What are the surgical procedures involving total laparoscopic hysterectomy (TLH), bilateral salpingectomy, bilateral ureterolysis, excision of endometriosis, and cystoscopy?

From the Guidelines

Total laparoscopic hysterectomy, bilateral salpingectomy, bilateral ureterolysis, excision of endometriosis, and cystoscopy are commonly performed together for conditions like endometriosis or uterine pathology requiring hysterectomy, with the goal of minimizing morbidity, mortality, and improving quality of life. A total laparoscopic hysterectomy involves the complete removal of the uterus through minimally invasive laparoscopic techniques, which is associated with less postoperative pain, quicker recovery, and improved short-term quality of life, as seen in the study by 1. Bilateral salpingectomy is the removal of both fallopian tubes, which is increasingly recommended even during benign hysterectomy as it reduces ovarian cancer risk, as supported by the study by 1. Bilateral ureterolysis involves freeing the ureters from surrounding scar tissue or endometriosis implants to prevent urinary tract complications. Excision of endometriosis removes endometrial tissue growing outside the uterus, which can cause pain and infertility. Finally, cystoscopy is performed to examine the bladder and urethra to ensure no injury occurred during surgery and to check for any bladder involvement of endometriosis.

The benefits of this comprehensive surgical approach include:

• Reduced risk of ovarian cancer with bilateral salpingectomy
• Minimized risk of urinary tract complications with bilateral ureterolysis
• Relief from symptoms caused by endometriosis with excision of endometriosis
• Definitive treatment of uterine pathology with total laparoscopic hysterectomy
• Improved quality of life with reduced pain and quicker recovery

Some key considerations for this surgical approach include:

• The timing of risk-reducing surgery, such as bilateral salpingo-oophorectomy, which should be individualized based on the patient's personal risk and fertility considerations, as recommended by 1
• The importance of preoperative counseling and patient-friendly written information regarding the risks and benefits of risk-reducing surgery, as emphasized by 1
• The potential long-term effects of hysterectomy, including increased risk of cardiovascular disease, osteoporosis, and dementia, as reported by 1

Overall, the combination of total laparoscopic hysterectomy, bilateral salpingectomy, bilateral ureterolysis, excision of endometriosis, and cystoscopy is a comprehensive surgical approach that prioritizes morbidity, mortality, and quality of life outcomes, as supported by the most recent and highest quality studies, including 1, 1, and 1.

From the Research

Surgical Procedures

• Total laparoscopic hysterectomy: a study published in 2015 2 found that the incidence of urinary tract injury was 1.3% in patients undergoing laparoscopic hysterectomy, with ureteral injuries almost as common as bladder injuries.
• Bilateral salpingectomy: there is no direct evidence provided in the studies to discuss the specifics of this procedure in relation to the others listed.
• Bilateral ureterolysis: a study from 2010 3 discussed laparoscopic ureterolysis as a delicate procedure requiring advanced laparoscopic skills, with the authors reporting no ureteral injuries related to the ureterolysis procedure in over 15 years of experience.
• Excision of endometriosis: the 2015 study 2 found that the presence of endometriosis was associated with an increased risk of bladder injury during laparoscopic hysterectomy.
• Cystoscopy: the 2015 study 2 noted that normal intraoperative cystoscopy findings did not exclude the presence of ureteral injury, with 20% of patients undergoing intraoperative cystoscopy.

Risks and Complications

• Ureteral injury: the 2015 study 2 found that a BMI of 26 to 30 kg/m(2) was associated with an increased risk of ureteral injury, while the presence of endometriosis was associated with an increased risk of bladder injury.
• Bladder injury: the 2015 study 2 found that 85% of bladder injuries were identified intraoperatively, while 71% of ureteral injuries were diagnosed postoperatively.

Surgical Techniques and Training

• Total laparoscopic hysterectomy: studies from 2007 4 and 2006 5 discussed the techniques and outcomes of total laparoscopic hysterectomy, with the 2006 study noting the importance of advanced laparoscopic training and supervision to minimize complications.
• Laparoscopic ureterolysis: the 2010 study 3 described a modified technique for laparoscopic ureterolysis and noted the advantages of laparoscopy, including shorter hospital stay, reduced patient pain, and better cosmetic results.