Letter to the editor: Regarding 'Preventing ureteral injury at hysterectomy: an expert approach'

TO THE EDITOR:

Dr. Magrina’s article on ureteral injuries during hysterectomy [Preventing ureteral injury at hysterectomy: an expert approach, October 2014 Contemporary OB/GYN] was very informative. However, I think stating that the risk of ureteral injury is higher for vaginal hysterectomy (VH) was misleading. The reference for this information was a report from Mayo Clinic in Rochester, Minnesota.¹ The population of this study was highly skewed for pelvic floor disorders and included women who had already undergone hysterectomy. It was actually a descriptive analysis of all ureteral injuries during all major pelvic operations for benign conditions over 6 years. They identified 18 such cases and reported a 0.33% ureteral injury rate.¹ An overwhelming 16 of these occurred during vaginal reconstructive procedures (13 cases included VH) but exclusively in cases performed for correction of pelvic organ prolapse (POP) and urinary incontinence as a result of placement of uterosacral suspension sutures for a high McCall procedure or elevation of the bladder neck. High uterosacral suspension, which is known to cause intraoperative ureteral occlusion in up to 11% of the cases,² is not indicated during a simple vaginal hysterectomy if there is no POP. One must bear in mind that only a small fraction of all hysterectomies are performed for prolapse.

According to the most recent meta-analysis by the Cochrane Library on all hysterectomy routes, no statistically significant differences in bladder, ureter, or urinary tract injuries were noted between VH and abdominal hysterectomy (AH).³ There was a greater than 2-fold increased risk of urinary tract injury (bladder and ureter injuries were pooled together, as the combined sample size was too small to detect a statistical difference) for laparoscopic hysterectomy (LH) versus AH but no difference between LH and VH. Among different types of LH techniques such as laparoscopic total (TLH), supracervical and laparoscopically assisted vaginal hysterectomy, specifically TLH was found to increase the risk of urinary tract injuries over 3-fold when compared to VH.

References

1. Stanhope CR, Wilson TO, Utz WJ, Smith LH, O’Brien PC. Suture entrapment and secondary ureteral obstruction. Am J Obstet Gynecol. 1991;164:1513–1517.

2. Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC. Bilateral uterosacral ligament vaginal vault suspension with site-specific endopelvic fascia defect repair for treatment of pelvic organ prolapse. Am J ObstetGynecol. 2000;183:1402–1411.

3. Nieboer TE^, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2009;3:CD003677.

Oz Harmanli, MD

Springfield, MA

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IN REPLY:

Dr. Harmanli indicates in his letter that in my article, "Prevention of ureteral injury at hysterectomy: an expert approach,” I misquoted Dr. Stanhope's results of ureteral obstruction¹ in saying that the rate of ureteral obstruction after vaginal hysterectomy is higher than abdominal hysterectomy, and he finds this misleading.

Dr. Harmanli is incorrect in his letter. Dr. Stanhope reported a rate of ureteral obstruction of 0.07% for 2833 abdominal hysterectomies, while the rate of ureteral obstruction after vaginal hysterectomy was 9 times higher: 0.63% for 2546 vaginal hysterectomies.¹ While the rate may be higher, lower, or similar in other reports, this was not the case in that study.

Javier F. Magrina, MD

Reference

1. Stanhope CR, Wilson TO, Utz WJ, Smith LH, O'Brien PC. Suture entrapment and secondary ureteral obstruction. Am J Obstet Gynecol. 1991;164:1513–1517.