Intraoperative urologic safety in radical hysterectomy: surgical approach and the role of the perioperative team

We read with great interest the study by Hwang et al[1], entitled “Meta-analysis reveals higher intraoperative urologic complication rates in minimally invasive radical hysterectomy compared to abdominal radical hysterectomy.” In this work, the authors conducted a systematic review and meta-analysis to compare intraoperative urologic complications between minimally invasive radical hysterectomy (laparoscopic or robotic-assisted) and conventional abdominal radical hysterectomy, with particular emphasis on bladder and ureteral injuries – outcomes that are highly relevant to perioperative patient safety. The research question is clearly defined and addresses an important clinical concern in the context of the rapid adoption of minimally invasive techniques in gynecologic oncology. From a methodological perspective, the authors adhered to the PRISMA guidelines for literature search and study selection and performed quality assessment along with multiple subgroup analyses. Overall, the study design conforms to the fundamental standards of systematic reviews, and the inclusion of a relatively large number of studies provides a reasonable statistical basis for the analyses. Nevertheless, most of the included studies were retrospective in nature and originated from different countries and health care systems. This heterogeneity implies not only variations in surgical expertise and technical approaches, but also differences in perioperative management strategies and operating room team structures – factors that are difficult to quantify and standardize across studies. The pooled analysis demonstrated a trend toward higher odds of intraoperative urologic complications, including bladder and ureteral injuries, in minimally invasive radical hysterectomy compared with the abdominal approach. Importantly, subsequent subgroup analyses indicated that this difference was largely driven by studies of lower methodological quality. In contrast, among studies classified as high quality, the observed differences were not statistically significant. These findings suggest that the current evidence may be influenced, at least in part, by case selection, variability in complication definitions, and differences in reporting practices, warranting cautious interpretation of the overall conclusions. The observed temporal effect also merits attention. Earlier studies did not demonstrate significant differences, whereas more recent publications reported higher urologic complication rates associated with minimally invasive procedures. This pattern may reflect increasing case complexity, improved detection and reporting of complications, or differences in learning curves across centers during the widespread implementation of minimally invasive techniques, rather than an inherent increase in procedural risk over time. With regard to robotic-assisted radical hysterectomy, the limited number of included studies and wide confidence intervals preclude definitive conclusions regarding its relative safety. From a clinical standpoint, the findings suggest that intraoperative urologic injury is not determined solely by surgical approach, but rather results from the interaction of multiple factors. In addition to surgeon experience and anatomical dissection, the quality of perioperative team collaboration plays an important role, particularly in complex gynecologic oncology procedures. Minimally invasive radical hysterectomy, characterized by a restricted operative field and technically demanding maneuvers, places greater demands on procedural continuity and intraoperative stability. From the perspective of the nursing team, operating room nurses – especially scrub nurses and circulating nurses – provide essential support in maintaining surgical safety. Their familiarity with critical anatomical steps, real-time monitoring of laparoscopic and energy devices, and timely recognition and communication of intraoperative abnormalities may indirectly influence the risk of urologic injury. During high-risk phases such as ureteral mobilization and bladder dissection, coordinated and anticipatory nursing support can help maintain optimal visualization and procedural flow, thereby facilitating safer surgical performance. Furthermore, with the expanding use of laparoscopic and robotic technologies in gynecologic oncology, systematic training of nursing teams in new equipment and workflows has become increasingly important. Establishing dedicated minimally invasive gynecologic oncology nursing teams and reinforcing standardized protocols and intraoperative risk awareness may contribute to reducing intraoperative urologic complications. This perspective underscores the importance of incorporating nursing and team-related factors into a broader perioperative safety framework when evaluating the risks associated with different surgical approaches. In summary, this meta-analysis provides a comprehensive synthesis of available evidence regarding intraoperative urologic safety in minimally invasive versus abdominal radical hysterectomy and offers valuable insights for clinical practice. However, its findings should be interpreted primarily as a reminder of the importance of perioperative safety management rather than as a definitive judgment on the superiority or inferiority of a specific surgical approach. Future research should not only refine study design and outcome definitions, but also more systematically consider operating room team factors to achieve a more comprehensive understanding of surgical safety in gynecologic oncology[2].