Peroperative bladder injury during hysterectomy for benign disorders

The bladder is a common site of injury during hysterectomy for benign disorders 123. Investigations have shown that endometriosis and previous surgery such as cesarean section are risk factors, as well as some operative methods, for instance laparoscopic assisted vaginal hysterectomy (23). However, few studies have focused primarily on bladder injuries. The aim of the present study was to investigate the risk factors for peroperative bladder injury during hysterectomy for benign disorders. Since 1997 the Gynecology Departments at the Central Hospitals in Herning, Holstebro and Silkeborg, Denmark, have reported data from all hysterectomies to a regional database. The database contains information on the incidence of hysterectomy, previous gynecologic surgery and previous cesarean section, body mass index (BMI), mode of hysterectomy, additional surgery, amount of bleeding, duration of surgery, presence of preoperative complications, uterine weight, per- and postoperative complications and duration of hospital stay. A complication is defined as an unintended condition requiring additional therapy. A follow-up questionnaire was sent to all women in the database 4 months after the hysterectomy. The questionnaire provided information on their well-being, pelvic and abdominal pain, bladder and bowel function, and whether they have been admitted to a hospital postoperatively (4). A study group of 2855 women was selected after the following criteria: hysterectomy because of meno-metrorrhagia, pelvic relaxation, endometriosis, adenomyosis or uterovaginal prolapse. Women with a malignant histology were excluded. Vaginal hysterectomy is the routine first-line treatment. Abdominal hysterectomy is performed when the patient has a history of endometriosis, intraperitoneal adhesions, nullipara and having a fixated uterus or a uterus expected to weight more than 400 g. Information on peroperative bladder injuries was extracted. We compared women with peroperative bladder injury to women without bladder injury after hysterectomy for benign disorders. We also compared women who had previously had a cesarean section, colposuspension ad modum Burch, prolapse surgery, conisatio, BMI > 30kg/m2, gynecologic laparotomy, vaginal birth, and the size of the uterus with the surgical outcome of hysterectomy for benign conditions. The vesico-vaginal fistula was not represented in the study. The data in Table I were tested with the χ2-test or Fisher's exact test if any number was less than six. Association was tested with stepwise manual regression, with bladder injury as the dependent variable and the continuous variables as independent variables. The statistical software package SOLO (distributed by BMPD, Statistical Software, Los Angeles, California, USA) was used for analysis. A two-sided p < 0.05 was used as the level of significance. In the study group 1752 women had an abdominal hysterectomy and 1103 women had a vaginal hysterectomy. Forty-four of these 2855 (1.54%) women had a bladder injury during hysterectomy for benign disorders. Bladder injuries were associated with vaginal hysterectomy (p < 0.02) and previous cesarean section (p < 0.01), as shown in Table I. There was no statistically significant correlation with endometriosis, prolapse surgery or urogynecologic surgery. All injuries to the bladder were recognized primarily and repaired during surgery. The bladder is vulnerable to injury during hysterectomy because of its close developmental proximity to the uterus, cervix and anterior fornix of the vagina. Vaginal hysterectomy has increased the numbers of injuries to the base of the bladder (7). It is essential to avoid bladder injury, and when the bladder is injured it is important not to perform fast track surgery. The bladder has a rich collateral blood supply and will easily heal when opened. Therefore, it is important to identify any bladder injuries during surgery and to repair them immediately. In the present study we found an overall prevalence of bladder injuries of 1.54% during different modes of hysterectomy for benign disorders. There was a statistical significance between bladder injury and vaginal hysterectomy (p < 0.02) and previous cesarean section (p < 0.01). Studying the literature there is an incidence of bladder injuries after hysterectomy of 0.9–1.70% (1–3,5–7). Mathevet et al. found in 3076 women who had vaginal hysterectomies for benign indications that previous cesarean section was the only significant factor associated with bladder injuries. They concluded that bladder injury during vaginal hysterectomy is relative rare (1). This is in accordance with our results. Other studies have shown that previous pelvic surgery, endometriosis, nulliparity and uterine size are risk factors (1,2,5). Cosson et al. studied 1604 patients and they recommended that a high-risk population should be defined based on the patient history of pelvic surgery, endometriosis and parity (2). Injury to the bladder during hysterectomy is unpredictable but it is statistically significant and correlated with the vaginal route and previous cesarean section. However, injury is rare and the benefit of the surgical outcome is high in relationship to the vaginal approach (3,5). In conclusion, we found a significant prevalence of bladder injuries after vaginal hysterectomy for benign disorders and in women who had previously had a cesarean section. We conclude that injuries are rare but do happen regularly. The surgical route should be selected in accordance with the patient and her history of cesarean section.