Lower urinary tract injury during gynecologic surgery and its detection by intraoperative cystoscopy

OBJECTIVE: To review the frequency of lower urinary tract injuries after major gynecologic surgery and the role of routine intraoperative cystoscopy during major gynecologic surgery in the detection of lower urinary tract injuries. DATA SOURCES: We combined a MEDLINE search for reports from 1966 to October 1998, using the terms "urinary tract injury," "ureter/ureteric/ureteral obstruction/fistula/injury," "bladder fistula/injury," and "vesico-vaginal fistula," with a second search for all reports of gynecologic surgical procedures. Additional references were obtained from relevant articles and review articles. METHODS OF STUDY SELECTION: Included were all English language articles on the frequency of unintentional urinary tract injuries identified during or after benign gynecologic surgery. There were 22 reports on the frequency of lower urinary tract injuries after gynecologic surgery and eight on the use of routine cystoscopy during gynecologic surgery to diagnose unsuspected injuries. TABULATION, INTEGRATION, AND RESULTS: In the reports of studies not involving routine cystoscopy, the frequency of ureteral injury varied from 0 to 14.6 injuries per 1000 operations, with an overall frequency of 1.6 per 1000. The frequency of bladder injury varied from 0.2 to 19.5 per 1000, with an overall frequency of 2.6 per 1000. Only 11.5% of ureteral injuries and 51.6% of bladder injuries were identified and managed intraoperatively. In the reports of studies involving routine cystoscopy, the frequency of ureteral injury varied from 0 to 26.8 per 1000, with an overall frequency of 6.2 per 1000. The frequency of bladder injury varied from 0 to 29.2 per 1000, with an overall frequency of 10.4 per 1000. Up to 90% of unsuspected ureteral injuries and 85% of unsuspected bladder injuries were identified with the use of cystoscopy and were managed successfully intraoperatively. In 69% of the unsuspected ureteral and bladder injuries, the intraoperative management consisted of removing and replacing sutures or repairing unintentional cystotomies. CONCLUSION: Use of routine intraoperative cystoscopy during major gynecologic and urogynecologic surgery might prevent sequelae from lower urinary tract injuries.