Complications of hysteroscopic and uterine resectoscopic surgery.
ABSTRACT Adverse events associated with hysteroscopic procedures are in general rare, but, with increasing operative complexity, it is now apparent that they are experienced more often. A spectrum of complications exist ranging from those that relate to generic components of procedures such as patient positioning and anesthesia and analgesia, to a number that are specific to intraluminal endoscopic surgery (perforation and injuries to surrounding structures and blood vessels). The response of premenopausal women to excessive absorption of nonionic fluids deserves special attention. There is also an increasing awareness of uncommon but problematic sequelae related to the use of monopolar uterine resectoscopes that involve thermal injury to the vulva and vagina. The uterus that has previously undergone hysteroscopic surgery can behave in unusual ways, at least in premenopausal women who experience menstruation or who become pregnant. Better understanding of the mechanisms involved in these adverse events, as well as the use or development of several devices, have collectively provided the opportunity to perform hysteroscopic and resectoscopic surgery in a manner that minimizes risk to the patient.
Article: Lower urinary tract injury during gynecologic surgery and its detection by intraoperative cystoscopy.[show abstract] [hide abstract]
ABSTRACT: To review the frequency of lower urinary tract injuries after major gynecologic surgery and the role of routine intraoperative cystoscopy during major gynecologic surgery in the detection of lower urinary tract injuries. We combined a MEDLINE search for reports from 1966 to October 1998, using the terms "urinary tract injury," "ureter/ureteric/ureteral obstruction/fistula/injury," "bladder fistula/injury," and "vesico-vaginal fistula," with a second search for all reports of gynecologic surgical procedures. Additional references were obtained from relevant articles and review articles. Included were all English language articles on the frequency of unintentional urinary tract injuries identified during or after benign gynecologic surgery. There were 22 reports on the frequency of lower urinary tract injuries after gynecologic surgery and eight on the use of routine cystoscopy during gynecologic surgery to diagnose unsuspected injuries. In the reports of studies not involving routine cystoscopy, the frequency of ureteral injury varied from 0 to 14.6 injuries per 1000 operations, with an overall frequency of 1.6 per 1000. The frequency of bladder injury varied from 0.2 to 19.5 per 1000, with an overall frequency of 2.6 per 1000. Only 11.5% of ureteral injuries and 51.6% of bladder injuries were identified and managed intraoperatively. In the reports of studies involving routine cystoscopy, the frequency of ureteral injury varied from 0 to 26.8 per 1000, with an overall frequency of 6.2 per 1000. The frequency of bladder injury varied from 0 to 29.2 per 1000, with an overall frequency of 10.4 per 1000. Up to 90% of unsuspected ureteral injuries and 85% of unsuspected bladder injuries were identified with the use of cystoscopy and were managed successfully intraoperatively. In 69% of the unsuspected ureteral and bladder injuries, the intraoperative management consisted of removing and replacing sutures or repairing unintentional cystotomies. Use of routine intraoperative cystoscopy during major gynecologic and urogynecologic surgery might prevent sequelae from lower urinary tract injuries.Obstetrics and Gynecology 12/1999; 94(5 Pt 2):883-9. · 4.73 Impact Factor
[show abstract] [hide abstract]
ABSTRACT: To estimate the incidence and location of injury to the urinary tract during hysterectomy for benign gynecologic disease. This was a prospective clinical study in an academic environment performed at three sites. Diagnostic cystourethroscopy was performed on all patients after hysterectomy for benign disease. Eight hundred thirty-nine patients were enrolled. The incidence of urinary tract injury associated with hysterectomy for benign disease was 4.3% (39 of 839 cases). The rate of bladder injury was 2.9% (24 of 839 cases), and rate of ureteral injury was 1.8% (15 of 839 cases). There were three cases of simultaneous bladder and ureteral injuries, resulting in a cumulative injury rate of 4.3%. The injury detection rate using intraoperative diagnostic cystoscopy was 97.4% (817 of 839 cases). The most common site of injury to the ureter was at the junction of the ureter and the uterine artery in 80% (12 of 15 cases) of ureteral injuries. Transection and kinking injuries were the most frequent type of injury. There were 21 cases of subnormal dye efflux from the ureteral orifices, with no subsequent injury detected on further evaluation. Ureteral injury occurred most commonly at the level of the uterine artery, and transection and kinking injuries were most frequent. Diminished dye efflux from ureteral orifices was not associated with injury. III.Obstetrics and Gynecology 02/2009; 113(1):6-10. · 4.73 Impact Factor
Article: Disability and litigation from urinary tract injuries at benign gynecologic surgery in Canada.[show abstract] [hide abstract]
ABSTRACT: To estimate the prevalence of urinary tract injury and the relative risk of litigation from an injury for benign gynecologic surgery in Canada and to analyze a subset of cases of litigation, determining independent risk factors that predicted medical and legal outcomes. The prevalence of urinary tract injury and the relative risks of litigation from an injury were determined from the national hospital discharge abstract and the national physician malpractice databases. Multiple logistic regression was performed on a subset of litigation cases. The prevalence of urinary tract injury at benign gynecologic surgery was low (0.33%). If a patient sustained a urinary tract injury, there was a high relative risk of litigation (relative risk 91, 95% confidence interval [CI] 55-158). Patients had a higher chance of major disability after urinary tract injury from hysterectomy for abnormal uterine bleeding (odds ratio [OR] 6.16, 95% CI 1.13-39.01, P = .04), but a lower chance of this being a permanent disability (OR 0.23, 95% CI 0.05-0.96, P = .05). Permanent disability was more likely after an obstructed ureter compared with other types of urinary tract injuries (OR 4.54, 95% CI 1.55-14.88, P = .008). Only 18% of the injuries were recognized intraoperatively. An acute bladder injury was more likely to be recognized intraoperatively than other types of injury (OR 14.98, 95% CI 3.89-57.74, P < .001). No obstructed ureters or urinary tract fistulae were recognized intraoperatively. Urinary tract injuries are an uncommon but significant complication from benign gynecologic surgery. Such injuries are associated a high relative risk of litigation.Obstetrics and Gynecology 02/2005; 105(1):109-14. · 4.73 Impact Factor
Obstetetric & Gynecology Clinics Of North America
September, 2010; 37Volume(3)
Gynecologic Surgery and the Management of Hemorrhage Parker WH
- Obstet Gynecol Clin North Am - September, 2010; 37(3); 427-436
Hollow Viscus Injury During Surgery Sharp HT - Obstet Gynecol Clin
North Am - September, 2010; 37(3); 461-467
CME Accreditation Page and Author Disclosure - Obstet Gynecol Clin
North Am - September, 2010; 37(3); iii
Preface Sharp HT - Obstet Gynecol Clin North Am - September, 2010;
Preventing Electrosurgical Energy-Related Injuries Lipscomb GH -
Obstet Gynecol Clin North Am - September, 2010; 37(3); 369-377
Complications of Hysteroscopic and Uterine Resectoscopic Surgery
Munro MG - Obstet Gynecol Clin North Am - September, 2010; 37(3);
Postoperative Neuropathy in Gynecologic Surgery Bradshaw AD -
Obstet Gynecol Clin North Am - September, 2010; 37(3); 451-459
Understanding Errors During Laparoscopic Surgery Parker WH -
Obstet Gynecol Clin North Am - September, 2010; 37(3); 437-449
Foreword Rayburn WF - Obstet Gynecol Clin North Am - September,
2010; 37(3); xi-xii
Avoiding Major Vessel Injury During Laparoscopic Instrument
Insertion Pickett SD - Obstet Gynecol Clin North Am - September,
2010; 37(3); 387-397
Prevention, Diagnosis, and Treatment of Gynecologic Surgical Site
Infections Lazenby GB - Obstet Gynecol Clin North Am - September,
2010; 37(3); 379-386
The goal of Obstetrics and Gynecology Clinics of North America is to keep practicing physicians up to date with
current clinical practice in OB/GYN by providing timely articles reviewing the state of the art in patient care.
The Obstetrics and Gynecology Clinics of North America is planned and implemented in accordance with the
Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the
joint sponsorship of the University of Virginia School of Medicine and Elsevier. The University of Virginia School
of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
The University of Virginia School of Medicine designates this educational activity for a maximum of 15 AMA PRA
Category 1 Credits? for each issue, 60 credits per year. Physicians should only claim credit commensurate with
the extent of their participation in the activity.
The American Medical Association has determined that physicians not licensed in the US who participate in this
CME activity are eligible for a maximum of 15 AMA PRA Category 1 Credits? for each issue, 60 credits per year.
Category 1 credit can be earned by reading the text material, taking the CME examination online at http://www.
theclinics.com/home/cme, and completing the evaluation. After taking the test, you will be required to review any
and all incorrect answers. Following completion of the test and evaluation, your credit will be awarded and you
may print your certificate.
FACULTY DISCLOSURE/CONFLICT OF INTEREST
The University of Virginia School of Medicine, as an ACCME accredited provider, endorses and strives to comply
with the Accreditation Council for Continuing Medical Education (ACCME) Standards of Commercial Support, Com-
monwealth of Virginia statutes, University of Virginia policies and procedures, and associated federal and private
regulations and guidelines on the need for disclosure and monitoring of proprietary and financial interests that
may affect the scientific integrity and balance of content delivered in continuing medical education activities under
The University of Virginia School of Medicine requires that all CME activities accredited through this institution be
developed independently and be scientifically rigorous, balanced and objective in the presentation/discussion of its
content, theories and practices.
All authors/editors participating in an accredited CME activity are expected to disclose to the readers relevant finan-
cial relationships with commercial entities occurring within the past 12 months (such as grants or research support,
employee, consultant, stock holder, member of speakers bureau, etc.). The University of Virginia School of Medicine
will employ appropriate mechanisms to resolve potential conflicts of interest to maintain the standards of fair and
balanced education to the reader. Questions about specific strategies can be directed to the Office of Continuing
Medical Education, University of Virginia School of Medicine, Charlottesville, Virginia.
The faculty and staff of the University of Virginia Office of Continuing Medical Education have no financial affiliations
The authors/editors listed below have identified no professional or financial affiliations for themselves
or their spouse/partner:
Megan R. Billow, DO; Amber D. Bradshaw, MD; Nichole M. Giannios, DO; Vanessa M. Givens, MD; Carla Holloway
(Acquisitions Editor); William W. Hurd, MD, MSc; William Irvin, MD (Test Author); Gary H. Lipscomb, MD; Stephanie
D. Pickett, MD; Katherine J. Rodewald, MD; Howard T. Sharp, MD (Guest Editor); David E. Soper, MD; Carolyn
Swensen, MD; and Willis H. Wagner, MD.
The authors/editors listed below identified the following professional or financial affiliations for themselves
or their spouse/partner:
Arnold P. Advincula, MD is a consultant for Intuitive Surgical, Cooper Surgical, and Ethicon Endo-Surgery.
Gweneth B. Lazenby, MD is an industry funded research/investigator for GenProbe.
Malcolm G. Munro, MD, FRCS(c) is a consultant for Karl Storz Endoscopy Americas, Ethicon Women’s Health and
Urology, Bayer Women’s Health Care, and AMAG Pharmaceuticals; is on the Advisory Committee/Board of Ethicon
Women’s Health and Urology; and is an industry funded research/investigator for Bayer Women’s Health Care.
William H. Parker, MD is a consultant for Ethicon.
William F. Rayburn, MD, MBA (Consulting Editor) is an industry funded research/investigator and a consultant for
Disclosure of Discussion of non-FDA approved uses for pharmaceutical products and/or medical devices:
The University of Virginia School of Medicine, as an ACCME provider, requires that all faculty presenters identify and
disclose any off-label uses for pharmaceutical and medical device products. The University of Virginia School of
Medicine recommends that each physician fully review all the available data on new products or procedures prior
to clinical use.
To enroll in the Obstetrics and Gynecology Clinics of North America Continuing Medical Education program, call
customer service at 1-800-654-2452 or visit us online at www.theclinics.com/home/cme. The CME program is
available to subscribers for an additional fee of $180.00