Risk Factors of Lower Urinary Tract Injury at the Time of Hysterectomy for Benign Reasons

Lower urinary tract injury is a rare but potentially devastating complication of hysterectomy. Its incidence ranges from 0.13% to 3.6% for bladder injury and from 0.1% to 1.8% for ureteral injury. Suggested risk factors of lower urinary tract injury at the time of hysterectomy include older age, higher body mass index, increased uterine size, longer operating times, and increased blood loss. Differences in routes of hysterectomy have also been suggested to be risk factors of lower urinary tract injuries. It has been difficult to identify risk factors based on the route or type of hysterectomy because of the low prevalence rates of injury. This multicenter retrospective study was designed to determine risk factors of lower urinary tract injury among women undergoing hysterectomy for benign indications. A case-control study design was used. Cases including all women who underwent a hysterectomy at 7 clinical sites between 2007 and 2011 were identified by the appropriate International Classification of Diseases, Ninth revision and current procedural terminology codes. Controls were the next 2 sequential hysterectomies in the same institution that did not have lower urinary tract injury. Univariate and multivariate logistic regressions were used to compare the groups. A total of 135 cases and 270 controls were identified. The cases included 110 bladder injuries and 25 ureteral injuries and 8 women with both. Bladder and ureteral injuries were associated with total abdominal hysterectomy (TAH); the odds ratios (ORs) were 1.9 (95% confidence interval [CI], 1.06–3.4) and 4.7 (95% CI, 1.4–15.6), respectively. Bladder injury was also associated with a history of cesarean delivery (OR, 2.9; 95% CI, 1.7–5) and surgery by a generalist obstetrician-gynecologist (OR, 2.4; 95% CI, 1.2–5.2). In addition to TAH, ureteral injury was more likely in women who underwent laparoscopic-assisted vaginal hysterectomy; the OR was 10.4, with a 95% CI of 2.3 to 46.6. These data show that bladder injury at the time of benign hysterectomy is associated with TAH and a history of cesarean delivery as well as surgery by generalist obstetrician-gynecologist. Ureteral injury is associated with TAH and laparoscopic-assisted vaginal hysterectomy.