Major complications associated with laparoscopic-assisted vaginal hysterectomy: ten-year experience

STUDY OBJECTIVE: To describe our experience with major complications associated with laparoscopic-assisted vaginal hysterectomy (LAVH) and compare our results with those of the American Association of Gynecologic Laparoscopists (AAGL) membership survey and another similar study. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: University-affiliated hospital. PATIENTS: Two thousand seven hundred two women. Intervention. LAVH. MEASUREMENTS AND MAIN RESULTS: Demographic data and medical histories (age, parity, surgical indications, pathologic findings, major complications) were analyzed. Major complications were 11 bladder injuries, 4 ureter injuries, 11 bowel injuries, 2 vascular injuries, 2 cases of massive bleeding from the vaginal cuff or colpotomy wound with associated impending shock, 2 cases of postoperative ileus, and 2 pelvic abscesses. Our overall major complication rate was 1.3% compared with 2.7% in the AAGL 1995 membership survey (p <0.001). Similar rates of febrile morbidity (2.2% and 2.0%), bleeding requiring transfusion (0.05% and 0.06%), and bowel, ureteral, or bladder injury (1.0% and 1.0%) were noted between our study and the other 1995 study (all p >0.05). Of 34 major complications in our study, 24 occurred during hysterectomy performed by inexperienced general gynecologists and 10 by an experienced endoscopist (p = 0.005). CONCLUSION: The rate of major complications associated with LAVH can be reduced when the procedure is performed by a well-trained laparoscopic surgeon compared with a less-experienced general gynecologist.     

Vesicoureteral Injury during Benign Hysterectomy: Minimally Invasive Laparoscopic Surgery versus Laparotomy

Study ObjectiveThe findings of previous studies have been inconsistent as to whether benign hysterectomy via minimally invasive laparoscopic surgery increases the risk of vesicoureteral injury when compared with laparotomy. The objectives of our study were to (1) examine the rate of vesicoureteral injury on benign hysterectomy by the surgical approach and (2) compare the risk of vesicoureteral injury specifically between minimally invasive laparoscopic and abdominal hysterectomy on a populational level.DesignRetrospective population-based observational study.SettingThe National Inpatient Sample.PatientsA total of 501 110 women who had undergone hysterectomy for benign gynecologic disease between January 2012 and September 2015 were included as follows: total abdominal hysterectomy (TAH, n = 284 365 [56.7%]), total laparoscopic hysterectomy (TLH, n = 60 410 [12.1%]), abdominal supracervical hysterectomy (Abd-SCH, n = 55 655 [11.1%]), laparoscopic-assisted vaginal hysterectomy (LAVH, n = 45 620 [9.1%]), total vaginal hysterectomy (TVH, n = 34 865 [7.0%]), and laparoscopic supracervical hysterectomy (LSC-SCH, n = 20 195 [4.0%]).InterventionsA comprehensive risk assessment for vesicoureteral injury by hysterectomy mode was performed, adjusting for patient demographics and gynecologic disease types. Propensity score inverse probability of treatment weighing was used to compare (1) TLH versus TAH and (2) LSC-SCH versus Abd-SCH with generalized estimating equations. In a sensitivity analysis, gynecologic disease−specific injury risk and vaginal route−specific injury risk (LAVH vs TVH) were assessed.Measurements and Main ResultsVesicoureteral injury was reported in 1045 (0.21%) women overall. LAVH (0.28%) had the highest bladder injury rate, whereas LSC-SCH had the lowest (0.10%) (p <.001). TLH (0.13%) had the highest ureteral injury rate, whereas TAH had the lowest (0.04%) (p <.001). In propensity score inverse probability of treatment weighing models, compared with TAH, TLH was associated with an increased risk of ureteral injury (odds ratio [OR] 3.95, 95% confidence interval [CI] 2.03−7.67, p <.001) but not bladder injury (OR 1.04, 95% CI 0.57−1.90, p = .897). Risk of ureteral injury was particularly high when TLH was performed for endometriosis (OR 6.15, 95% CI 1.18−31.9, p = .031) or for uterine myoma (OR 4.15, 95% CI 2.13−8.11, p <.001). In contrast, for supracervical or vaginal hysterectomy, minimally invasive laparoscopic approaches were not associated with an increased risk of vesicoureteral injury (LSC-SCH vs Abd-SCH: OR 0.62, 95% CI 0.19−1.98, p = .419; LAVH vs TVH: OR 1.21, 95% CI 0.63−2.33, p = .564).ConclusionThe risk of vesicoureteral injury on benign hysterectomy is low overall regardless of hysterotomy modalities but varies widely with the surgical approach. Compared with TAH, TLH may be associated with an increased risk of ureteral injury.     

A simple procedure for the prevention of ureteral injury in laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE: To introduce a surgical technique to minimize the chance of ureteral injury during laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Retrospective case review (Canadian Task Force classification II-3). SETTING: Show Chwan Memorial Hospital, Changhua, Taiwan. PATIENTS: Two thousand and six women who underwent LAVH between January 1992 and June 2001. INTERVENTION: A simple step of creating a "window" over the anterior and posterior broad ligaments to push inferolaterally the areolar tissue (in which the ureter is embedded) on the posterior broad ligament. MEASUREMENTS AND MAIN RESULTS: No ureteral injury occurred in patients whose cases were reviewed. There were, however, five bladder injuries (0.25%) and three nerve pareses (0.15%). Other minor complications, including fever, abscess or hematoma of the vaginal cuff, subcutaneous emphysema, and delayed vaginal cuff bleeding, occurred in less than 5% of patients. CONCLUSION: The technique proposed is simple and very effective in preventing ureteral injury during LAVH.     

Urinary tract injury in laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE: To evaluate the incidence and characteristics of urinary tract injury after laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: A retrospective study that evaluated all cases of urinary tract injury at the time of LAVH in an 11-year period. Parameters including surgical indication, site of injury, time of diagnosis, method of treatment, and long-term follow-up were analyzed. (Canadian Task Force classification II-2). SETTING: Tertiary care university hospital. PATIENTS: A total of 38 urinary tract injuries were found in 7725 LAVH. INTERVENTION: LAVH and repair of urinary tract injuries with transvaginal or transabdominal approach. MEASUREMENTS AND MAIN RESULTS: The incidence of urinary tract injury after LAVH was 4.9/1000 procedures: 3.9/1000 for urinary bladder injury and 1.0/1000 for ureteral injury. Prior cesarean section was the most common risk factor for bladder injuries. Ninety-six percent (29/30) of urinary bladder injuries were detected and treated during surgery. Half (4/8, 50%) of the ureteral injuries were identified during surgery. Of the 38 complications, 28 (75.7%) occurred in surgery. CONCLUSION: Most urinary tract injuries in LAVH were identified during surgery and are associated with the surgeon's experience. Bladder injury can be repaired either transvaginally or abdominally; ureteral injury can be repaired abdominally.     

Rational type of laparoscopic hysterectomy and safety in anesthetic profiles

OBJECTIVE: To evaluate what type of surgery would be more reasonable among 3 types of laparoscopic hysterectomy and to evaluate the safety of cardio-pulmonary changes on these patients during these operations. METHOD: A retrospective study was carried out in 215 women who underwent laparoscopic hysterectomy including laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic hysterectomy (LH), total laparoscopic hysterectomy (TLH). Blood gas analysis, end-tidal CO2 levels and vital signs were checked and compared with control and preceding values. RESULTS: The average duration of operation was 102.5 min, 83.8 min and 118.3 min for LAVH (n = 97), LH (n = 75) and TLH (n = 43), respectively (p < 0.05). The average amount of bleeding was 297.5 ml, 152.3 ml and 149.2 ml for each type of hysterectomy, respectively. Hemoglobin decreased by an average of 1.6 g/100 ml, 0.9 g/100 ml and 0.8 g/100 ml, respectively. There was a lesser amount of bleeding for LH and TLH than for LAVH (p < 0.05). Profiles of blood gas analysis and expiratory CO2 varied significantly according to the operative stages under controlled anesthesia (p < 0.05), but were within the normal range. CONCLUSION: These results demonstrate that laparoscopic procedures advancing below the uterine vasculature can be considered effective for hysterectomies and that proper anesthesia can safely control the cardio-pulmonary changes during laparoscopic hysterectomy.     

The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy

OBJECTIVE: To evaluate the incidence of urinary tract injury due to hysterectomy for benign disease. STUDY DESIGN: Patients were enrolled prospectively from 3 sites. All patients undergoing abdominal, vaginal, or laparoscopic hysterectomy for benign disease underwent diagnostic cystourethroscopy. RESULTS: Four hundred seventy-one patients participated. Ninety-six percent (24/25) of urinary tract injuries were detected intraoperatively. There were 8 cases of ureteral injury (1.7%) and 17 cases of bladder injury (3.6%). Ureteral injury was associated with concurrent prolapse surgery (7.3% vs 1.2%; P = .025). Bladder injury was associated with concurrent anti-incontinence procedures (12.5% vs 3.1%; P = .049). Abdominal hysterectomy was associated with a higher incidence of ureteral injury (2.2% vs 1.2%) but this was not significant. Only 12.5% of ureteral injuries and 35.3% of bladder injuries were detected before cystoscopy. CONCLUSION: The incidence of urinary tract injury during hysterectomy is 4.8%. Surgery for prolapse or incontinence increases the risk. Routine use of cystoscopy during hysterectomy should be considered.     

Bladder injury after LAVH: a prospective, randomized comparison of vaginal and laparoscopic approaches to colpotomy during LAVH

STUDY OBJECTIVE: To compare results of a vaginal approach to colpotomy (type IA) and laparoscopic-assisted abdominal colpotomy (type ID) in performing a laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Prospective, randomized study (Canadian Task Force classification I). SETTING: Tertiary teaching hospital. PATIENTS: Five hundred forty-one women, 274 in group 1 (type 1D) and 267 in group 2 (type 1A). INTERVENTION: LAVH with follow-up for 3 months to 5 years. MEASUREMENTS AND MAIN RESULTS: There were no statistically significant differences in age, preoperative and postoperative hemoglobin values, or postoperative hospital stay between groups. Operating time and estimated blood loss were significantly reduced in group 2 (p <0.001 and <0.001, respectively). Women in group 1 had nine urinary tract injuries (3.28%), including eight cases of intraoperative bladder injury (2.91%) and one vesicovaginal fistula (0.36%), but no ureteral injury.The bladder injury rate in group 2 was 0.37%, which was significantly lower (p = 0.038). There were no significant differences in ureteral or bowel injuries, pelvic hematomas, or pelvic abscesses. CONCLUSION: LAVH type IA achieved better results than type ID in preventing bladder injury.     

妇科腹腔镜手术泌尿系损伤的临床分析

目的：探讨妇科腹腔镜手术发生泌尿系损伤的相关因素、诊断、治疗方法及预防措施。方法：回顾分析2002年1月至2012年12月北京大学人民医院妇科腹腔镜手术发生泌尿系损伤患者的临床资料。总结分析患者的疾病类型、手术方式、损伤特点、诊疗情况及预后等。结果：妇科腹腔镜手术共4773例,泌尿系损伤发生18例（0.38％）,其中8例发生于腹腔镜恶性肿瘤手术,8例发生于腹腔镜辅助阴式全子宫切除术（LAVH）,2例发生于腹腔镜附件手术。18例泌尿系损伤患者中5例有腹部手术史,有腹部手术史者的泌尿系损伤发生率高于无手术史者（P〈0.05）。18例泌尿系损伤患者中膀胱损伤4例,其中3例位于膀胱后壁,1例位于膀胱三角区;输尿管损伤14例,其中输尿管上段损伤2例,中段损伤10例,下段损伤2例;左侧输尿管损伤2例,右侧12例。术中发现损伤10例,其中4例膀胱损伤和6例输尿管损伤;术后发现8例,均为输尿管损伤,于术后1～10天发现,均经静脉肾盂造影确诊。11例经再次手术修补成功,7例放置输尿管支架6个月（3～12个月）保守治疗成功。结论：腹腔镜下恶性肿瘤手术、LAVH、有腹部手术史患者发生泌尿系损伤机率较高,输尿管损伤多于膀胱损伤。术者需高度警惕,术后严密观察,如发现泌尿道损伤,尽早请泌尿科医师共同决定治疗方法。     

腹腔镜辅助阴式子宫切除术98例分析

目的通过对９８例患者行腹腔镜辅助阴式子宫切除术（ＬＡＶＨ）分析,进一步探讨ＬＡＶＨ的适应证、手术要点及临床应用价值。方法自１９９５年２月至１９９７年２月,对９８例因各种良性妇科疾病而需行子宫全切除术的患者,采用ＬＡＶＨ术式。患者平均年龄５２岁（３８～６６岁）,术前子宫正常大小者３８例,子宫增大、小于孕１２周４４例,大于孕１２周１６例,其中有下腹手术史者２９例。结果９８例行ＬＡＶＨ中,２例中转开腹手术,中转率２．０％。平均手术时间１０６分钟（６０～２４０分钟）,出血量约５０～１５０ｍｌ。平均住院日为６天。结论ＬＡＶＨ拓宽了阴式子宫切除的适应证,可避免开腹、减少手术创伤     

Major complications of operative gynecologic laparoscopy in southern Taiwan

STUDY OBJECTIVE: To describe our experience with major complications in gynecologic laparoscopy compared with literature reports. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Two regional teaching hospitals in southern Taiwan. Patients. One thousand five hundred seven women. INTERVENTION: Gynecologic laparoscopy. MEASUREMENTS AND MAIN RESULTS: The overall number of major complications in 1507 laparoscopies was 24 (1.6%): 6 bladder injuries, 5 bowel injuries, 4 ureteral injuries, 3 cases of delayed vaginal stump bleeding, 2 cases of postoperative ileus, 2 abscesses, 1 vessel injury, and 1 umbilical hernia. Complication rates were analyzed by type of surgery-laparoscopic-assisted vaginal hysterectomy (LAVH) versus non-LAVH. We correlated clinical outcome with time of recognition and treatment of complications. Our complication rates were similar to those reported in the literature and were not significantly different between LAVH and non-LAVH. CONCLUSION: Early recognition of injuries, preferably intraoperatively, with immediate appropriate treatment is crucial. It is also important to be alert to early manifestations of complications in the postoperative observation period. (J Am Assoc Gynecol Laparosc 8(1):61-67, 2001)     

Operative injuries during vaginal hysterectomy.

OBJECTIVE: To evaluate incidence, characteristics and consequences of urinary and intestinal tract injuries during vaginal hysterectomy for benign conditions. STUDY DESIGN: From January 1970 to December 1996, 3076 vaginal hysterectomies with or without additional procedures, were performed for benign conditions in our department. We retrospectively analyzed operative injury cases. RESULTS: Incidence of urinary and intestinal tract injuries were 1.7 and 0.5%, respectively. Concerning urinary tract injuries, we observed only one ureteral lesion, all others being bladder lacerations (54 cases). The bladder lacerations occured during the hysterectomy step of the surgery in 61% of cases and during the additional procedures in 39%. All bladder injuries were recognized and treated during the primary operation. We observed four cases of vesico-vaginal fistula as a consequence of these injuries; all fistulas occured after bladder laceration during the hysterectomy step of the surgical procedure. Intestinal tract injuries (16 cases) were rectal lacerations occuring during the hysterectomy step of the surgery (31% of cases) and during the additional procedures (69%). All rectal injuries were recognized and repaired during the primary operation and all healed without sequellae. CONCLUSION: Operative injuries during vaginal hysterectomy are relatively rare. They are easily recognized and treated during the primary operation without important sequellae.     

Laparoscopic-assisted vaginal hysterectomy versus total laparoscopic hysterectomy for the management of endometrial cancer: a randomized clinical trial

STUDY OBJECTIVE: To compare laparoscopic-assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH) for the treatment of endometrial cancer. DESIGN: Randomized, controlled trial. DESIGN CLASSIFICATION: Randomized controlled trial (Canadian Task Force classification I). SETTING: Two gynecologic oncologic units of university hospitals. PATIENTS: Seventy-two women with endometrial cancer randomized to undergo either LAVH or TLH. INTERVENTIONS: Total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, peritoneal washing, and systematic pelvic lymphadenectomy. MEASUREMENTS AND MAIN RESULTS: Parameters of technical feasibility (operating time of hysterectomy phase, estimated blood loss, perioperative complications) were considered as major statistical endpoints. Thirty-seven women were allocated to the LAVH arm, and 35 were allocated to the TLH arm. Mean total operating time was significantly shorter in the TLH than in the LAVH group (184.0 +/- 46.0 vs 213.2 +/- 39.4 minutes, p = .003). The hysterectomy phase was longer in the LAVH than in the TLH group only in overweight (77.9 +/- 9.8 vs 68.1 +/- 9.3 min, p = .005) and obese patients (87.7+/- 13.1 vs. 62.1+/- 9.9 min, p < .0001). The median estimated blood loss during hysterectomy was similar between groups. Intraoperative complications occurred in three (8.1%) patients in the LAVH group and in one patient (2.8%) in the TLH group (p = .61). No difference was found in the postoperative complication rate between women undergoing LAVH and those who had TLH (24.3% vs 17.1%, p = .56). Within a median follow-up period of 10 months (range 3-17 months), 2 patients in the LAVH group developed recurrent disease. No port site metastasis and no vaginal cuff recurrence were detected in either group. CONCLUSION: Both LAVH and TLH can be performed successfully to manage endometrial cancer, with similar surgical outcomes. Obese patients benefit more from TLH than from LAVH in terms of shorter operating time.     

The Hohl instrument for optimizing total laparoscopic hysterectomy: results of more than 500 procedures in a university training center

Purpose

To evaluate complication rates associated with total laparoscopic hysterectomy (TLH) using the Hohl instrument in women with benign indications for hysterectomy, a prospective cohort study was conducted in a university teaching hospital.

Methods

A total of 567 women with benign indications for hysterectomy underwent the TLH procedure using the Hohl instrument between January 2005 and July 2009. The laparoscopic approach was used when the patient had undergone more than one previous pelvic abdominal operation, when an adnexal finding was present, and/or if the patient had reduced vaginal capacity.

Results

One ureteral injury (0.18%), four bladder injuries (0.71%), one small-bowel injury (0.18%), one vaginal injury (0.18%), and one conversion to abdominal hysterectomy (0.18%) occurred. The general complication rate during surgery was 1.42%, whereas in the postoperative period was 3.19%. The mean loss of hemoglobin was 1.47?g/dL (SD 1.06), the mean operating time was 103.87?min (SD 43.89), and the mean uterus weight was 241.41?g (SD 196.73).

Conclusions

Total laparoscopic hysterectomy using the Hohl instrument simplifies the surgical procedure. The technique reported here is safe and effective in preventing ureteral complications during TLH, even in a university training program.     

Comparison of two procedures for laparoscopic-assisted vaginal hysterectomy of large myomatous uteri

STUDY OBJECTIVE: To evaluate whether laparoscopic bipolar coagulation of uterine vessels (LBCUV) and supracervical amputation improve laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Prospective, randomized, longitudinal study (Canadian Task Force classification II-1). SETTING: Private practice, university-affiliated hospital. PATIENTS: Sixty-four women (age 31-52 yrs) with symptomatic myomatous uteri larger than 12 weeks on bimanual examination. INTERVENTIONS: LAVH with or without LBCUV and laparoscopic supracervical amputation followed by trachelectomy. MEASUREMENTS AND MAIN RESULTS: LBCUV and laparoscopic supracervical amputation followed by trachelectomy and removal of the specimen vaginally were performed successfully in 29 women (group A). Hysterectomy was performed successfully in 32 comparable patients (group B) with severing of the round ligament, ovarian ligament, or infundibulopelvic ligament, and preparation of the bladder flap in the laparoscopic phase, and severing of uterine vessels and cardinal-uterosacral ligament complex through the vagina. Average blood loss was 169.8 and 308.7 ml in groups A and B, respectively (p <0.05); average operating time was 126.4 and 152.8 minutes, respectively (p <0.05); hemoglobin decreased on average 0.9 and 1.7 g/100 ml, respectively (p <0.05). Conclusion. LBCUV and laparoscopic supracervical amputation followed by trachelectomy reduce operating time and blood loss in LAVH, and allow conversion of many abdominal procedures to laparoscopy.     

The Hohl instrument for optimizing total laparoscopic hysterectomy procedures

STUDY OBJECTIVE: To evaluate the feasibility of total laparoscopic hysterectomy (TLH) using the Hohl instrument in an initial cohort of patients. DESIGN: Retrospective cohort analysis (Canadian Task Force classification II-3). SETTING: Department of Obstetrics and Gynecology, Erlangen University Hospital, Erlangen, Germany. PATIENTS: Forty-four women underwent the new TLH procedure using the Hohl instrument from May 2004 through January 2005. The laparoscopic approach was used when the patient had undergone more than one previous pelvic abdominal operation and/or had a reduced vaginal capacity. The indications for hysterectomy were symptomatic leiomyoma in 25 patients and hypermenorrhea in 19 patients. INTERVENTION: Total laparoscopic hysterectomy using the Hohl instrument. MEASUREMENTS AND MAIN RESULTS: No ureteral or bladder injury occurred in any of the patients. The complication rate during surgery and in the postoperative period was zero. The mean loss of hemoglobin was 1.68+/-0.96 g/dL, the mean operating time was 108+/-21 minutes, and the mean uterine weight was 302+/-121 g. CONCLUSION: Total laparoscopic hysterectomy using the Hohl instrument simplifies the surgical procedure. The reported technique is an option comparable with laparoscopic-assisted vaginal hysterectomy and may be effective in preventing minor and major complications during TLH.     

Ureteroscopy: Savior to the gynecologist?—Ureteroscopic management of post laparoscopic-assisted vaginal hysterectomy ureterovaginal fistulas

Iatrogenic ureteral injuries are among the most serious complications in gynecologic surgery. With the increasing popularity of laparoscopic gynecologic surgery, the incidence of ureteral injuries is on the rise. We report 2 cases of post laparoscopic-assisted vaginal hysterectomy (post LAVH) ureterovaginal fistulas, which were managed successfully with retrograde stenting using ureteroscopy. Three middle-aged women who underwent LAVH for symptomatic myomas of the uterus presented with ureterovaginal fistulas in the late postoperative period. Excretory urography revealed ureterovaginal fistulas involving the distal ureter. Retrograde stenting was possible in 2 patients, using a 7.5F rigid ureteroscope. Both patients became continent 2 days after surgery. Urography at 6 weeks revealed normal renal function without obstruction or extravasation of urine, and the stents were removed. Stenting failed in the third patient; the patient underwent a ureteric reimplantation successfully. Post LAVH ureterovaginal fistulas are amenable to ureteroscopic retrograde double-J stenting, which enables spontaneous recovery of the injured ureter. An attempt of ureteroscopic stenting should be considered in all patients with post LAVH ureterovaginal fistulas before subjecting them to other modalities.     

Laparoscopic hysterectomy

STUDY OBJECTIVE: To determine the soundness of laparoscopic hysterectomy compared with vaginal and abdominal hysterectomy Design. Nonrandomized, uncontrolled, retrospective study (Canadian Task Force classification III). SETTING: Medium-size community hospitals. PATIENTS: One thousand six hundred forty-eight women undergoing laparoscopic hysterectomy, including those with uterine size 17 weeks' gestation or less. INTERVENTION: Laparoscopic hysterectomy staged as level 4, which includes laparoscopic dissection of the uterine artery. MEASUREMENTS AND MAIN RESULTS: The median duration of surgery was 36 minutes (range 24-104 min), compared with the usual 115 minutes for laparoscopic-assisted vaginal hysterectomy. Complication rate was 0.66%. No complications occurred in the last 3 years when the procedures included transillumination of the ureters. Although the costs associated with disposable equipment are high, the technique is cost effective. CONCLUSION: With proper training and ureteral transillumination, laparoscopic hysterectomy is safe and effective, and with stents, ureteral injury is avoided.     

Urological injuries during hysterectomies: a 6-year review

AIM: Urological injuries that occur during hysterectomy are a rare but important cause of morbidity. An understanding of the risk factors can help us to reduce their incidence and studying their management and outcome could help us to evolve optimal management strategies. The aim of the present study was to examine the incidence of urological injuries that occur during hysterectomy and to determine the risk factors, management and outcome of such injuries. METHODS: A retrospective analysis of cases of urological injuries sustained during hysterectomies carried out from June 1996 until May 2002, at our institution. The chi-squared test was applied for statistical analysis. RESULTS: The overall incidence of urological injuries was 0.40% (0.28% bladder and 0.12% ureteral). No ureteral injuries occurred during vaginal surgery. The incidence of bladder injury was significantly higher in non-descent vaginal hysterectomies compared with abdominal hysterectomies or vaginal hysterectomies for genital prolapse (P<0.05). Hysterectomy for ovarian malignancies had a significantly higher risk for bladder injuries compared with other indications. Bladder injuries detected during vaginal hysterectomies could be managed through the vaginal route. All the repairs healed successfully. CONCLUSIONS: Non-descent vaginal hysterectomy and hysterectomy for ovarian malignancies have a higher risk of bladder injury. Urological injuries during hysterectomy are uncommon. Early detection and appropriate management ensure successful healing and minimal long-term sequelae.     

The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases

STUDY OBJECTIVE: To compare the frequency of complications of total laparoscopic hysterectomy performed in the first and more recent years of our experience, and based on that, offer ways to prevent them. DESIGN: Retrospective, comparative study (Canadian Task Force classification II-2). SETTING: University tertiary referral center for endoscopic surgery. PATIENTS: During 1989-1995 and 1996-1999, 695 and 952 women, respectively, with benign pathology. INTERVENTION: Total laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: No differences in patient characteristics were found between 1989-1995 and 1996-1999. Substantial decreases in major complication rates were noted, 5.6% and 1.3%, respectively. No major vessel injury occurred. Excessive hemorrhage (1.9%) and need for blood transfusion (2.2%) during the first period were statistically higher than in the second period (both 0.1%, p <0.005). Urinary complications (2.2%) including 10 bladder lacerations, 4 ureter injuries, and 1 vesicovaginal fistula occurred more frequently in the first period than in the second period (0.9%), when 6 bladder and 2 ureter lacerations and 1 vesicovaginal fistula occurred (p <0.005). One bowel injury and one bowel obstruction occurred in the first period, but no bowel complications in the second. Between periods, 33 (4.7%) and 8 (1.4%) conversions to laparotomy were necessary. During the first period there were nine reoperations; of six laparotomies, four were due to urinary injuries, one due to heavy vaginal bleeding, and one due to a vesicovaginal fistula; three diagnostic laparoscopies were required due to postoperative abdominal pain. Three reoperations during the second period were two laparoscopies due to heavy vaginal bleeding and one laparotomy due to a vesicovaginal fistula (p <0.005). Statistically significant differences in median (range) uterine weight 179.5 g (22-904 g) and 292.0 g (40-980 g) and operating times 115 minutes (40-270 min) and 90 minutes (40-180 min), respectively, were recorded (p <0.005). CONCLUSION: Laparoscopic hysterectomy was safe, effective, and reproducible after training, and with current technique, had a low rate of complications.     

Twenty-first century laparoscopic hysterectomy: should we not leave the vaginal step out?

The objective of this study was to compare surgical outcomes for laparoscopically assisted vaginal hysterectomy (LAVH) with total laparoscopic hysterectomy (TLH) in three teaching hospitals in the Netherlands. This study is a multicenter cohort retrospective analysis of consecutive cases (Canadian Task Force classification II-2). One hundred and four women underwent a laparoscopic hysterectomy between March 1995 and March 2005 at one of three teaching hospitals. This included 37 women who underwent LAVH and 67 who underwent TLH. Blood loss, operating time, and intraoperative complications such as bladder or ureteric injury as well as conversion to an open procedure were recorded. In the TLH group, average age was statistically significant lower, as well as the mean parity, whereas estimated uterus size was statistically significant larger, compared to the LAVH group. Main indication in both groups was dysfunctional uterine bleeding. In the TLH group, mean blood loss (173 mL) was significant lower compared to the LAVH group (457 mL), whereas length of surgery, uterus weight, and complication rates were comparable between the two groups. The method of choice at the start of the study period was LAVH, and by the end of the study period, it had been superceded by TLH. LAVH should not be regarded as the novice’s laparoscopic hysterectomy. Moreover, with regard blood loss, TLH shows advantages above LAVH. This might be due to the influence of the altered anatomy in the vaginal stage of the LAVH procedure. Therefore, when a vaginal hysterectomy is contraindicated, TLH is the procedure of choice. LAVH remains indicated in case of vaginal hysterectomy with accompanying adnexal surgery.