Urinary Tract Injury During Benign Hysterectomy for Endometriosis: An NSQIP Study

STUDY OBJECTIVE: To determine an updated rate of urinary tract injuries at the time of hysterectomy after the widespread adoption of laparoscopy and cystoscopy, with attention to patients with endometriosis. DESIGN: Retrospective cohort. SETTING: Hospitals participating in the National Surgical Quality Improvement Program from 2018 to 2020. PATIENTS: Patients aged 18 to 55 years undergoing total hysterectomies performed for benign indications. INTERVENTIONS: Rates of urinary tract injuries were calculated for patients undergoing hysterectomy for benign indications with adjustment for previous pelvic surgery, laparoscopic surgical route, and lysis of adhesions. A secondary analysis of concurrent cystoscopy, timing of injury repair, and presence and location of endometriosis was conducted. Intended reconstruction vs accidental injury of the urinary tract cannot be distinguished in this database. MEASUREMENTS AND MAIN RESULTS: A total of 41 901 patients underwent hysterectomy for benign indications, 5268 (12.6%) for endometriosis. Rates of urinary tract injury ranged from 1.0% to 1.5%, including ureteral injury at 0.4% to 0.8% and bladder injury at 0.7%. Although cystoscopy was performed in 19.4% of cases, most urinary tract injuries (83.4%) were identified at the initial procedure. Ureteral injuries occurred most frequently during laparoscopic hysterectomy (0.8%) compared with other surgical routes (p <.001). There was a significant association between hysterectomy for endometriosis and urinary tract injury (2.4% vs 1.3%; odds ratio [OR], 1.83; 95% confidence interval [CI], 1.49-2.21; p <.001), including ureteral injury (1.8% vs 0.7%; OR, 2.8; 95% CI, 2.2-3.53; p <.001), but not bladder injury. After adjustment, there remained a significant association between endometriosis and ureteral injury (adjusted OR, 1.39; 95% CI, 1.08-1.78; p = .011). Compared with other locations, endometriosis on the urinary tract was significantly associated with urinary tract injuries (7.0% for urinary tract, 4.6% for bowel, 2.0% for genital tract/pelvis; p <.001). CONCLUSIONS: Overall rates of urinary tract injury are low, and delayed identification of injury is uncommon. Patients undergoing hysterectomy via the laparoscopic route or for endometriosis may be at a higher risk of urinary tract injury.