What is the incidence of ureteral injury in laparoscopic (surgical removal of the uterus using a minimally invasive technique) hysterectomy?

Incidence of Ureteral Injury in Laparoscopic Hysterectomy

The incidence of ureteral injury during laparoscopic hysterectomy ranges from 0.2% to 1.3%, with recent data showing an increasing trend over the past decade to approximately 0.95% in minimally invasive hysterectomies. 1

Epidemiology and Risk Factors

Ureteral injuries are among the most serious complications of gynecologic surgery, with laparoscopic hysterectomy carrying a significantly higher risk compared to open procedures:

• Laparoscopic hysterectomy has 2.6-35 times higher risk (0.2-6.0%) of ureteral injury compared to abdominal hysterectomy 2
• Recent large-scale national data (2013-2023) shows:
  • 0.95% incidence in minimally invasive hysterectomy vs. 0.57% in open hysterectomy 1
  • Increasing trend in minimally invasive procedures (0.76% in 2013-2018 to 1.1% in 2019-2023) 1
  • Highest recorded incidence of 1.3% in 2023 1

Risk factors that increase the likelihood of ureteral injury include:

• Radical hysterectomy (highest incidence: 0.82-3.99%) 3
• Use of heat-generating instruments (associated with 26.7% of injuries) 3
• Massive uterine myomas causing ureteral deviation 2
• Previous pelvic surgery or radiation 4

Types and Recognition of Injuries

Ureteral injuries can be classified as:

1. Direct injuries (26.6% of cases):

   • Only half are identified during the operative procedure 3
   • Immediate recognition allows for prompt repair with better outcomes 5

2. Indirect injuries (majority of cases):

   • Result from micro-trauma leading to delayed necrosis of the ureteral wall 3
   • Often undetected intraoperatively 6
   • Symptoms typically manifest days to months after surgery 6

Consequences of Ureteral Injury

Patients who experience ureteral injury during laparoscopic hysterectomy face significant complications:

• Higher rates of infectious complications 1
• Increased hospital readmissions 1
• Development of ureteral strictures 1
• Potential for ureterovaginal fistula formation 1
• Severe morbidity when recognition is delayed 4
• Increased healthcare costs and medicolegal implications 5

Prevention Strategies

Preventive measures to reduce the risk of ureteral injury include:

• Preoperative ureteral catheter placement: Shown to be effective in preventing injury (0/60 with catheters vs. 1/34 without) 2

  • Average placement time: 9.35 minutes
  • Allows clear visualization of the ureter
  • Minor complications include low back pain, urinary discomfort, and transient hematuria

• Surgical technique considerations:

  • Careful identification of anatomical landmarks
  • Awareness of potential ureteral deviation due to pathology
  • Cautious use of heat-generating instruments near ureters

Management of Identified Injuries

When ureteral injury is identified:

• Immediate intraoperative repair is associated with better outcomes 4, 5
• Robotic-assisted repair of ureteral injuries has shown good outcomes and appears safe and feasible 5
• Repair techniques include:
  • Ureteroureterostomy with end-to-end anastomosis 5
  • Ureteroneocystostomy with or without vesico-psoas hitch or Boari flap for distal injuries 4
  • Placement of ureteral stents or nephrostomy tubes as bridge to definitive treatment 4

Key Practice Points

• The majority of ureteral injuries (50-70%) are recognized postoperatively with a median delay of 10 days 4
• Consider ureteral injury in any patient with abnormal recovery after laparoscopic hysterectomy 6
• The role of a urologist is fundamental when ureteral injury is suspected or identified 4
• Conversion to open surgery may be necessary in complex cases, though laparoscopic repair has been demonstrated to be safe and feasible in experienced hands 4

The increasing trend in ureteral injury rates during minimally invasive hysterectomy highlights the importance of prevention strategies, careful surgical technique, and prompt recognition and management of injuries when they occur.