Risk Factors of Lower Urinary Tract Injury with Laparoscopic Sacrocolpopexy

Abstract Background Lower urinary tract injuries can occur during pelvic reconstructive surgery including sacrocolpopexy. Reported injury rates range 0.4-10.6% with laparoscopic sacrocolpopexy, 1.1-3.3% with abdominal SCP, and 2.3-10% with robotic SCP.1-6 Specific literature identifying risk factors for lower urinary tract injury during pelvic reconstructive surgery are lacking, therefore we aim to identify patient characteristics predisposing lower urinary tract injury during laparoscopic sacrocolpopexy. Objective The primary objective of this study is to identify patient-specific risk factors for lower urinary tract injury with laparoscopic sacrocolpopexy. Study Design This was an age-matched case-control study including patients who underwent laparoscopic sacrocolpopexy from July 2014 to December 2017 in a high volume Female Pelvic Medicine and Reconstructive Surgery practice. Patients were excluded if they underwent laparoscopic uterosacral ligament suspension, had abnormal urinary tract anatomy, or for incorrect, incomplete, or duplicated data. Risk factors such as race, body mass index, pelvic organ prolapse quantification stage, prior abdominal and/or vaginal surgeries, and concurrent procedures (lysis of adhesions, adnexal surgery, mid-urethral sling placement, and anterior or posterior colporrhaphy) were analyzed. Groups were compared using Student's t-test for independent samples and chi-square tests. Conditional logistic regression was used to estimate crude and adjusted odds ratios. Results A total of 930 patients were identified during electronic medical record chart review using the CPT code 57425 (laparoscopic colpopexy). One hundred and sixty-seven patients met exclusion criteria, resulting in a total of 763 patients for primary analysis. The prevalence of lower urinary tract injury was 2.4% (17 bladder injuries and 1 ureteral injury out of 763 laparoscopic sacrocolpopexy procedures). These 18 cases were age-matched to 72 controls. The mean age and body mass index of all patients was 64.8 years ± 9.32 and 26.5 kg/m2 ± 3.99, respectively. The majority of patients were Caucasian, had previously undergone abdominal and/or vaginal surgery, had pelvic organ prolapse stage 3 or greater, and underwent concurrent surgeries including adnexal surgery and mid-urethral sling placement at the time of laparoscopic sacrocolpopexy. History of prior hysterectomy (OR 19.94; CI 2.48, 160.38; p= 0.005) as well as lysis of adhesions at time of laparoscopic sacrocolpopexy (OR 4.94; CI 1.05, 23.19; p= 0.043) were associated with an increased odds of lower urinary tract injury in unadjusted models. In a multivariable logistic regression model controlling for the previously listed variables, history of prior hysterectomy remained significantly associated with lower urinary tract injury (adjusted OR 162.41, CI 3.21, 8227; p= 0.011). Race, body mass index, POP-Q stage, prior abdominal and/or vaginal surgery, and concurrent procedures were not associated with increased risk of LUT injury. Conclusions Although lower urinary tract injury with laparoscopic sacrocolpopexy only occurred in 2.4% of patients, prior hysterectomy increased this risk substantially. Since sacrocolpopexy is the common treatment for prolapse after hysterectomy or recurrent prolapse, this increased risk of lower urinary tract injuries can guide surgical counseling based on patient-specific risk factors and aid in setting appropriate post-operative patient expectations.