Laparovaginal hysterectomy has its main advantages over abdominal hysterectomy in the short term, with faster patient recovery and a quicker return to normal activity . LH, where the uterine vessels are secured endoscopically , can allow for more difficult cases to be performed endoscopically [7, 19]. There are those cases in which vaginal access is too inadequate to permit safe vaginal hysterectomy. This situation may pertain to nulliparous patients, to those who have only had Caesarean section deliveries, to patients with severe endometriosis with obliteration of the pouch of Douglas and/or adherent ovaries, or indeed patients with large uterine fibroid masses. Under these clinical circumstances a surgeon who performs only laparoscopically assisted vaginal hysterectomies (LAVH; in which the uterine vessels are secured vaginally ) may have to revert to an open operation, but with LH these potential AHs can mostly be performed endoscopically.
The recent Cochrane Review  on the different surgical approaches to hysterectomy for benign gynaecological diseases compares ureteric injuries from LH and AH, with the Review citing four published trials [21–25]. The Review found that the ureteric injury rate was higher with LH than AH (10 out of 796 vs. 1 out of 512) with OR of 3.83 (0.94, 15.57) .
Langebrekke et al.  reported two ureteric injuries in the LH arm in one hospital where the staff had had little training in LH prior to their trial. This prompted the authors to recommend: “a need for thorough training prior to embarking on such a technically advanced operation method.” Perino et al.  had one ureteric injury in the LH arm of their trial using bipolar diathermy.
In the trial by Lumsden et al. , 76 of the 95 patients in the LH arm had the “uterine arteries divided using the Endo GIA disposable stapling device” and yet the Review  classified the LHs in this trial as “non-categorisable”. The Review  makes important errors with regard to ureteric injuries in this trial by quoting two ureteric injuries in the LH arm and one in the AH arm (see Fig. 27 in ), whereas in fact there were no ureteric injuries after LH and two after AH. Of the two urinary tract injuries in the LH arm (see Table 3 in ), one was in fact a cystotomy and not a ureteric injury. The other ureteric injury was in a patient who, despite being randomised to the LH arm, “opted to have an AH after randomization but prior to being admitted for operation .” These corrections would give a cumulative relative risk of ureteric injury of LH compared with AH in these four trials [21–25] of 2.5.
Garry et al.  had five ureteric injuries in the LH arm of the abdominal trial, but “in this trial most of the procedures were of the LAVH type.” . Thus, most of the patients who were entered into the abdominal trial (rather than the vaginal trial) and then randomised to the LH arm, subsequently had laparoscopically assisted vaginal hysterectomies, fully justifying the classification of these LHs as “non-categorisable”  and indicating that the surgeons involved had little experience of LH. Garry et al. found that: “The method used to secure the blood vessel pedicles did appear to influence the rate of complications with the lowest risk apparently associated with securing vascular pedicles with diathermy or staples rather than sutures .”
Makinen et al.  in a review of 10,110 hysterectomies in Finland found that ureteric injuries at laparoscopic hysterectomy were 4.4 times more common with surgeons who had performed 30 procedures or fewer than with surgeons who had performed more than 30 (incidence: 2.2 vs. 0.5%). Wattiez et al.  had significantly more renal tract injuries in their first 695 laparoscopic hysterectomies than in the subsequent 952, with ureteric injuries falling by almost two-thirds from 0.58 to 0.21%. These results along with those from the trials [21–25] and our data would indicate that surgical inexperience and technique development are major factors in ureteric injury at LH.
Our series of LHs using the cutter stapling device to secure the uterine vessel pedicles reports only one ureteric injury as a result of this technique in the last 1,000 cases. Our overall ureteric injury rate for the last 1,000 cases was 0.20% and that of Wattiez et al. of 0.21% in their latter 952 cases compared favourably with the reported rates in AH of 0.24% from western Sydney , 0.20 and 0.40% from Finland [26, 29], and 0.39% overall for all the AHs performed in the above reported trials [21–25].
In conclusion, we suggest that in experienced hands and with a perfected technique the ureteric injury rate is no higher for LH than for AH, even with more difficult cases and with low conversion rates to AH [7, 19].
None of the above trials [21–25] implicates staples as a cause of ureteric injury at LH. The ureteric injury rate in the latter 952 cases of the French series , in which bipolar diathermy was used, was virtually the same as in our latter 1,000 cases with staples, leading us to conclude that the ureteric injury rate at LH in experienced hands using staples to secure the uterine vessels is similar to that when bipolar diathermy is used.