Delayed recognition of lower urinary tract injuries following hysterectomy for benign indications: A NSQIP-based study

Objective: To describe the incidence of and factors associated with lower urinary tract complications recognized in the immediate postoperative period following hysterectomy for benign gynecologic indications using the NSQIP (National Surgical Quality Improvement Program) database. Methods: Patients who underwent hysterectomy for benign indications from 2014 through 2016 were identified in the NSQIP database using Current Procedural Terminology codes and International Classification of Diseases codes. Patient demographics, preoperative comorbidities, ASA classification system scores, and total operating time were collected. Data on 30-day postoperative complication rates, including rates of reoperation and readmission, were also captured. Genitourinary complications were defined as ureteral obstruction, ureteral fistula, and bladder fistula. Results: A total of 45,139 patients met inclusion criteria during the study period. Mean age and body mass index were 31 ± 11years and 32 ± 8 kg/m². The majority of patients were white (66%), had an ASA class of 2 (67%), and had no major medical comorbidities (68%). The most commonly performed primary surgery was laparoscopic hysterectomy (43%), followed by abdominal hysterectomy (27%). The incidence of any lower urinary tract complication was 0.2% (95% confidence interval, 0.19–0.28): 55 ureteral obstructions (0.1%, 95% confidence interval, 0.09–0.16), 33 ureteral fistulae (0.07%, 95% confidence interval, 0.05–0.1), and 28 bladder fistulae (0.06%, 95% confidence interval, 0.04–0.09). In a multivariable logistic regression model, black race (adjusted odds ratio, 1.90; 95% confidence interval, 1.20–2.96), endometriosis (adjusted odds ratio, 2.29; 95% confidence interval, 1.44–3.52), and prior abdominal surgery (adjusted odds ratio, 1.53; 95% confidence interval, 1.01–2.28) remained significantly associated with the occurrence of any lower urinary tract complication recognized in the immediate 30-day postoperative window. Conclusion: Lower urinary tract complications recognized in the immediate postoperative period following hysterectomy for benign gynecologic disease are rare, with ureteral obstruction being the most commonly reported complication. The risk of these complications may be higher in patients who identify as black, had prior abdominal surgery, and/or have a diagnosis of endometriosis.