Iatrogenic urinary tract injuries are potential complications of gynecologic and obstetric surgery due to the proximity to the female internal genitals (1). Early recognition of an injury is of great importance and has been associated with a more successful outcome. Delayed recognition and diagnosis can cause increased morbidity such as risk of ureterovaginal and vesicovaginal fistula formation and impact on quality of life (1). The aim of this descriptive study was to evaluate the management and outcome of iatrogenic bladder and ureteral injuries following gynecologic and obstetric surgery. Specifically, we evaluated suture type and suture size, length of urethral catheterization, length of hospitalization, length of follow-up, reoperation rate, complications, and impact on quality of life.

In total, 91 women were retrospectively identified using ICD-10 codes, and 81 women met inclusion criteria. Data were collected from medical records. Furthermore, a questionnaire on urinary tract symptoms and quality of life was sent to the women. Questions on urinary tract symptoms were obtained from The Danish Urogynecological Database (DugaBase) (2) and included International Consultation on Incontinence Questionnaire – Urinary Incontinence Short form (ICIQ-UI SF) (3). 
Numerical data are presented as mean and 95% confidence interval. Categorical data are presented as number and percentage. Multiple linear regression adjusting for age, body mass index, prior abdominal/pelvic surgery, smoking history, and operation time was used to assess numerical outcomes and are presented as median ratios.

Among the included women 55 women had a bladder injury, 23 women had a ureteral injury, and three women had both bladder and ureteral injuries. The women were divided into three subgroups: Benign (Group 1: N=37), cesarean section (Group 2: N=11), and malignant (Group 3: N=33), based on operation indication. Most bladder injuries were managed by a two-layer suture followed by transurethral catheter drainage for an average of 11.4 days (95% CI: 9.1 – 13.6). The most frequent suture type was 3.0 Vicryl in all subgroups. Most ureteral injuries were managed by either neoimplantation (7 (26.7%) followed by ureteral stenting in 38 days (95% CI: 22.0 – 54.0) and transurethral catheterization in 16.9 days (95% CI: 5.3 – 28.4), or by ureteral stenting for 46.7 days (15 (57.7%)) (95% CI: 31.5 – 61.2) and transurethral catheterization for 6.25 days (95% CI: 1.02 – 13.51). 
In total, six women (7.4%) developed a fistula of whom one woman (16.7%) was in the benign group compared to five women (83.3%) in the malignant group. Of these, four were vesicovaginal, one was ureterorectal and one was ureterovaginal. In addition, 32 women (39.5%) had a urinary tract infection, and six women (7.4%) had renal complications including hydronephrosis and dilatation of the proximal ureter. Three women from group 1, one woman from group 2, and two women from group 3 presented with urinary retention >300 ml following removal of the transurethral catheterization. 
Mean hospitalization in group 1 was 1.7 days (95% CI: 0.8 – 2.5) in women with a bladder injury and 2.7 days (95% CI: 0.6 – 4.8) in women with a ureteral injury, and overall, 14 (37.8%) women underwent reoperation. In group 2, mean hospitalization was 6.7 days (95% CI: 1.4 – 12.1), and one woman (9.1%) underwent reoperation. In group 3, mean hospitalization was 4.9 days (95%CI: 2.5 – 7.2) for those with a bladder injury and 10.8 days (95% CI: 4.7 – 16.8) for those with a ureteral injury. In group 3, ten women had a reoperation (30.3%), of whom three had a bladder injury and seven had a ureteral injury. 
A multiple linear regression model showed a statistic significant increased median length of urethral catheterization when duration of surgery increased. Furthermore, we found that women in the cesarean group had a statistically significant longer median length of catheterization on 156% compared to the benign group.
In total, 53 women answered the questionnaire of whom 11 (20.8%) women reported urinary tract symptoms before the lesion compared to 28 (52.8%) reporting urinary incontinence symptoms following the injury. Of these, 19 were in the benign group and nine were in the malignant group. In total, 19 (67.9%) women reported urge incontinence, 14 (50.0%) women in association with coughing and sneezing, and 9 (32.1%) reported in association with physical activity. Two women reported to have severer symptoms compared to prior to the injury. Regarding the lesions’ impact on quality of life, most women did not report any impact, whereas three (5.6%) women reported very much.

In our study, women with a bladder injury had a transurethral catheter for an average of 11.4 days, of whom two women developed a fistula (3.5%). This may suggest that two weeks of transurethral catheterization is sufficient for heeling, but a shorter period may be sufficient. Surprisingly, the median length was highest in women undergoing cesarean section in accordance with previous studies. Considering that these women were healthy young women without fistula formation and a lower range of complications, this suggests the need for further studies of how long catheterization should be offered in case of cesarean section bladder injuries. 
We found that the ureteral stent was kept approximately six weeks. Five women developed a fistula, suggesting that the ureteral stent should not be removed before six weeks, especially in case of malignancy. 
Our study demonstrated a rather high reoperation rate and fistula formation rate. Further, six women developed a fistula (7.4%). These are serious complications and should be kept in mind when evaluating such patients postoperative. 
In accordance with the literature, the intraoperative detection rate was 77.8% in our study. In some cases, intravesical instillation of methylene blue was used intraoperatively (58.7%) as well as cystoscopy. Others have suggested that use of cystoscopy can improve the detection of urinary tract injuries. However, in our study only 17.5% of the women had a cystoscopy. This may reflect the fact that usage of cystoscopies at our department, in general, are low. Furthermore, the use of cystoscopy may be useful to increase the detection rate.

Our study demonstrated a high reoperation and fistula rate following management of iatrogenic bladder and ureteral lesions. Length of catheterization was high even in case of benign surgery, although only one woman developed a fistula in the benign group, suggesting reduction of catheterization length. In addition, most women reported that the iatrogenic urinary tract lesion did not influence on quality of life.

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