Universal Ureteral Stent Placement at Hysterectomy to Identify Ureteral Injury: A Decision Analysis

Abstract

Half or more of iatrogenic ureteral injuries may result from gynecological surgery. Such injuries, when not diagnosed at the time of initial surgery, are associated with increased morbidity. Inserting ureteral catheters preoperatively may promote the recognition and repair of injuries, but whether it helps to avoid injury remains uncertain. This study used the method of decision-tree analysis of clinical scenarios to compare universal ureteral catheterization with no catheter placement for two procedures: total abdominal hysterectomy for preoperatively diagnosed benign uterine leiomyomas, and radical hysterectomy for preoperatively diagnosed malignant disease. Total hospital-related costs were analyzed. It was assumed that preoperative ureteral catheterization would identify 99% of injuries. Without catheter placement, delayed diagnosis and repair were assumed in 70% of cases and immediate repair in 30%. Universal ureteral catheterization was a cost-saving procedure for patients having radical hysterectomy when the rate of ureteral injury was 3.2% or higher. There was, in addition, a trend toward cost savings when total abdominal hysterectomy was done for benign indications and when the rate of ureteral injury was 3.2%. The cost of undiagnosed ureteral injury necessitating readmission and delayed open repair was found to be 1.72 times the cost of a detected injury when immediate repair is carried out. It was estimated to be 2.29 times more expensive than when a patient has surgery without stents in place and without ureteral injury. The investigators recommend that ureteral catheterization be considered in women having either benign abdominal or radical hysterectomy when the risk of ureteral injury exceeds 3%.