Skip to main content
SpringerLink
Log in

Incidental urinary tract injury and the formation of vesicovaginal fistula at the time of hysterectomy for benign indications

  • Original Article
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

Introduction and hypothesis

The association between hysterectomy type, laparoscopy use and vesicovaginal fistula (VVF) is currently unclear and would be useful to determine route of surgery and provide adequate patient counseling. The objective of this study was to evaluate the magnitude of association between the use of laparoscopic assistance, recognized intraoperative urinary tract injury and subsequent VVF repair and to quantify any differences in fistula repair and injury detection by hysterectomy type. Lastly, we sought to determine whether the type of hysterectomy is a risk factor for VVF repair independent of injury identification.

Methods

We performed a retrospective cohort study utilizing the Healthcare Cost and Utilization Project database examining benign hysterectomies performed in California, New York and Florida from 2005–2011. Multivariable logistic regression models were used to evaluate associations among hysterectomy type, reported injury and VVF.

Results

Of 581,395 eligible hysterectomies, urinary tract injuries occurred in 6702 patients (1.15%) and 640 patients developed VVF (0.11%). Patients with reported injury were 20-fold more likely to develop VVF than those without (OR = 20.6; 1.96% vs. 0.089% respectively). The association between reported injury and VVF development was stronger if laparoscopy was involved (OR = 30) than if it was not (OR = 17). Patients undergoing laparoscopic procedures were less likely to have injury reported (OR = 0.6) but more likely to undergo VVF repair (OR = 1.5). This association with VVF repair was independent of injury identification. Patients developing VVF were more likely to have undergone total abdominal hysterectomy compared to other hysterectomy types.

Conclusions

Laparoscopy is an independent risk factor for the need for subsequent VVF repair, independent of hysterectomy type and presence of intraoperatively recognized urinary tract injury.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Hilton P, Ward A. Epidemiological and surgical aspects of urogenital fistulae: A review of 25 years’ experience in southeast Nigeria. Int Urogynecol J. 1998;9(4):189–94. https://doi.org/10.1007/BF01901602.

    Article  CAS  Google Scholar 

  2. Goodwin WE, Scardino PT. Vesicovaginal and ureterovaginal fistulas: a summary of 25 years of experience. J Urol. 1980;123(3):370–4. https://doi.org/10.1016/S0022-5347(17)55941-8.

    Article  CAS  Google Scholar 

  3. Lee RA, Symmonds RE, Williams TJ. Current Status of Genitourinary Fistula. Obstet Gynecol. 1988;72(3):313–9.

    CAS  Google Scholar 

  4. Tancer ML. Observations on prevention and management of vesicovaginal fistula after total hysterectomy. Surgery, Gynecol Obstet. 175(6):501–6. https://pubmed.ncbi.nlm.nih.gov/1448730/.

  5. Mathevet P, Valencia P, Cousin C, Mellier G, Dargent D. Operative injuries during vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol. 2001;97(1):71–5. https://doi.org/10.1016/S0301-2115(00)00484-X.

    Article  CAS  Google Scholar 

  6. Forsgren C, Lundholm C, Johansson ALV, Cnattingius S, Altman D. Hysterectomy for benign indications and risk of pelvic organ fistula disease. Obstet Gynecol. 2009;114(3):594–9. https://doi.org/10.1097/aog.0b013e3181b2a1df.

    Article  Google Scholar 

  7. Hilton P, Cromwell D. The risk of vesicovaginal and urethrovaginal fistula after hysterectomy performed in the English National Health Service—a retrospective cohort study examining patterns of care between 2000 and 2008. BJOG Int J Obstet Gynaecol. 2012;119(12):1447–54. https://doi.org/10.1111/j.1471-0528.2012.03474.x.

    Article  CAS  Google Scholar 

  8. Dallas KB, Rogo-Gupta L, Elliott CS. Urologic Injury and Fistula After Hysterectomy for Benign Indications. Obstet Gynecol. 2019;134(2):241–9. https://doi.org/10.1097/aog.0000000000003353.

    Article  Google Scholar 

  9. Duong TH, Gellasch TL, Adam RA. Risk factors for the development of vesicovaginal fistula after incidental cystotomy at the time of a benign hysterectomy. Am J Obstet Gynecol. 2009;201(5):512.e1–4. https://doi.org/10.1016/j.ajog.2009.06.046.

    Article  Google Scholar 

  10. Harkki-Siren PIH, Berg JS, Kurki T. Major complications of laparoscopy: A follow-up finnish study. Obstet Gynecol. 1999;94(1):94–8. https://pubmed.ncbi.nlm.nih.gov/10389725/.

  11. Härkki-Sirén P, Sjöberg J, Tiitinen A. Urinary Tract Injuries After Hysterectomy. Obstet Gynecol. 1998;92(1):113–8. https://doi.org/10.1016/S0029-7844(98)00146-X.

    Article  Google Scholar 

  12. Adelman MR, Bardsley TR, Sharp HT. Urinary Tract Injuries in Laparoscopic Hysterectomy: A Systematic Review. J Minim Invas Gyn L. 2014;21(4):558–66. https://doi.org/10.1016/j.jmig.2014.01.006.

    Article  Google Scholar 

  13. HCUP-US Databases. Accessed April 26, 2021. https://www.hcup-us.ahrq.gov/databases.jsp.

  14. Teeluckdharry B, Gilmour D, Flowerdew G. Urinary Tract Injury at Benign Gynecologic Surgery and the Role of Cystoscopy: A Systematic Review and Meta-analysis. Obstet Gynecol. 2015;126(6):1161–9. https://doi.org/10.1097/AOG.0000000000001096.

    Article  Google Scholar 

  15. Hesselman S, Bergman L, Högberg U, Jonsson M. Risk of fistula formation and long-term health effects after a benign hysterectomy complicated by organ injury: A population-based register study. Acta Obstet Gynecol Scand. 2018;97(12):1463–70. https://doi.org/10.1111/aogs.13450.

    Article  Google Scholar 

  16. Aarts JW, Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Gynaecology and Fertility Group, ed. Cochrane Database of Systematic Reviews. Published online August 12, 2015. https://doi.org/10.1002/14651858.CD003677.pub5.

Download references

Funding

Dr. Ayush Giri was a scholar of the Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) program [2K12HD043483 (PI: Katherine Hartmann)] and a recipient of the NIDDK Research Scientist Development Award [1K01DK120631-01A1] when this work was performed.

Author information

Authors and Affiliations

  1. Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA

    Brandy M. Butler & Rony A. Adam

  2. Division of Quantitative Sciences, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA

    Ayush Giri

  3. Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA

    Ayush Giri

Authors
  1. Brandy M. Butler
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rony A. Adam
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ayush Giri
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

BM Butler: literature review, manuscript writing/editing

RA Adam: project design, manuscript editing

A Giri: project design, analysis, manuscript writing/editing

Corresponding author

Correspondence to Ayush Giri.

Ethics declarations

Conflict of interest

None.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendices

Appendix A

Table 6

Table 6 ICD-9 and CPT codes used to define hysterectomy, bladder repair and fistula repair procedures
Full size table

Appendix B

Gynecologic malignancy diagnostic and procedural codes used to exclude cases that involved gynecologic malignancy.

ICD-9 Gynecologic Malignancy diagnostic codes

179 Malignant neoplasm of uterus, part unspecified

180.xx Malignant neoplasm of cervix uteri

182.xx Malignant neoplasm of body of uterus

183.xx Malignant neoplasm of ovary and other uterine adnexa

184.xx Malignant neoplasm of other and unspecified female genital organs

233.1 Carcinoma in situ of cervix uteri

233.2 Carcinoma in situ of other and unspecified parts of uterus

ICD-9-CM procedure codes

68.6x Radical abdominal hysterectomy

68.7x Radical vaginal hysterectomy

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Butler, B.M., Adam, R.A. & Giri, A. Incidental urinary tract injury and the formation of vesicovaginal fistula at the time of hysterectomy for benign indications. Int Urogynecol J 34, 391–398 (2023). https://doi.org/10.1007/s00192-022-05367-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00192-022-05367-3

Keywords

Search

Navigation