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Revisiting Urological Injury Risks in Minimally Invasive Hysterectomy for Benign Indications: A Rare-Events Network
Chiara Cassani1,2, Arsenio Spinillo3,4, Mattia Dominoni4
1Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy. chiara.cassani@unipv.it.
Introduction And Hypothesis:
The surgical approach to hysterectomy influences the risk of urological injuries, but the optimal technique for minimizing this risk remains unclear. Our objective was to evaluate, through a network meta-analysis (NMA) of randomized controlled trials (RCTs), the risk of intraoperative bladder and ureteral injuries among different hysterectomy techniques.
Methods:
We systematically searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Google Scholar, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and European Clinical Trials Register (inception to 15 January 2025) for RCTs. NMA and pairwise meta-analyses were performed using penalized logistic regression and Bayesian models, accounting for rare events.
Results:
Out of 170 screened records, 63 RCTs involving 7470 women were included. Sixty-nine bladder injuries (9.2 out of 1000), 23 ureteral injuries (3.1 out of 1000), and 96 combined injuries (12.9 out of 1000) were reported. Compared with abdominal hysterectomy (AH), total laparoscopic hysterectomy (LH) showed a significantly higher risk of ureteral injury (odds ratio [OR] 7.74; 95% confidence interval [CI] 2.46-24.37), as did LH/laparoscopically assisted vaginal hysterectomy (LAVH; OR 7.73; 95% CI 2.42-24.7). LH and LH/LAVH also carried a higher risk of any urological injury than AH (OR 2.66 and 2.34 respectively). Estimated injury rates per 1000 were 9.5 (ureteral) and 18.1 (combined) for LH, versus 0.5 and 7.5 for AH. Meta-regression showed that the elevated risk with LH persisted over time.
Conclusions:
Laparoscopic hysterectomy and LH/LAVH are associated with a higher risk of ureteral/bladder injuries than AH. This increased risk has not declined over time, suggesting that the standardization and broader adoption of LH have not mitigated urological complications.
