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Urinary Tract Injury in Gynecologic Laparoscopy for Benign Indication: A Systematic Review

Wong, Jacqueline M., K., MD; Bortoletto, Pietro, MD; Tolentino, Jocelyn, MD, MPH; Jung, Michael, J., MD, MBA; Milad, Magdy, P., MD, MS

doi: 10.1097/AOG.0000000000002414
Contents: Review
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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 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 vaginal hysterectomy (1.0%, 95% CI 0.9–1.2) had the highest rates of injury. Most ureteral injuries resulted from electrosurgery (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.

Lower urinary tract injuries in gynecologic laparoscopy have an overall incidence of 0.33%, with bladder injuries (0.24%) three times more common than ureteral injuries (0.08%).

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.

Corresponding author: Jacqueline M. K. Wong, MD, Department of Obstetrics and Gynecology, 250 East Superior Street, Suite 5-2177, Chicago, IL 60611; email:

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the American Society for Reproductive Medicine meeting, October 15–19, 2016, Salt Lake City, Utah; and at the American Association of Gynecologic Laparoscopists meeting, November 14–18, 2016, Orlando, Florida.

Each author has indicated that he or she has met the journal's requirements for authorship.

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.