Vesico-Ureteral Injury During Benign Hysterectomy: Minimally-Invasive Laparoscopic Surgery Versus Laparotomy

Abstract

Study Objective Previous studies have been inconsistent as to whether benign hysterectomy via minimally-invasive laparoscopic surgery increases risk of vesico-ureteral injury when compared to laparotomy. We examined the impact of surgical approach (minimally-invasive laparoscopy versus laparotomy) on vesico-ureteral injury during inpatient hysterectomy for benign gynecological disease. Design Retrospective population-based observational study. Setting The Nationwide Inpatient Sample. Patients or Participants 501,110 women who underwent hysterectomy for benign gynecological disease from 1/2012-9/2015 were included: total abdominal hysterectomy (TAH, n=284,365 [56.7%]), total laparoscopic hysterectomy (TLH, n=60,410, [12.1%]), abdominal supra-cervical hysterectomy (Abd-SCH, n=55,655 [11.1%]), laparoscopic-assisted vaginal hysterectomy (LAVH, n=45,620 [9.1%]), total vaginal hysterectomy (TVH, n=34,865 [7.0%]), and laparoscopic supracervical hysterectomy (LSC-SCH n=20,195 [4.0%]). Interventions A comprehensive risk assessment for vesico-ureteral injury by hysterectomy mode was performed, adjusting for patient demographics and gynecologic disease types. Propensity score inverse probability of treatment weighing (PS-IPTW) was used to compare (i) TLH versus TAH and (ii) LSC-SCH versus Abd-SCH with generalized estimating equations. Measurements and Main Results Vesico-ureteral injury was reported in 1,045 (0.21%) women overall. LAVH (0.28%) had the highest bladder injury rate, whereas laparoscopic SCH had the lowest (0.10%) (P<0.001). TLH (0.13%) had the highest ureteral injury rate, whereas TAH had the lowest (0.04%) (P<0.001). In PS-IPTW models, TLH was associated with increased risk of ureteral injury (odds ratio [OR] 3.95, 95% confidence interval [CI] 2.03-7.67, P<0.001) but not bladder injury (OR 1.04, 95%CI 0.57-1.90, P=0.897) compared to TAH. In contrast, LSC-SCH was not associated with increased risk of vesico-ureteral injury when compared to Abd-SCH (OR 0.62, 95%CI 0.19-1.98, P=0.419). Conclusion The risk of vesico-ureteral injury varies widely by the surgical approach to benign hysterectomy but is overall low regardless of modality. TLH may be associated with an increased risk of ureteral injury when compared to TAH. Previous studies have been inconsistent as to whether benign hysterectomy via minimally-invasive laparoscopic surgery increases risk of vesico-ureteral injury when compared to laparotomy. We examined the impact of surgical approach (minimally-invasive laparoscopy versus laparotomy) on vesico-ureteral injury during inpatient hysterectomy for benign gynecological disease. Retrospective population-based observational study. The Nationwide Inpatient Sample. 501,110 women who underwent hysterectomy for benign gynecological disease from 1/2012-9/2015 were included: total abdominal hysterectomy (TAH, n=284,365 [56.7%]), total laparoscopic hysterectomy (TLH, n=60,410, [12.1%]), abdominal supra-cervical hysterectomy (Abd-SCH, n=55,655 [11.1%]), laparoscopic-assisted vaginal hysterectomy (LAVH, n=45,620 [9.1%]), total vaginal hysterectomy (TVH, n=34,865 [7.0%]), and laparoscopic supracervical hysterectomy (LSC-SCH n=20,195 [4.0%]). A comprehensive risk assessment for vesico-ureteral injury by hysterectomy mode was performed, adjusting for patient demographics and gynecologic disease types. Propensity score inverse probability of treatment weighing (PS-IPTW) was used to compare (i) TLH versus TAH and (ii) LSC-SCH versus Abd-SCH with generalized estimating equations. Vesico-ureteral injury was reported in 1,045 (0.21%) women overall. LAVH (0.28%) had the highest bladder injury rate, whereas laparoscopic SCH had the lowest (0.10%) (P<0.001). TLH (0.13%) had the highest ureteral injury rate, whereas TAH had the lowest (0.04%) (P<0.001). In PS-IPTW models, TLH was associated with increased risk of ureteral injury (odds ratio [OR] 3.95, 95% confidence interval [CI] 2.03-7.67, P<0.001) but not bladder injury (OR 1.04, 95%CI 0.57-1.90, P=0.897) compared to TAH. In contrast, LSC-SCH was not associated with increased risk of vesico-ureteral injury when compared to Abd-SCH (OR 0.62, 95%CI 0.19-1.98, P=0.419). The risk of vesico-ureteral injury varies widely by the surgical approach to benign hysterectomy but is overall low regardless of modality. TLH may be associated with an increased risk of ureteral injury when compared to TAH.