What the gynaecologist fears most in the pelvis?

  • C A Walsh
  • Published 2016 in
    BJOG : an international journal of obstetrics and…


The old axiom tells us ‘what the gynaecologist fears most in the pelvis is the ureter; what the urologist fears most in the pelvis is the gynaecologist’. It is true that iatrogenic ureteric injury remains one of the most worrisome complications for gynaecological surgeons. Gynaecologists are especially fearful of the unrecognised ureteric injury, with the potential for abscess or fistula formation or eventual loss of a healthy kidney. In this issue, Kiran et al. report trends in hysterectomy-related ureteric injury in England from 2001 to 2010. Using coded hospital data extracted from a national database, the authors found a non-significant downward trend in rates of benign hysterectomy (P = 0.058) but a significant rise in hysterectomy for malignancy (P < 0.001) over the 10-year study period. Overt cases of ureteric injury or fistula (or need for ureteric stenting, repair or re-implantation) occurring in the first 12 months post-operatively were identified. Among 377 000 hysterectomies, the rate of ureteric injury was 0.5%, which is consistent with previous publications (Clarke-Pearson et al. Obstet Gynecol 2013;121:654–73). The most striking finding in this study is the apparent rise in hysterectomy-related ureteric injury rates, from 0.3% in the first half of the study period to 0.66% in the second half. Not surprisingly, the rate of ureteric injury was higher with hysterectomies for malignancy (1.2%) than for benign cases (0.3%). Although this increased ureteric injury rate may simply be the result of improved case ascertainment at the hospital coding level, no clear process change during the study period is available to support this. Identification of cases may also have been improved with increased surgical suspicion and incorporation of cystoscopy into the hysterectomy procedure (Ibeanu et al. Obstet Gynecol 2009;113:6–10). However, the study design cannot drill down into individual surgical technique and the finding that less than half of the ureteric injuries were diagnosed during the index admission does not appear to corroborate this theory. If the number of ureters injured during hysterectomy in English units has truly doubled from 2001–2005 to 2006– 2010, it is a sobering thought. The underlying cause is likely to be the surgery, the surgeon or both. Ambitious gynaecology registrars will testify that the numbers of routine benign hysterectomies have fallen, a trend confirmed by the present study. The phenomenal success of uterus-conserving treatments, including the Mirena system and endometrial ablation, means that those hysterectomies that do reach the operating theatre are, increasingly, the surgically challenging cases. And there are fewer and fewer of even these tricky hysterectomies to go around. Given the high proportion of gynaecology trainees who do not feel surgically competent (Moss et al. BMC Med Educ 2011;11:32), it seems plausible that this might impact complication rates. On a related issue, the study by Kiran et al. found that only 5% of hysterectomies were laparoscopic, with nearly 60% of benign cases performed via laparotomy. Despite concerns over increased ureteric injury at laparoscopic hysterectomy raised a decade ago by the eVALuate trial (Garry et al. BMJ 2004;328:129), recent studies have been more reassuring (Adelman et al. J Minim Invas Gynecol 2014;21:558–66). Given the multitude of other advantages offered by laparoscopic hysterectomy, it is imperative that gynaecologists continue to consider the best surgical option for their patients and that future gynaecologists are armed with the necessary surgical tools.

DOI: 10.1111/1471-0528.13620

Cite this paper

@article{Walsh2016WhatTG, title={What the gynaecologist fears most in the pelvis?}, author={C A Walsh}, journal={BJOG : an international journal of obstetrics and gynaecology}, year={2016}, volume={123 13}, pages={2189} }