IS PRIOR CESAREAN SECTION A RISK FOR INCIDENTAL CYSTOTOMY AT THE TIME OF HYSTERECTOMY?: A CASE CONTROLLED STUDY

C.M. Rooney, A. Crawford, B. Vassallo, S. Kleeman, M.M. Karram
Seton Center, Good Samaritan Hospital, Cincinnati, OH

OBJECTIVE: To determine if prior cesarean section is an independent risk factor for incidental cystotomy at the time of hysterectomy.
MATERIALS AND METHODS:  This is a case controlled study that evaluated all cases of incidental cystotomy at the time of hysterectomy between January 1998 and December 2001.  5092 hysterectomies were performed in the time period mentioned above, and 51 cases of incidental cystotomy were identified. Each case of incidental cystotomy was then matched to three controls (for a total of 153 controls) with similar patient characteristics as well as the absence of incidental cystotomy at the time of hysterectomy. Cases and controls had similar histories of endometriosis, leiomyomata, genital tract malignancy, incontinence, pelvic organ prolapse, previous pelvic surgery and previous cesarean section.  The data was then entered into Excel.  Dichotomous variables were analyzed utilizing Chi-squared analysis, while continuous variables were analyzed using t-tests.  All statistical calculations were performed using SPSS 12.0 for Windows.
RESULTS: Overall, 5092 hysterectomies were performed during the study period [TAH: 3141 (61.7%), TVH: 1519 (29.8%), LAVH: 433 (8.5%).  51 cases of incidental cystotomy were identified [TAH: 24 (47.1%, TVH: 19 (37.3%), LAVH: 8 (15.7%).  The overall incidence of cystotomy was 1.0%. When considering TAH, there were 24/3141 (0.76%) cases of incidental cystotomy with 8 (33%) of these patients with a history of prior cesarean section.  During TVH, we encountered 19/1519 (1.3%) cases of incidental cystotomy with 4 (21%) of these women having undergone a prior cesarean.  Finally, during LAVH, there were 8/433 (1.8%) cases of incidental cystotomy.  Five (62.5%) of these patients had a prior history of cesarean section. In comparison, 19/72 (26.4%) TAH controls had a prior history of cesarean.  4/57 (7.0%) TVH controls had a history of cesarean section.  Finally, 2/24 (8.3%) LAVH controls had a history of prior cesarean.  
CONCLUSION: Prior cesarean section is indeed a significant risk factor for damage to the lower urinary tract at the time of hysterectomy (OR: 2.04; CI: 1.20-3.46).  When analyzed separately, the relative risk of incidental cystotomy at the time of TAH, TVH, and LAVH in a woman with a history of prior cesarean is 1.66, 3.00 and 7.50 respectively.  Only the value for LAVH is statistically significant (p = 0.005; 95% CI: 1.792-31.38).

Key Words: hysterectomy, cystotomy, cesarean section

Disclosure - Consultant: S. Kleeman, AMS, Boston Scientific, Mentor; M. Karram, Gynecare; Speakers Bureau: S. Kleeman, Pfizer; M. Karram, Ortho-McNeil, Watson, Indevus, Gynecare;

Grant/Research: M. Karram, AMS.