ORLANDO – Injuring the bladder during a hysterectomy is associated with a greater likelihood of developing a postoperative vesicovaginal fistula, according to a retrospective analysis presented at the annual scientific meeting of the Society of Gynecologic Surgeons.
In data captured from 641,056 hysterectomies performed in California, New York, and Florida in 2005-2010, the odds ratio of a vesicovaginal fistula was nearly 19 times higher if a urinary tract injury was sustained at the time of hysterectomy, a complication that increased in frequency during the 5-year study period, reported Dr. Rony A. Adam, professor of obstetrics and gynecology in the division of female pelvic and reconstructive surgery at Vanderbilt University Medical Center, Nashville, Tenn.
“Although we do not know all the factors that impact formation of vesicovaginal fistula post hysterectomy, it is clear that bladder injury at the time of hysterectomy even when identified and repaired is significantly associated [with this complication],” Dr. Adam reported at the meeting, jointly sponsored by the American College of Surgeons.
The statistical analyses were conducted with the inpatient and ambulatory surgery databases from the Healthcare Cost and Utilization Project (HCUP) for the three states. The large geographically diverse populations were considered by the authors to be nationally representative.
For this analysis, vesicovaginal fistulas and urinary tract injuries were tracked for total abdominal hysterectomy, subtotal abdominal hysterectomy, and total vaginal hysterectomy with or without laparoscopic assistance. Over the 5-year study period, urinary tract injuries climbed steadily in all three groups. When the last year of analysis was compared with the first, a greater increase in odds ratio was observed in the total abdominal group (1.88) than in the subtotal (1.27) or the vaginal (1.26) groups, but each increase was significant.
“The uniformly increasing bladder injury rate may be explained by the increasing cesarean section rates,” according to Dr. Adam, who cited evidence suggesting that cesarean section increases risk of urinary tract injuries in subsequent hysterectomy.
The rate of vesicovaginal fistulas was 21.07 per 1,000 women when a urinary tract injury was incurred during hysterectomy versus 0.95 per 1,000 women when it was not (odds ratio, 18.91). The overall rate of vesicovaginal injury increased in the last year of the study relative to the first (OR, 1.28), although this increase fell just short of statistical significant (P = .059).
“It is possible that surgeons have gotten better at detecting and repairing urinary tract injury, which could explain why the vesicovaginal fistula rate has remained stable in the face of an increasing rate of urinary tract injuries,” Dr. Adam reported.
Not only did the rate of urinary tract injuries climb faster over the study period in those undergoing total abdominal hysterectomy, but also there was a stronger association in patients undergoing this form of hysterectomy between urinary tract injury and vesicovaginal fistula formation, said Dr. Adam. Overall, the OR for vesicovaginal fistula after urinary tract injury was about half as great when either subtotal or vaginal hysterectomy was compared to total abdominal hysterectomy
Although Dr. Adam emphasized that a retrospective study of this type can only establish an association and cannot confirm causation, he said that this study suggests urinary tract injury may be a useful quality-of-care measure for performance of hysterectomy. The SGS-invited discussant Dr. Blair Washington, a urogynecologist at Virginia Mason Hospital and Medical Center, Seattle, agreed.
“Characterizing morbidity associated with hysterectomy is increasingly important as we define benchmarks for quality outcomes in the changing health care economy,” Dr. Washington said. Calling this study “outstanding,” she suggested these data are potentially helpful for counseling patients about risks of hysterectomy, and identifying and evaluating strategies that will help to improve outcomes.
Dr. Adam reported no relevant financial disclosures.