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Hysterectomy

Hysterectomy is one of the most common major gynecologic operations, and the lower urinary tract sits immediately adjacent to every route used to perform it: abdominal, vaginal, laparoscopic and robotic. Bladder injury occurs chiefly at anterior colpotomy, vesicouterine-space mobilization and dense bladder–uterine adhesiolysis; ureteral injury occurs chiefly at the uterine-artery crossing, the infundibulopelvic pedicle and the vaginal cuff.[1][2] Most injuries at hysterectomy occur during benign surgery, where cumulative volume outweighs the lower per-case risk of radical surgery; the operation-specific anatomy of radical hysterectomy and pelvic lymphadenectomy is covered separately on this site.[3]

See also: Intraoperative Urologic Consultation for the general injury-recognition and repair framework, Ureteral Trauma and Bladder Trauma for organ-specific repair, and Vesicovaginal Fistula and Ureterovaginal Fistula for the delayed-presentation sequelae.

Epidemiology​

Reported injury rates vary widely with case ascertainment, route and indication. In a prospective three-site study of 839 women who underwent universal diagnostic cystourethroscopy after hysterectomy for benign disease, the combined bladder-and-ureteral injury rate was 4.3% (36/839): bladder injury 2.9% (24/839) and ureteral injury 1.8% (15/839), with three patients injured in both organs. Cystoscopy detected 97.4% (817/839) of all injuries recognized intraoperatively, and the ureter was most often injured at the junction with the uterine artery (12/15, 80%), with transection and kinking the most frequent injury types.[4]

Larger administrative-database series that do not rely on routine cystoscopy report lower rates. In a California cohort of 296,130 benign hysterectomies, ureteral injury occurred in 1.0% (2,817), bladder injury in 0.7% (2,058), and a genitourinary fistula developed in 0.3% (834), for an overall genitourinary injury rate of 1.8%.[5] In an English National Health Service cohort of 377,073 hysterectomies (2001–2010), the ureteric injury rate for benign indications was typically below 1%, with endometriosis carrying the highest risk among benign conditions (1.7% after total abdominal hysterectomy); for malignant indications, abdominal radical hysterectomy for uterine cancer reached 10.7%, and ovarian and cervical cancer surgery ranged 1.9–4.0% depending on procedure. Injury rates rose between 2001–2005 and 2006–2010 in both groups.[3]

Risk by Surgical Route​

SeriesComparisonFinding
NSQIP, 101,021 benign hysterectomies[6]Laparoscopic vs. vaginalLaparoscopic hysterectomy carried higher adjusted odds of urologic intervention excluding cystoscopy (aOR 1.47, 95% CI 1.29–1.69); no difference between open and vaginal or laparoscopic and open
California cohort, 296,130 benign hysterectomies[5]Vaginal and laparoscopic vs. abdominalVaginal (aOR 0.56, 95% CI 0.53–0.64) and laparoscopic (aOR 0.80, 95% CI 0.75–0.86) approaches were each associated with lower injury risk than an abdominal approach
Single-system retrospective review, 3,114 hysterectomies[7]Robotic vs. laparoscopic vs. vaginal vs. abdominalOverall urologic injury 0.87%; by route, 0.92% robotic, 0.90% laparoscopic, 0.33% vaginal, 0.96% abdominal. Rates were similar for robotic and laparoscopic hysterectomy in this cohort
Systematic review of laparoscopic hysterectomy, 40 studies[8]Laparoscopic hysterectomy onlyOverall urinary tract injury rate 0.73%; bladder injury 0.05–0.66% and ureteral injury 0.02–0.4% across procedure types
Meta-analysis, total laparoscopic vs. vaginal hysterectomy[9]Laparoscopic vs. vaginalNo difference in combined ureter-and-bladder injury risk (OR 0.81, 95% CI 0.34–1.92); vaginal hysterectomy had a shorter operative time and lower conversion-to-laparotomy rate

These studies differ in case mix, ascertainment method and era, and their point estimates should not be averaged across studies. The consistent signal across route comparisons is that an abdominal approach and a vaginal approach anchor opposite ends of injury risk in most series, with laparoscopic and robotic approaches intermediate and close to one another.

Risk Factors​

Factors independently associated with genitourinary injury at benign hysterectomy include concurrent prolapse repair (OR 1.44), a concurrent incontinence procedure (OR 1.40), mesh-augmented prolapse repair (OR 1.55), endometriosis (OR 1.46), and surgery at a facility in the lowest quartile of hysterectomy volume (OR 1.37).[5] Prior cesarean delivery, pelvic inflammatory disease, malignancy and dense adhesions are additional recognized risk factors, particularly for bladder injury during adhesiolysis, vesicouterine-space dissection and anterior cul-de-sac entry at vaginal hysterectomy.[1]

Anatomic Danger Zones​

Bladder — Vesicouterine Space and Anterior Colpotomy​

The bladder is mobilized off the lower uterine segment and cervix to expose the anterior colpotomy or hysterotomy plane. In a scarred field from prior cesarean, endometriosis or cancer, this plane is obliterated, and sharp dissection replaces blunt development to avoid entering the bladder wall directly.[1] At vaginal hysterectomy specifically, aggressive instrumental advancement through dense bladder–uterine adhesions can thin or perforate the bladder; sharp dissection to mobilize the adherent bladder and obtain a tension-free closure is preferred if cystotomy occurs.[2]

Ureter — Uterine Artery, Infundibulopelvic Pedicle and Vaginal Cuff​

The ureter is at risk at three principal points during hysterectomy:[1]

  • The uterine-artery/cardinal-pedicle crossing, where the uterine artery passes anterior to the ureter approximately 1.5–2 cm lateral to the cervix ("water under the bridge"). This is the single most common site of ureteral injury at hysterectomy, accounting for 80% of ureteral injuries in one cystoscopy-based series.[4]
  • The infundibulopelvic pedicle, where the ureter crosses the common iliac vessels medial to the ovarian vessels; injury here is more likely when the adnexa are removed and the ureter is not identified before pedicle control.
  • The vaginal cuff, where a laterally placed cuff suture at colpotomy or cuff closure can kink or ligate the distal ureter, particularly when the cuff angle is extended to control bleeding.

Approach-Specific Technique​

At vaginal hysterectomy, operative teaching distinguishes anterior from posterior entry. When anterior entry has already been achieved, the ureter can be palpated before clamping the cardinal pedicles; when only posterior entry is available (for example, a scarred or inaccessible anterior cul-de-sac), small successive pedicle bites taken close to the uterus reduce the chance of incorporating the ureter, which lies farther from the cervix than the cardinal pedicle itself.[1] These are described operative approaches rather than outcomes compared head-to-head in a trial.

Intraoperative Recognition​

Cystoscopy​

Diagnostic cystoscopy after hysterectomy directly inspects the bladder mucosa for a missed cystotomy and assesses ureteral efflux (with or without IV dye) for patency. Detection sensitivity for ureteral injury with cystoscopy has been reported at 80–90% in published series, and routine cystoscopy regularly identifies injuries that would otherwise be missed.[8][10] In the 839-patient prospective cystoscopy study above, 21 cases of subnormal ureteral dye efflux were not associated with a subsequent injury on further evaluation, illustrating that diminished efflux alone is not diagnostic.[4]

The AAGL 2012 practice guideline for laparoscopic hysterectomy states that the risk of lower urinary tract injury may be as high as 3%, that cystoscopy should be readily available to the operating gynecologic surgeon, and that current evidence supports cystoscopy at the time of laparoscopic hysterectomy, given that the rate of detectable but unsuspected injury is high enough to warrant routine evaluation.[10] This is the position of a specialty practice guideline rather than a universal mandate derived from a demonstrated reduction in long-term harm from stenting or repair after detection; some chapter authors advocate universal cystoscopy at every hysterectomy, and that recommendation should be read as attributed expert opinion rather than an established standard applied uniformly to every route and risk category.[1] Selective cystoscopy by risk factor and procedure complexity remains an accepted alternative framework; see Intraoperative Urologic Consultation for the general recognition toolkit (retrograde pyelography, indigo carmine, sodium fluorescein).

Prophylactic Ureteral Stenting​

Routine prophylactic ureteral stenting before hysterectomy is not generally recommended; it does not reliably prevent injury, and some chapter authors advise against routine use even in anatomically difficult cases, reserving stents for the most distorted anatomy.[1] See Intraoperative Urologic Consultation — Prophylactic Ureteral Stenting for the mixed trial and meta-analysis evidence across gynecologic and colorectal surgery.

Delayed Presentation​

An unrecognized bladder or ureteral injury at hysterectomy most often presents days to weeks later as vaginal watery drainage, flank pain, fever, ileus or unexplained creatinine rise. Delayed diagnosis measurably worsens outcome: in the California cohort, delayed (versus immediate) recognition was associated with a higher rate of subsequent fistula for both ureteral injury (3.4% vs. 0.7%, OR 0.28 favoring immediate recognition) and bladder injury (6.5% vs. 2.5%, OR 0.37), and immediate stenting alone was far more likely to avert a second ureteral repair when the injury was recognized immediately rather than late (99.0% vs. 39.8%).[5] A contemporary 30-day NSQIP-based cohort of 226,398 hysterectomies found a lower-urinary-tract fistula rate of 0.1% (222 cases: 106 ureterovaginal, 107 vesicovaginal, 9 combined), with gynecologic malignancy and a contaminated or dirty wound classification as significant risk factors and postoperative ureteral obstruction strongly associated with fistula development; this 30-day window, and improvements in technique and perioperative detection, likely explain why this estimate is lower than the historical 0.1–4% range quoted elsewhere.[11] A national English cohort found the overall post-hysterectomy urogenital fistula rate was 1 in 788, ranging from 1 in 87 after radical hysterectomy for cervical cancer to 1 in 3,861 after vaginal hysterectomy for prolapse, with the fistula rate rising 46% across the 2000–2008 study period.[12]

Workup and repair of the established fistula or stricture follow the organ-specific pathways: see Vesicovaginal Fistula, Ureterovaginal Fistula and Ureteral Trauma. This page does not duplicate that management detail; it describes where and why the originating injury occurs.

Intraoperative Repair​

Repair technique for a recognized injury during hysterectomy does not differ in principle from repair during any other pelvic operation. Bladder injury near the dome is closed in layers with a drain and extended catheter decompression; injury near the trigone or an ureteral orifice is managed with stent placement or reimplantation rather than closure over the orifice. Ureteral injury is repaired by location — ureteroureterostomy for most injuries above the pelvic brim, ureteroneocystostomy with or without a psoas hitch for distal injuries near the cuff. The full decision framework, including the Skokan algorithm for timing-based management, is on Intraoperative Urologic Consultation and the organ-specific pages.

See Also​

References​

1. Selle J, Gebhart J. Hysterectomy. In: Hoffman M, Hull TL, Bochner BH, eds. Major Complications of Female Pelvic Surgery: A Multidisciplinary Approach. Springer; 2025:61-71.

2. Karram MM, Gebhart JB. Repair of Advertent and Inadvertent Cystotomy. In: Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. 5th ed. Elsevier; 2021:1071-1078.

3. Kiran A, Hilton P, Cromwell DA. The risk of ureteric injury associated with hysterectomy: a 10-year retrospective cohort study. BJOG. 2016;123(7):1184-1191. doi:10.1111/1471-0528.13576

4. Ibeanu OA, Chesson RR, Echols KT, et al. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol. 2009;113(1):6-10. doi:10.1097/AOG.0b013e31818f6219

5. Dallas KB, Rogo-Gupta L, Elliott CS. Urologic Injury and Fistula After Hysterectomy for Benign Indications. Obstet Gynecol. 2019;134(2):241-249. doi:10.1097/AOG.0000000000003353

6. Wallis CJ, Cheung DC, Garbens A, et al. Occurrence of and Risk Factors for Urological Intervention During Benign Hysterectomy: Analysis of the National Surgical Quality Improvement Program Database. Urology. 2016;97:66-72. doi:10.1016/j.urology.2016.06.037

7. Petersen SS, Doe S, Rubinfeld I, et al. Rate of Urologic Injury with Robotic Hysterectomy. J Minim Invasive Gynecol. 2018;25(5):867-871. doi:10.1016/j.jmig.2018.01.004

8. Adelman MR, Bardsley TR, Sharp HT. Urinary tract injuries in laparoscopic hysterectomy: a systematic review. J Minim Invasive Gynecol. 2014;21(4):558-566. doi:10.1016/j.jmig.2014.01.006

9. Sandberg EM, Twijnstra ARH, Driessen SRC, Jansen FW. Total Laparoscopic Hysterectomy Versus Vaginal Hysterectomy: A Systematic Review and Meta-Analysis. J Minim Invasive Gynecol. 2017;24(2):206-217.e22. doi:10.1016/j.jmig.2016.10.020

10. AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL Practice Report: Practice guidelines for intraoperative cystoscopy in laparoscopic hysterectomy. J Minim Invasive Gynecol. 2012;19(4):407-411. doi:10.1016/j.jmig.2012.05.001

11. Bhandari Randhawa S, McIntire DD, Florian-Rodriguez ME. Thirty-Day Incidence and Risk Factors for Lower Urinary Tract Fistula After Hysterectomy. Urogynecology (Phila). Published online September 29, 2026. doi:10.1097/SPV.0000000000001934

12. Hilton P, Cromwell DA. The risk of vesicovaginal and urethrovaginal fistula after hysterectomy performed in the English National Health Service--a retrospective cohort study examining patterns of care between 2000 and 2008. BJOG. 2012;119(12):1447-1454. doi:10.1111/j.1471-0528.2012.03474.x