{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T19:09:09Z","timestamp":1792782549611,"version":"4.5.0"},"reference-count":21,"publisher":"Springer Science and Business Media LLC","issue":"9","license":[{"start":{"date-parts":[[2026,3,25]],"date-time":"2026-03-25T00:00:00Z","timestamp":1774396800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,3,25]],"date-time":"2026-03-25T00:00:00Z","timestamp":1774396800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Universit\u00e0 degli Studi di Pavia","id":[{"id":"https:\/\/ror.org\/00s6t1f81","id-type":"ROR","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Int Urogynecol J"],"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction and Hypothesis<\/jats:title>\n                    <jats:p>The surgical approach to hysterectomy influences the risk of urological injuries, but the optimal technique for minimizing this risk remains unclear. Our objective was to evaluate, through a network meta-analysis (NMA) of randomized controlled trials (RCTs), the risk of intraoperative bladder and ureteral injuries among different hysterectomy techniques.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We systematically searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Google Scholar, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and European Clinical Trials Register (inception to 15 January 2025) for RCTs. NMA and pairwise meta-analyses were performed using penalized logistic regression and Bayesian models, accounting for rare events.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Out of 170 screened records, 63 RCTs involving 7470 women were included. Sixty-nine bladder injuries (9.2 out of 1000), 23 ureteral injuries (3.1 out of 1000), and 96 combined injuries (12.9 out of 1000) were reported. Compared with abdominal hysterectomy (AH), total laparoscopic hysterectomy (LH) showed a significantly higher risk of ureteral injury (odds ratio [OR]\u20097.74; 95% confidence interval [CI] 2.46\u201324.37), as did LH\/laparoscopically assisted vaginal hysterectomy (LAVH; OR\u20097.73; 95% CI 2.42\u201324.7). LH and LH\/LAVH also carried a higher risk of any urological injury than AH (OR\u20092.66 and 2.34 respectively). Estimated injury rates per 1000 were 9.5 (ureteral) and 18.1 (combined) for LH, versus 0.5 and 7.5 for AH. Meta-regression showed that the elevated risk with LH persisted over time.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Laparoscopic hysterectomy and LH\/LAVH are associated with a higher risk of ureteral\/bladder injuries than AH. This increased risk has not declined over time, suggesting that the standardization and broader adoption of LH have not mitigated urological complications.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00192-026-06566-y","type":"journal-article","created":{"date-parts":[[2026,3,25]],"date-time":"2026-03-25T17:34:05Z","timestamp":1774460045000},"page":"2791-2798","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Revisiting Urological Injury Risks in Minimally Invasive Hysterectomy for Benign Indications: A Rare-Events Network Meta-Analysis with Sensitivity Analyses"],"prefix":"10.1007","volume":"37","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8055-5086","authenticated-orcid":false,"given":"Chiara","family":"Cassani","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arsenio","family":"Spinillo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mattia","family":"Dominoni","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Barbara","family":"Gardella","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,3,25]]},"reference":[{"key":"6566_CR1","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD003677.pub6","author":"CM Pickett","year":"2023","unstructured":"Pickett CM, Seeratan DD, Mol BWJ, Nieboer TE, Johnson N, Bonestroo T, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2023. https:\/\/doi.org\/10.1002\/14651858.CD003677.pub6.","journal-title":"Cochrane Database Syst Rev"},{"issue":"6","key":"6566_CR2","doi-asserted-by":"publisher","first-page":"1373","DOI":"10.1097\/AOG.0000000000005434","volume":"142","author":"A Azadi","year":"2023","unstructured":"Azadi A, Masoud AT, Ulibarri H, Arroyo A, Coriell C, Goetz S, et al. Vaginal hysterectomy compared with laparoscopic hysterectomy in benign gynecologic conditions: a systematic review and meta-analysis. Obstet Gynecol. 2023;142(6):1373\u201394. https:\/\/doi.org\/10.1097\/AOG.0000000000005434.","journal-title":"Obstet Gynecol"},{"issue":"4","key":"6566_CR3","doi-asserted-by":"publisher","first-page":"447","DOI":"10.1093\/jsxmed\/qdac051","volume":"20","author":"SJ Dedden","year":"2023","unstructured":"Dedden SJ, Werner MA, Steinweg J, Lissenberg-Witte BI, Huirne JAF, Geomini PMAJ, et al. Hysterectomy and sexual function: a systematic review and meta-analysis. J Sex Med. 2023;20(4):447\u201366. https:\/\/doi.org\/10.1093\/jsxmed\/qdac051.","journal-title":"J Sex Med"},{"issue":"2","key":"6566_CR4","doi-asserted-by":"publisher","DOI":"10.1016\/j.xagr.2024.100355","volume":"4","author":"GJ Marchand","year":"2024","unstructured":"Marchand GJ, Ulibarri H, Arroyo A, Blanco M, Herrera DG, Hamilton B, et al. Systematic review and meta-analysis of vaginal natural orifice transluminal endoscopic surgery hysterectomy versus vaginal hysterectomy for benign indications. AJOG Glob Rep. 2024;4(2):100355. https:\/\/doi.org\/10.1016\/j.xagr.2024.100355.","journal-title":"AJOG Glob Rep"},{"issue":"3","key":"6566_CR5","doi-asserted-by":"publisher","first-page":"807","DOI":"10.1007\/s00404-022-06821-9","volume":"307","author":"P Buderath","year":"2023","unstructured":"Buderath P, Kimmig R, Dominowski L, Mach P. Hysterectomy in benign conditions: a 20-year single-center retrospective on the development of surgical techniques. Arch Gynecol Obstet. 2023;307(3):807\u201312. https:\/\/doi.org\/10.1007\/s00404-022-06821-9.","journal-title":"Arch Gynecol Obstet"},{"issue":"6","key":"6566_CR6","doi-asserted-by":"publisher","first-page":"817","DOI":"10.1097\/AOG.0000000000005745","volume":"144","author":"S Santiago","year":"2024","unstructured":"Santiago S, Richardson D, Kamdar N, Till SR, As-Sanie S, Hong CX. Association among surgeon volume, surgical approach, and uterine size for hysterectomy for benign indications. Obstet Gynecol. 2024;144(6):817\u201325. https:\/\/doi.org\/10.1097\/AOG.0000000000005745.","journal-title":"Obstet Gynecol"},{"issue":"1","key":"6566_CR7","doi-asserted-by":"publisher","first-page":"100","DOI":"10.1097\/AOG.0000000000002414","volume":"131","author":"JMK Wong","year":"2018","unstructured":"Wong JMK, Bortoletto P, Tolentino J, Jung MJ, Milad MP. Urinary tract injury in gynecologic laparoscopy for benign indication: a systematic review. Obstet Gynecol. 2018;131(1):100\u20138. https:\/\/doi.org\/10.1097\/AOG.0000000000002414.","journal-title":"Obstet Gynecol"},{"issue":"2","key":"6566_CR8","doi-asserted-by":"publisher","first-page":"72","DOI":"10.1136\/eb-2018-102911","volume":"21","author":"O Efthimiou","year":"2018","unstructured":"Efthimiou O. Practical guide to the meta-analysis of rare events. Evid Based Ment Health. 2018;21(2):72\u20136. https:\/\/doi.org\/10.1136\/eb-2018-102911.","journal-title":"Evid Based Ment Health"},{"issue":"1","key":"6566_CR9","doi-asserted-by":"publisher","first-page":"103","DOI":"10.1007\/s11739-016-1583-7","volume":"12","author":"B Rouse","year":"2017","unstructured":"Rouse B, Chaimani A, Li T. Network meta-analysis: an introduction for clinicians. Intern Emerg Med. 2017;12(1):103\u201311. https:\/\/doi.org\/10.1007\/s11739-016-1583-7.","journal-title":"Intern Emerg Med"},{"issue":"1","key":"6566_CR10","doi-asserted-by":"publisher","DOI":"10.1111\/jep.14301","volume":"31","author":"Z Wang","year":"2025","unstructured":"Wang Z, Xing X, Mun EY, Wu C, Lin L. The role of double-zero-event studies in evidence synthesis: evaluating robustness using the fragility index. J Eval Clin Pract. 2025;31(1):e14301. https:\/\/doi.org\/10.1111\/jep.14301.","journal-title":"J Eval Clin Pract"},{"issue":"7","key":"6566_CR11","doi-asserted-by":"publisher","first-page":"1097","DOI":"10.1002\/sim.6383","volume":"34","author":"O Kuss","year":"2015","unstructured":"Kuss O. Statistical methods for meta-analyses including information from studies without any events\u2014add nothing to nothing and succeed nevertheless. Stat Med. 2015;34(7):1097\u2013116. https:\/\/doi.org\/10.1002\/sim.6383.","journal-title":"Stat Med"},{"issue":"9","key":"6566_CR12","doi-asserted-by":"publisher","first-page":"1351","DOI":"10.1002\/sim.1761","volume":"23","author":"MJ Sweeting","year":"2004","unstructured":"Sweeting MJ, Sutton AJ, Lambert PC. What to add to nothing? Use and avoidance of continuity corrections in meta-analysis of sparse data. Stat Med. 2004;23(9):1351\u201375. https:\/\/doi.org\/10.1002\/sim.1761.","journal-title":"Stat Med"},{"issue":"2","key":"6566_CR13","doi-asserted-by":"publisher","first-page":"176","DOI":"10.1002\/jrsm.1521","volume":"13","author":"C Xu","year":"2022","unstructured":"Xu C, Furuya-Kanamori L, Lin L. Synthesis of evidence from zero-events studies: a comparison of one-stage framework methods. Res Synth Methods. 2022;13(2):176\u201389. https:\/\/doi.org\/10.1002\/jrsm.1521.","journal-title":"Res Synth Methods"},{"issue":"1","key":"6566_CR14","doi-asserted-by":"publisher","first-page":"74","DOI":"10.1002\/jrsm.1370","volume":"11","author":"BK G\u00fcnhan","year":"2020","unstructured":"G\u00fcnhan BK, R\u00f6ver C, Friede T. Random-effects meta-analysis of few studies involving rare events. Res Synth Methods. 2020;11(1):74\u201390. https:\/\/doi.org\/10.1002\/jrsm.1370.","journal-title":"Res Synth Methods"},{"issue":"26","key":"6566_CR15","doi-asserted-by":"publisher","first-page":"5203","DOI":"10.1002\/sim.9562","volume":"41","author":"T Evrenoglou","year":"2022","unstructured":"Evrenoglou T, White IR, Afach S, Mavridis D, Chaimani A. Network meta-analysis of rare events using penalized likelihood regression. Stat Med. 2022;41(26):5203\u201319. https:\/\/doi.org\/10.1002\/sim.9562.","journal-title":"Stat Med"},{"issue":"11","key":"6566_CR16","doi-asserted-by":"publisher","first-page":"777","DOI":"10.7326\/M14-2385","volume":"162","author":"B Hutton","year":"2015","unstructured":"Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med. 2015;162(11):777\u201384. https:\/\/doi.org\/10.7326\/M14-2385.","journal-title":"Ann Intern Med"},{"key":"6566_CR17","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.l4898","volume":"366","author":"JAC Sterne","year":"2019","unstructured":"Sterne JAC, Savovi\u0107 J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.","journal-title":"BMJ"},{"issue":"4","key":"6566_CR18","doi-asserted-by":"publisher","first-page":"285","DOI":"10.1002\/jrsm.1054","volume":"3","author":"G Van Valkenhoef","year":"2012","unstructured":"Van Valkenhoef G, Lu G, de Brock B, Hillege H, Ades AE, Welton NJ. Automating network meta-analysis. Res Synth Methods. 2012;3(4):285\u201399. https:\/\/doi.org\/10.1002\/jrsm.1054.","journal-title":"Res Synth Methods"},{"issue":"4","key":"6566_CR19","doi-asserted-by":"publisher","first-page":"569","DOI":"10.1002\/jrsm.1373","volume":"10","author":"RK Owen","year":"2019","unstructured":"Owen RK, Bradbury N, Xin Y, Cooper N, Sutton A. MetaInsight: an interactive web-based tool for analyzing, interrogating, and visualizing network meta-analyses using R-shiny and netmeta. Res Synth Methods. 2019;10(4):569\u201381. https:\/\/doi.org\/10.1002\/jrsm.1373.","journal-title":"Res Synth Methods"},{"issue":"11","key":"6566_CR20","doi-asserted-by":"publisher","DOI":"10.1002\/hsr2.70137","volume":"7","author":"M Guan","year":"2024","unstructured":"Guan M, Li H, Tian T, Peng J, Huang Y, He L. Different minimally invasive surgical methods to hysterectomy for benign gynecological disease: a systematic review and network meta-analysis. Health Sci Rep. 2024;7(11):e70137. https:\/\/doi.org\/10.1002\/hsr2.70137.","journal-title":"Health Sci Rep"},{"issue":"2","key":"6566_CR21","doi-asserted-by":"publisher","first-page":"91","DOI":"10.4103\/jmh.jmh_235_23","volume":"15","author":"A Bahadur","year":"2024","unstructured":"Bahadur A, Zaman R, Mundhra R, Mani K. Robotic-assisted versus conventional laparoscopic hysterectomy for benign gynecological conditions: a systematic review and meta-analysis. J Midlife Health. 2024;15(2):91\u20138. https:\/\/doi.org\/10.4103\/jmh.jmh_235_23.","journal-title":"J Midlife Health"}],"container-title":["International Urogynecology Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00192-026-06566-y.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00192-026-06566-y","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00192-026-06566-y.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T13:36:22Z","timestamp":1791466582000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00192-026-06566-y"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,25]]},"references-count":21,"journal-issue":{"issue":"9","published-print":{"date-parts":[[2026,9]]}},"alternative-id":["6566"],"URL":"https:\/\/doi.org\/10.1007\/s00192-026-06566-y","relation":{},"ISSN":["0937-3462","1433-3023"],"issn-type":[{"value":"0937-3462","type":"print"},{"value":"1433-3023","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,25]]},"assertion":[{"value":"26 May 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"5 February 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"25 March 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"Not required, as the study used only published data and did not involve any new data collection from human participants.","order":1,"name":"Ethics","label":"Ethical\/Institutional Review Board Approval","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"PROSPERO (registration number: CRD42025635288, 21 January 2025).","order":2,"name":"Ethics","label":"Registration","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"None.","order":3,"name":"Ethics","label":"Conflicts of Interest","group":{"name":"EthicsHeading","label":"Declarations"}}]}}