Surgical Outcomes and Complications of Total Laparoscopic Hysterectomy in Patients with a Surgical History of Cesarean Section

A 2015 Cochrane review reported that the risk of vesicoureteral injury was significantly higher with laparoscopic hysterectomy (LH) than with total abdominal hysterectomy (TAH) in cases of benign gynecologic disease.[ 1 ] Another study in 2020 compared the incidence of vesicoureteral injuries in TAH with those in minimally invasive surgery.[ 2 ] The overall incidence was 0.21%, and the incidence of ureteral injury was significantly higher in total LH (TLH) than in TAH, while that of bladder injury was similar between the 2 groups.[ 2 ] In addition, although the number of births has been declining in recent years, the cesarean section (CS) rate has been rising,[ 3 ] and with the increasing popularity of LH, especially TLH,[ 4 ] the number of TLH procedures performed in patients with a history of CS is expected to increase. In this study, we evaluated the surgical outcomes and complications in cases of TLH performed at our hospital and compared them according to whether or not patients had a history of CS. In addition, we present the case of bladder injury that occurred in a patient with 3 previous CSs and discuss how to avoid bladder injury in individuals with a history of CS.

Figure 1 shows the annual changes in the number of TLHs performed from 2013 to 2023, according to the number of previous CSs. The total number of TLHs increased during the study period and of the 609 TLHs performed, 92 (15.1%) were for patients with a history of CS. The number of patients with prior CSs was as follows: 58 (9.5%) with 1 CS, 27 (4.4%) with 2 CSs, 6 (1.0%) with 3 CSs, and 1 (0.16%) with 4 CSs. Annual change in the number of total laparoscopic hysterectomy (TLH) procedures according to the number of previous cesarean sections (CSs) (0–4). Of the 609 TLH procedures overall, there were 92 patients (15.1%) in the CS group and seven patients (1.15%) with ≥3 CSs. CSs: Cesarean sections, TLH: Total laparoscopic hysterectomy Among patients who underwent TLH, we compared the backgrounds of those with or without previous CSs. The results are shown in Table 1 . There were no significant differences between the two groups regarding factors that could influence TLH outcomes, such as body mass index, parity, type of surgery (concurrent adnexal surgery), and the histopathological diagnosis of the excised material. There was a significant difference between the two groups in the number of vaginal deliveries. Comparison of the patient background between the noncesarean section and cesarean section groups *Others: Pyometra: 2, Adenomatoid tumor: 2, Adenomyoma: 2, hydatidiform mole: 1. There were no significant differences in patient background between the non-CS and CS groups except in the number of vaginal deliveries. BMI: Body mass index, TLH: Total laparoscopic hysterectomy, CS: Cesarean section, CIN: cervical intraepithelial neoplasm, CIS: carcinoma in situ, AIS: adenocarcinoma in situ The surgical outcomes of the 517 patients without a history of CS and the 92 with such a history are shown in Table 2 . For the non-CS and CS groups, the mean blood loss during surgery, mean operative time, and mean weight of the resected uterus showed no significant differences. Comparison of the surgical outcomes between the noncesarean section and cesarean section groups There were no significant differences in surgical results between the non-CS and CS groups. NS: Not significant, CS: Cesarean section The number of major complications in the CS group, non-CS group, and the group of patients with ≥3 previous CSs (≥3 CS group) are shown in Table 3 . Overall TLH complications included VCD in four patients, bladder injury in 1, and blood loss of ≥500 mL in 12. There were no cases of ureteral or bowel injury. Bladder injury occurred in one patient with 3 previous CSs. Although there was no significant difference in the incidence of bladder injury between the CS and non-CS groups, there was a significant difference between the ≥3 CS and non-CS groups. Comparison of the number of complications occurring in the noncesarean section and cesarean section groups Bladder injury was significantly more common in the ≥3 CS group compared with the non-CS group. NS: Not significant, CS: Cesarean section The patient who sustained a bladder injury had multiple uterine fibroids and a chief complaint of hypermenorrhea and had a history of 3 CSs. Surgery revealed that the bladder was elevated cranially due to adhesions [ Figure 2a1 ]. Although the surgeon thought that he had made a routine incision in the vesicouterine peritoneal fold, in fact he incised the peritoneum over the displaced bladder [ Figure 2a2 ] and continued the dissection while mistaking the bladder for the cervical wall [ Figure 2a3 ]. This caused damage that reached the bladder lumen [ Figure 2a4 ]. After the injury was confirmed, the bladder was detached at the correct layer, the TLH was completed, and the repair was performed laparoscopically in the presence of an urologist. The damaged area was sutured in 2 layers of 2-0 absorbable thread, and the absence of urine leakage was confirmed. The operative time was 187 min; the intraoperative blood loss was 15 mL; and the weight of the uterus was 112 g. After the operation, a Foley catheter was left in for 7 days, and the patient was discharged after cystoscopy confirmed that there were no abnormal findings at the surgical site. The postoperative course after the discharge was favorable. Bladder injury case (a1-a4) and the intravesical air inflation technique (b1-b4). (a1-a4) The bladder was elevated in the cranial direction due to adhesions (a1). The vesicouterine peritoneal fold was incised, and the bladder, which was placed below the peritoneum, was misrecognized for the uterine cervix and the dissection was continued (a2 and b3). This led to bladder injury that reached the bladder lumen (a4). *The bladder wall that was misrecognized for the uterine cervix. Yellow arrow: Bladder injury that has reached the bladder lumen. (b1-b4) Intravesical air inflation technique. Adhesions caused by 2 previous cesarean sections resulted in bladder elevation in the cranial direction (b1). One hundred milliliters of air was inserted into the bladder (b2). Two hundred milliliters of air was inserted into the bladder (b3 and b4). White arrows: Cranial margin of the bladder, which became clearer with air inflation. CSs: Cesarean sections

It was previously demonstrated that the incidence of ureteral injury was increased in TLH compared with TAH and VH, whereas the incidence of bladder injury was similar among these 3 procedures. However, studies showed that the incidence of bladder injury was higher in patients with a history of CS, especially those with ≥3 CSs. The results of this study confirmed that compared with the non-CS group, bladder injury was significantly more common in the ≥3 CS group, but not in the CS group. In recent years, the number of TLH cases has increased markedly [ Figure 3a ], and the CS rate is on the rise [ Figure 3b ]; thus, it is thought that TLH in patients with a history of CS will become even more common in future. Although bladder injury is a complication with a relatively good prognosis, it is critical to be aware of its risk in patients with a history of CS, especially those with multiple previous CSs. It is also important to devise the ways to prevent this complication, such as the “intravesical air inflation technique,” as well as to provide sufficient informed consent before surgery. Data collection and analysis were performed by all the authors Yazawa H, Ojima TS, Yazawa R, Anjo K. The first draft of the manuscript was written by Yazawa H and all authors read and approved the final manuscript. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. There are no conflicts of interest.

In 2010, our hospital began transitioning from Laparoscopically Assisted Vaginal Hysterectomy (LAVH) to TLH. TLH became the standard surgical procedure in 2013, and in this study, we compared the surgical outcomes and complication rates in 609 cases of TLH performed between 2013 and 2023 in patients with and without a history of CS. The rapid increase in the popularity of LH has been remarkable, and the results of a questionnaire survey by the Japanese Society of Endoscopic Surgery (based on case registration and complication reports by the Japanese Society of Gynecologic Endoscopy) showed that over the 15-year period from 2006 to 2021, the number of LH procedures (LAVH + LH/TLH) increased by approximately 14 times, and that of TLH/LH procedures increased by approximately 48 times [ Figure 3a ]. Annual trends in the number of laparoscopic hysterectomy/total laparoscopic hysterectomy precedsures (a), deliveries, and cesarean sections (b) in Japan. *Nationwide Survey of Endoscopic Surgery in Japan, 9 th –16 th (2006–2021), Japan Society for Endoscopic Surgery website. **Ministry of Health, Labour and Welfare of Japan website There have been several studies on the incidence of complications from total hysterectomy performed for benign diseases. A 2015 Cochrane review reported that compared with TAH, LH was associated with a significantly higher risk of ureterovesical injury (but not either ureteral injury or bladder injury alone).[ 1 ] Another large-scale study in 2020 that accumulated a total of over 500,000 cases, the incidence of vesicoureteral injury in minimally invasive surgery (TLH, LAVH, total vaginal hysterectomy: TVH, etc.) and TAH were compared.[ 2 ] In that article, the overall incidence of vesicoureteral injury in total hysterectomy was 0.21% (1045/501,110 cases), and the incidence according to surgical procedure decreased in the following order: LAVH (0.28%) > TLH (0.24%) > TVH (0.24%) > TAH (0.20%). In addition, the incidence of ureteral injury differed from that of bladder injury: Ureteral injury occurred in the order of TLH (0.13%) > LAVH (0.06%) > TVH (0.06%) > TAH (0.04%), while bladder injury occurred in the order of LA VH (0.23%) > TVH (0.20%) > TAH (0.16%) > TLH (0.12%). It was also reported that the incidence of ureteral injury was significantly higher in TLH than in TAH, but the incidence of bladder injury was similar in the two procedures.[ 2 ] Furthermore, the study found that while risk factors for ureteral injury included endometriosis-related adhesions and ureteral displacement caused by large uterine fibroids, no relationship was found with previous CS history.[ 2 ] However, a 2010 study of 574 TLH cases comparing complication rates between non-CS and CS groups (CS rate: 24.6%) found that the incidences of bladder injury were 1.2% and 5.0% in the non-CS and CS groups, respectively, indicating a significant increase ( P < 0.05);[ 6 ] in particular, among individuals that had undergone at least 3 CSs, the incidence was 21.1%, an increase of about 18 times. That study also reported that the rate of conversion to laparotomy was significantly higher in the CS group (10.6%) than in the non-CS group (5.5%).[ 6 ] On the other hand, a 2017 paper comparing the surgical outcomes of 482 patients who underwent TLH and who were divided into non-CS and CS groups (CS rate; 32.8%) showed that the operative time was significantly longer in the CS group (+7 min) than in the non-CS group, but there was no significant difference in the incidence of bladder injury, bowel injury, or VCD.[ 7 ] Similarly, another study comparing 505 patients in non-CS and CS groups (CS rate; 11.7%) who underwent TLH found no significant difference in surgical outcomes or complication rates,[ 8 ] and it has been reported that TLH can be performed safely even in patients with a history of CS.[ 7 8 ] Among 609 patients in our hospital who underwent TLH (CS rate; 15.1%), there was no significant difference in surgical outcomes or complication rates between the non-CS and CS groups, but when analyzed by the number of CSs, the incidence of bladder injury was significantly higher in the ≥3 CS group. These results suggest that while a previous CS does not necessarily confer an increased risk of complications, the risk of bladder injury is increased in cases of with 3 or more previous CSs. In general and consistent with the experience at our hospital, if bladder injury is recognized during surgery and repaired appropriately, the prognosis is favorable. Therefore, TLH is recommended even in patients with a history of CS, but it should be recognized that the occurrence of TLH-related complications is higher among patients with a history of ≥3 CSs, and this may be an important factor in obtaining informed consent preoperatively.[ 6 ] While there is also the option of choosing open surgery for patients with ≥3 previous CSs, we believe that TLH should be selected according to indications other than CS history, because the number of CS procedures does not necessarily increase the strength of adhesions, and open surgery does not necessarily avoid bladder injury. Depending on the surgeon’s experience and skill of laparoscopic surgery, it is crucial to be able to rapidly transition to open surgery when necessary. One of the complications of TLH is VCD, and we experienced 4 cases of VCD in this study (0.65%). The incidence of vaginal dehiscence after TLH has been reported to be 0.65% to 5.4%, which is significantly higher than that after TAH or TVH.[ 9 ] It has also been reported that VCD following laparoscopic surgery is significantly less common when the vaginal cuff is sutured vaginally than when it is sutured laparoscopically.[ 9 10 ] The main risk factors for VCD include vaginal atrophy, radiation therapy, early resumption of sexual intercourse, and postoperative infection. In terms of surgical techniques, risks of tissue damage include inadequate suturing of the vaginal wall and excessive electrocoagulation when cutting the vaginal wall and achieving hemostasis after the incision, but it has been reported that most cases occur without any identifiable predisposing factors.[ 10 ] In addition, there is no evidence to suggest that a history of CS is a risk factor for VCD.[ 7 ] Similarly, there were no known causes for the four cases of VCD in this study, but 3 of the 4 cases occurred in the early phase after TLH was introduced at our hospital; thus, it is not possible to rule out causative factors related to techniques involved in vaginal wall incision, hemostasis, or suturing. We also confirmed that the frequency of VCD was not higher among patients with a history of CS than among those without. The incidence of bowel injury in laparoscopic total hysterectomy was reported to be 0.39% in 2 articles.[ 11 12 ] By technique, it was significantly higher in LH and AH compared with VH, and by indication for surgery, it was significantly higher in surgeries performed for endometriosis compared with other indications (myoma, menstrual abnormalities, and prolapse of pelvic organs).[ 11 ] There is no evidence that a history of CS increases the risk of bowel injury. The mortality rate of bowel injury is very low, and all reported fatalities involved delayed diagnosis, with the injury not identified intraoperatively.[ 12 ] The bladder injury case was performed by an experienced gynecologist who had performed approximately 500 TLH procedures up to that point in time, and it was not thought to have been caused by inexperience in surgical technique. Since our experience with this case, we have made several additional refinements to the bladder separation maneuver and have taken a more careful approach. When necessary, we have started using techniques to prevent bladder injury during bladder separation in patients with a history of CS, such as starting the separation from the lateral side where the effect of adhesions is lower, and the “intravesical air inflation technique,” which involves injecting air into the bladder. In particular, we strongly feel that the latter technique is useful for preventing bladder injury by making the cranial border of the bladder easier to identify [ Figure 2b1 - 4 ].

In 609 TLHs performed from 2013 to 2023 at Fukushima Red Cross Hospital, surgical outcomes and the number of complications were compared according to the presence or absence of a history of CS and the number of previous CSs. The choice between TLH or TAH was determined on an individual basis by taking into account the uterine size and shape, possibilities of malignancy and adhesions, patient condition and wishes, and other factors. As far as uterine size, on the basis of our experience, we proposed TLH as the first choice in patients with an estimated uterine weight of ≤500–600 g. The presence or absence of a history of CS was not a criterion for selecting the surgical procedure (TLH or TAH). At our hospital, the TLH procedure during the study period was as follows. Four trocar ports were placed in a diamond pattern. The uterus was controlled using a Uterine manipulator ® (ATOM MEDICAL, Tokyo, Japan) inserted just before the operation began. First, the vesicouterine peritoneal fold was opened, and using sharp incision and blunt dissection, the bladder was fully detached from the uterine cervix in the direction of the foot. The upper uterine ligaments were then dissected using an energy-sealing device. In all cases, the ureter and uterine arteries were identified in the retroperitoneal space. The cardinal ligament was ligated and dissected using an energy-sealing device. The uterovaginal canal was incised using a monopolar electrosurgical knife. The uterus was placed in a collection bag within the abdominal cavity and then extracted transvaginally with cut-down. The vaginal cuff was closed laparoscopically with 1 layer of single-knot sutures with 0 Vicryl. Finally, the retroperitoneum was partially closed with continuous sutures with 2-0 Vicryl. Cystoscopy was performed and urinary flow from the bilateral ureters was confirmed after the vaginal cuff was sutured.[ 5 ] We compared the operative time, intraoperative blood loss, weight of the removed uterus, and complications (bladder injury, ureter injury, bowel injury, vaginal cuff dehiscence [VCD], intraoperative blood loss >500 mL, and transition to laparotomy) between patients with or without previous CSs. Statistical analysis was performed using the t -test and Chi-square test. P < 0.05 was considered statistically significant. This retrospective study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Fukushima Red Cross Hospital (approval number: 2022-68). Informed consent for the future use of medical records in scientific research was obtained from all the participants at the time of admission.