title: Laparoscopic Hysterectomy and Urinary Tract Injury: Experience in a Health Maintenance Organization.
abstract: OBJECTIVE
  To evaluate the incidence, detection, characteristics, and management of urinary tract injury in a cohort undergoing laparoscopic hysterectomy, and to identify potential risk factors for urinary tract injury with laparoscopic hysterectomy.
  
  
  METHODS
  Retrospective analysis (Canadian Task Force classification II-2).
  
  
  METHODS
  Kaiser Permanente San Diego Medical Center, 2001 to 2012.
  
  
  METHODS
  Women who underwent attempted laparoscopic hysterectomy for benign indications.
  
  
  METHODS
  Total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparoscopic supracervical hysterectomy.
  
  
  RESULTS
  Demographic and clinical characteristics, surgical techniques, and perioperative complications were abstracted from the medical record. Multivariable logistic regression analysis assessed independent risk factors for ureteral or bladder injury.
  
  
  RESULTS
  A total of 3523 patients (mean age, 45.9 ± 8.0 years; median parity, 2; range, 0-10), with a median body mass index (BMI) of 29 kg/m(2) (range, 16-72 kg/m(2)), underwent laparoscopic hysterectomy; 20% had intraoperative cystoscopy. The incidence of urinary tract injury was 1.3% (46 of 3523); of the 46 patients with injuries, 19 (0.54%) had ureteral injuries, 25 (0.71%) had bladder injuries, and 2 (0.06%) had both types. Of the 21 ureteral injuries, 6 (29%) were diagnosed intraoperatively and 15 (71%) were diagnosed postoperatively, including 4 with normal intraoperative cystoscopy. Of the 27 bladder injuries, 23 (85%) were identified intraoperatively. In multivariable logistic analysis, a BMI of 26 to 30 kg/m(2) (compared with >30 kg/m(2)) was associated with an increased risk of ureteral injury, and a BMI ≤25 kg/m(2) (compared with >30 kg/m(2)) and the presence of endometriosis were associated with an increased risk of bladder injury.
  
  
  CONCLUSIONS
  Urinary tract injury occurred in 1.3% of laparoscopic hysterectomies, with ureteral injuries almost as common as bladder injuries. Normal intraoperative cystoscopy findings did not exclude the presence of ureteral injury.
authors.affiliation: Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, CA. Electronic address: Jasmine.X.Tan-Kim@kp.org.
authors.forename: Jasmine
authors.initials: J
authors.lastname: Tan-Kim
authors.affiliation: Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, CA.
authors.forename: Shawn A
authors.initials: SA
authors.lastname: Menefee
authors.affiliation: Department of Obstetrics and Gynecology, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, CA.
authors.forename: Caryl S
authors.initials: CS
authors.lastname: Reinsch
authors.affiliation: Department of Obstetrics and Gynecology, St. Joseph Hospital, Orange, CA.
authors.forename: Cristina H
authors.initials: CH
authors.lastname: O'Day
authors.affiliation: Research and Evaluation, Southern California Permanente Medical Group, Pasadena, CA.
authors.forename: Judith
authors.initials: J
authors.lastname: Bebchuk
authors.affiliation: Department of Obstetrics and Gynecology, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, CA.
authors.forename: John S
authors.initials: JS
authors.lastname: Kennedy
authors.affiliation: Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Southern California Permanente Medical Group, Irvine Medical Center, Irvine, CA.
authors.forename: Emily L
authors.initials: EL
authors.lastname: Whitcomb
mesh_terms: D003558:Cystoscopy / Q000009:adverse effects*; D005260:Female; D006279:Health Maintenance Organizations; D006801:Humans; D007045:Hysterectomy, Vaginal / Q000009:adverse effects*; D015994:Incidence; D010535:Laparoscopy / Q000009:adverse effects*; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D014513:Ureter / Q000293:injuries*; D001743:Urinary Bladder / Q000293:injuries*
keywords: Cystoscopy; Laparoscopic hysterectomy; Urinary tract injury