The Role of Intraoperative Cystoscopy in Preventing Delayed Diagnosis of Urinary Tract Injury in a Single-Center Cohort of 11,310 Patients Undergoing Hysterectomy

INTRODUCTION: Urinary tract injuries are rare but known complications of hysterectomy. When these injuries go unrecognized intraoperatively, they impair the patient's quality of life with potentially devastating long-term complications. The role of universal intraoperative cystoscopy in timely recognition of urinary tract injuries during hysterectomy is still a debate. OBJECTIVE: The objective of this study is to assess the role of intraoperative cystoscopy in detection of urinary tract injuries in patients undergoing hysterectomy with a focus on those cases with delayed diagnosis. METHODS: In this retrospective cohort study, electronic medical records of patients undergoing hysterectomy for benign and malignant indications at a single institution from January 2013 to December 2021 were reviewed in detail. The primary outcome was the rate of urinary tract injuries with delayed diagnosis—those injuries detected after the hysterectomy was completed. The record review included the 6-month period after hysterectomy. RESULTS: A total of 11,310 women were included. Hysterectomy route was abdominal (18.3%), laparoscopic (26.6%), robotic (39.1%), vaginal (11.2%), and laparoscopy-assisted vaginal (4.8%). Overall, 4,635 women (41%) underwent cystoscopy during the hysterectomy. Cystoscopy was performed in 18.4% of abdominal, 46.7% of laparoscopic, 37.2% of robotic, 72.7% of vaginal, and 51.3% of laparoscopy-assisted vaginal hysterectomies. The use of cystoscopy increased significantly from 2013 (3.6%) to 2021 (16.4%) (p<0.001). Median length of surgery was increased by 30 minutes in hysterectomies where cystoscopy was performed (160 vs 130 minutes, p<0.001). Overall, there were a total of 136 urinary tract injuries (1.2%), of which 35 (25.7%) were detected by cystoscopy, 76 (55.9%) with intraoperative inspection, and 25 (18.4%) postoperatively. The sensitivity of cystoscopy was 83.3%. Among 25 urinary tract injuries detected postoperatively, 6 (24.0%) were vesical and 21 (84.0%) were ureteral injuries, while 2 patients had both ureteral and vesical injuries. Of those 25 patients, 7 underwent intraoperative cystoscopy with normal findings and 18 had no cystoscopy. The median time to diagnosis was 14 days (interquartile range: 3.5–56). The rate of postoperatively detected urinary tract injuries was similar between patients who underwent cystoscopy during hysterectomy and those who did not (0.2% vs 0.3%, p=0.186). In patients with postoperatively detected urinary tract injuries, abdominal route (56.0% vs 18.2%, p<0.001) and indication of endometriosis (16.0% vs 3.3%, p<0.001) were more common compared to patients without postoperatively detected urinary tract injuries. Patients with postoperatively detected urinary tract injuries also had higher concomitant salpingo-oophorectomy rates during hysterectomy compared to those without (76.0% vs 51.7%, p=0.015). To delineate the significant independent predictors of postoperatively detected urinary tract injuries, a multivariate logistic regression analysis was done with the variables of age, BMI, intraoperative cystoscopy use, salpingo-oophorectomy during hysterectomy, indication, and route of surgery. The abdominal route (OR: 11.35; 95% CI: 3.17–40.70; p<0.001) and salpingo-oophorectomy (OR: 4.25; 95% CI: 1.22–14.84; p=0.040) remained to be independent predictive factors. CONCLUSIONS: In this largest single-center cohort of hysterectomies, intraoperative cystoscopy did not lower the risk of postoperatively detected urinary tract injuries. Abdominal route and concomitant salpingo-oophorectomy significantly increased this risk, suggesting the appropriateness of a selective cystoscopy policy (T1).