomy. Harmonic and bipolar coagulation was used for all haemostasis and all surgical procedures were carried out with reusable instruments. The main points in the operating technique aimed at avoiding ureteral complications. Uterine manipulation was used in all surgery. It provides the means for the assistant placed between the patient's legs to push the uterus side away from the uterine artery. Uterine manipulator increases the distance between the ureter and uterine artery. Bipolar coagulation forceps are used for uterine artery haemostasis.

Bipolar coagulation section of the uterine artery must take place on the ascending portion of the uterine artery, level with the middle third of the lateral edge of the uterus, well above its arch. The ureter is at a good distance from this point. It lies well outside and below the coagulation area, and all the more so when exposure has been optimised using the uterine manipulator. Once bipolar coagulation–section of the uterine artery has been achieved, dissection should continue but remain without fail inside from the uterine artery. All the haemostasis procedures are then gradually carried out near the cervix and the vagina. In the event that adnexectomy is associated with the total hysterectomy, the first phase must consist of identifying the trajectory of the ureter. If there are any adhesions, carrying out preliminary adhesiolysis. When there are severe adhesions, it may be necessary to use a retroperitoneal approach to identify the ureter trajectory. Ureterolysis is carried out only in difficult cases like abdominopelvic surgery, endometriosis, myoma in the broad ligament. For each case, the following data were systematically collected and entered into a database: Patient's characteristics (age, height, weight, body mass index [BMI], gravidity, parity). The previous history of vaginal delivery, caesarean section and abdominopelvic surgery noted. Pre-operative transvaginal ultrasonography results (length, width and thickness of the uterus), endometrial biopsy, endocervical smear to rule out malignancy and relevant investigation for anaesthesia fitness was done. Indication for hysterectomy and fitness for laparoscopic hysterectomy was discussed and decided. Operative, post-operative results, operating time, and associated surgical procedures like adhesiolysis, adnexectomy, etc. Ureteral complications as incidence, surgical symptoms, methods of diagnosis, ureteral side and site, type of injury, treatment modalities were noted.

Routine cystoscopy was performed in all cases. Intra-operative cystoscopy with oral Pyridium given before surgery was routinely performed. The morbidity of cystoscopy is low and adds little additional time to a procedure. The goal of our work is to evaluate the risk of ureteral complications and to discuss how to avoid their occurrence.

Statistical analysis

All the data were interpreted using (v22 for windows, IL, USA).

RESULTS

The total laparoscopic hysterectomy was performed in 150 cases with mean age ± standard deviation of 43.1 ± 5.65 years, height 152.5 ± 6 cm, weight 58.3 ± 12.3 kg, BMI 21.22 ± 3.26 kg/m², gravidity 2.3 ± 1.5 and parity of 2.2 ± 1.5 [Table 1]. Indication of surgery was classified as per FIGO classification system (PALM-COEIN), AUB-A (adenomyosis) in 50 cases (33%), AUB-E (endometrial hyperplasia) in 47 (31%) cases, AUB-L (leiomyoma) in 43 (28.67%) cases, AUB-M (malignancy) in 4 (2.67%) cases and AUB-O ovarian pathology in 3 (2%) cases [Figure 1]. The previous caesarean was in 10 (6.6%) cases, and a history of previous surgery in 15 (10%) cases [Figure 2]. Average uterine length 80.2 ± 26.3 mm, width 65.4 ± 22.4 mm and thickness 55.4 ± 22.7 mm. The average duration of surgery158.77 + 40.13 min Table 2.

Figure 1: Indications for hysterectomy for uterine pathology.

Figure 2: Complications occurred during surgery.

Table 1: Patients demographics

Table 2: Details of patients' pathology and uterine pathology

Cystoscopy was done in all 150 patients, and a normal study was seen in 147 (98%) patients, bladder injury diagnosed in two (1.33%) patients and ureteric injury in one (0.67%) case [Figure 3]. Out of the encountered 6 cases (4%) of renal injuries in our study, two (1.3%) cystotomies were noted diagnosed and repaired. There were Ureteric injury in 4 cases (2.26%) of the patient [Figure 4]. An absent ureteral spill of Pyridium was detected in one subject, had a ureteral injury that was detected and confirmed with retrograde pyelography and managed with a stent and ureteric implantation. Three patients had a ureteric injury which was missed initially with a cystoscope. Later on, the patient presented with a urinary leak.

Figure 3: Details of patients who had previous history of surgery.

Figure 4: Details of the patients in which pathology was diagnosed during cystoscopy.

DISCUSSION

Our study showed a rate of urological injury of 4%, and ureteral injuries of 2.26%. These injuries occurred in cases that did not have any adhesion. The injury was due to excessive use of bipolar to ensure hemostasis.[¹¹] The overall prevalence of urologic injury at the time of benign hysterectomy was 2.1%, with 2.6% in post-universal cystoscopy group and 1.8% in the pre universal in the cystoscopy group. These operations were in every case made more difficult because of pre-operative risks connected with a history of surgery or uterine myomas in a lateral location.[¹²] The incidence of iatrogenic ureteral injury during major gynecologic surgery is estimated to be about 0.5%–1.5%.[¹³¹⁴] Although these rates are consistent with the range of urologic injury at the time of hysterectomy in published literature.

In our study, three injuries occurred on the right side, and one occurred on the left side. Similarly, other authors have observed that ureteral injuries occur most frequently on the right side.[⁷¹⁵] In every case, the lesions were observed at the distal ureter, close to the uterine artery and[¹⁶¹⁷] in our study, one injury occurred near the infundibulopelvic ligament but this injury is rare. None of the complications was secondary to bipolar coagulation–section of the infundibulopelvic ligament for those patients who underwent adnexectomy associated with laparoscopic hysterectomy.[¹²¹⁸]

Only one of the four ureteral injuries was diagnosed intraoperatively. For the other three patients, the complications were diagnosed sometime after the operation due to ureteral necrosis secondary to the use of bipolar coagulation to ensure haemostasis of the uterine pedicles. These ureteral injuries are serious complications that justify specialised surgical management. The site of injury was diagnosed by CT (IVP) and retrograde pyelography. All the patients had to undergo percutaneous nephrostomy and ureterovesical reimplantation. Three ureterovesical implantations were done laparoscopically, and one was by Robotic laparoscopic implantation. All the patients have been cured and have neither sequelae nor residual functional symptoms.

At our institution, implementation of a universal cystoscopy policy at the time of benign hysterectomy was associated with a significant decrease in delayed post-operative urologic complications and an increase in cystoscopy detection of urologic injuries. These findings are consistent with published studies showing that universal cystoscopy increases intra-operative detection of unsuspected urologic injuries.[¹⁹²⁰] However, our study shows that only out of four, only one injury was detected with cystoscopy. The problem is that routine cystoscopy does not guarantee recognition of all ureteral injuries.[²¹] However, there is no consensus at present.[²²] We recommend cystoscopy after oral Pyridium on the day of surgery for all cases of laparoscopic hysterectomy as cystoscopy is a minor procedure and having almost nil complication and add in the diagnosis of the urological injury. After operative laparoscopy patient complains of fever, flank pain or haematuria, the surgeon must be ready to consider the possibility of ureteral complications. Prompt recognition is essential to minimise secondary morbidity.

The modalities for the prevention of ureteral injuries with operative laparoscopic surgery, the surgeon has much-improved visibility of the pelvic structures, they must be certain where the ureters are located during all phases of the operation. The use of ureteral stents should be reserved for difficult cases recommended by some authors,[²³] especially since stents may lead to complications.[²⁴] In difficult situations associated with adnexal masses adherent to the lateral pelvic sidewall, endometriosis, dense adhesions and myoma in the broad ligament, the surgeon must be capable of using a retroperitoneal approach and carrying out ureterolysis.[²⁵] The systematic use of uterine manipulator may improve exposure, but this instrument does not significantly reduce the risk of ureteral injuries although recommend by some authors.[¹⁶] Bipolar coagulation of the uterine artery must be performed only at the level of the ascending branch to remain as far as possible from the ureter. Haemostasis must not be achieved with bipolar coagulation but by using endoscopic clips or sutures to stop bleeding near the ureter to avoid thermal injuries.

The surgeon's experience in these advanced laparoscopic surgical procedures is an essential factor. The risk levels for ureteral complications during laparoscopic hysterectomy are shown to be three to four times higher in multicentre studies than for expert surgeons.[²⁶] Whatever is the surgeon's experience, ureteral injuries significantly decrease with expertise.[²⁷] Urologist collaboration is required for the management of ureteral injuries to manage and prevent further complications.

CONCLUSIONS

The laparoscopic approach to complex gynaecological surgery continues to increase because of advancements in camera vision and instruments. It is important that surgeons be aware of the risk of ureteral injury. Patients should be appropriately counselled pre-operatively regarding baseline and individualised risks. Prevention of injury can be achieved by careful attention to the location of the ureter at all times during the procedure.

A solid foundation in pelvic anatomy will be an asset in surgeries where there is a distortion of the anatomy. Prophylactic ureteral stenting may be helpful in selected circumstances, and intra- or post-operative evaluation should be undertaken whenever suspicion arises of potential ureteral damage. The surgeon's experience in these advanced laparoscopic surgical procedures is an essential factor. Knowledge and familiarity with avenues for assessment throughout the operative process can empower a surgeon to prevent or reduce potential ureteral complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.