Urologic Injury and Fistula Following Hysterectomy for Benign Indications [37S

Abstract

INTRODUCTION: Genitourinary injury is a rare but devastating complication following hysterectomy. Literature regarding this topic is limited, so we explored genitourinary injury rates (and risk factors for injury) in a population based dataset with long term follow-up. METHODS: All women who underwent a hysterectomy for benign indications were identified using data from the Office of Statewide Health Planning and Development in California from 2005-2011. Cases of genitourinary injury were identified (either identified intraoperatively or missed). RESULTS: Of the 296,130 women who underwent hysterectomy, 5,455 (1.8%) suffered at least one urologic injury: 2,817 (1.0%) ureteral, 2,058 (0.70%) bladder and 831 (0.3%) fistulas. Sustaining an injury increased the risk of future fistula (1.1% and 2.7% versus 0.3%, p<0.001), however immediate identification and repair of the injury decreased this risk for both ureteral (0.7% versus 3.4%, p<0.001) and bladder (2.5% versus 6.5%, p<0.001) injuries. Multivariate modeling revealed that concomitant POP repair (OR 1.12, p=0.019), a diagnosis of endometriosis (OR 1.40 p<0.001) and surgery at a facility in the bottom 25% of hysterectomy volume (OR 1.37, p=0.049) were associated with increased likelihood of injury, while vaginal (OR 0.85, p=<0.001) or laparoscopic (OR 0.81, p<0.001) approach and diagnosis of endometrial hyperplasia/abnormal uterine bleeding (OR 0.91, p=0.004) were associated with a decreased risk of injury. CONCLUSION: Benign hysterectomy carries a ∼1.8% risk of genitourinary injury. Although injury increases the chance of fistula formation, recognizing the injury immediately reduces this risk. We identify several factors that are associated with injury, providing insight where a higher index of suspicion might be held.