Presentation Authors: Kai Dallas*, Lisa Rogo-Gupta, Christopher Elliott, Stanford, CA
Introduction: Genitourinary injury and fistula formation are devastating complications following hysterectomy. The literature regarding this topic is limited and generally focuses on ureteral injury or fistula formation alone, not in combination. We explore the combined genitourinary injury rates and risk factors for injury in a large contemporary 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. Those who underwent genitourinary repair at the time of hysterectomy or subsequent surgery for a urologic injury and/or urologic fistula were identified.
Results: Of the 296,130 women who underwent hysterectomy, 5,455 (1.8%) had at least one urologic injury including: 2,817 (1.0%) ureteral injuries, 2,058 (0.70%) bladder injuries and 831 (0.3%) resultant fistulas (Figure 1). Of the injuries, 23.6% were unrecognized at the time of hysterectomy (104 bladder injuries, 441 ureteral injuries and 754 fistulas) (Figure 1). Most fistulas (90.7%) occurred without a prior history of noted genitourinary injury. In those with injuries that were repaired (either at the time of hysterectomy or in a delayed fashion), a resultant fistula developed in 2.7% of bladder repairs and 1.1% of ureteral repairs. If an injury occurred, the rate of subsequent fistula formation was lower if the injury was recognized at the time of hysterectomy (as opposed to being found later in the perioperative period) for both ureteral injuries (0.7% versus 3.4%, p < 0.001) and bladder injuries (2.5% versus 6.5%, p < 0.001) injuries (Figure 1). 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 quartile of hysterectomy volume (OR 1.37, p=0.049) were all associated with an increased likelihood of a genitourinary injury.
Conclusions: Of women undergoing benign hysterectomy ~1.8% will have a genitourinary injury of some form. While any injury will increase the chances of a future fistula, recognizing and addressing the injury at the time it occurs reduces this risk. We identify several factors that are associated with genitourinary injury, providing insight into instances where a higher index of suspicion might be held.
Source of Funding: The Valley Medical Foundation