Urological injuries complicating pregnancy-related hysterectomy: Analysis of risk factors and proposal to improve the quality of care

Abstract

Purpose: While strategies aimed at preventing urological injuries complicating hysterectomy for gynaecological indications and placenta accreta surgery have been proposed, a comprehensive model for pregnancy-related hysterectomy (PRH) is lacking. The aim of this study was to investigate risk factors for urological complications of obstetric hysterectomy, and to propose strategies to improve the quality of care.

Methods: This retrospective study of patients undergoing PRH was conducted in an academic centre between 2009 and 2022. Surgical lesions of the urinary tract were defined by the need for direct repair or subsequent additional urological interventions. Univariate and multivariate analyses were performed to identify determinants of urological injuries.

Results: Among 141 patients undergoing obstetric hysterectomy, 25 (17.7 %) experienced urological injuries (22 bladder lesions, three ureteral lesions). Bladder injuries were repaired intraoperatively, while ureteral lesions were diagnosed 2-5 weeks after surgery. After adjustment for confounding variables, the number of previous caesarean deliveries (p = 0.006) and intraoperative estimated blood loss (p = 0.002) were independently associated with urological complications.

Conclusion: The burden of urological complications during obstetric hysterectomy is high. Subtotal hysterectomy can be considered in selected cases to reduce the risk of ureteral injury, while postoperative ultrasonographic screening of the urinary tract and analysis of serum markers may facilitate early detection of undiagnosed ureteral complications.

Keywords: Caesarean section; Postpartum haemorrhage; Pregnancy-related hysterectomy; Quality improvement; Urological injury.