Clinical characteristics and management of iatrogenic urological injuries in gynecological surgery: a retrospective analysis of 75 cases

To evaluate the incidence, clinical characteristics, primary management strategies, and long-term outcomes of urinary tract injuries after major gynecological surgeries. A retrospective analysis was conducted on a cohort of 34,568 major gynecological surgeries performed at our institution between October 2014 and September 2025. Patients identified with postoperative urinary tract injuries were evaluated for baseline demographic characteristics, surgical platforms utilized, anatomical injury types, symptom onset, urological interventions, and follow-up clinical outcomes. A total of 75 patients with urinary tract injuries were identified, yielding an overall incidence rate of 0.217%. Robotic-assisted laparoscopy, which is predominantly reserved for highly complex oncological resections, had the highest injury rate (0.783%), whereas conventional laparoscopy had the lowest injury rate (0.101%). Malignant conditions were the primary indication for surgery in 69.33% of the patients, with cervical cancer being the most prevalent (56.00%). Vaginal discharge was the most common postoperative symptom (62.67%), with a median onset of 13 days. Anatomically, ureteral injuries strongly predominated (86.67%), primarily ureterovaginal fistulas (50.67%), followed by bladder injuries (12.00%). Initial urological management heavily favored minimally invasive diversion, utilizing double-J (DJ) stents in 85.33% of the cohort. Long-term follow-up showed symptom resolution without secondary surgery in 56.00% of the overall cohort. The remaining 44.00% had persistent morbidity or required additional management; 12 patients underwent major surgical reconstruction (e.g., transvaginal vesicovaginal fistula repairs and laparoscopic ureteroneocystostomy). The overall incidence of urinary tract injuries following major gynecological surgery was low. The higher unadjusted rate observed among robotic-assisted procedures likely reflects confounding by indication and the concentration of complex oncological cases rather than an inherent disadvantage of the robotic platform. Primary conservative or minimally invasive management was followed by symptom resolution without secondary surgery in 56.00% of the overall cohort; however, a substantial subset required further intervention, including definitive reconstruction.