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Pelvic Floor Dysfunction UPDATE Pelvic floor dysfunction UPDATE A. Rebecca Meekins, MD Cindy L. Amundsen, MD Dr. Meekins is a Fellow in Female Pelvic Dr. Amundsen is Roy T. Parker Professor in Medicine and Reconstructive Surgery, Obstetrics and Gynecology, Urogynecology Department of Obstetrics and Gynecology, and Reconstructive Pelvic Surgery; Associate Duke University School of Medicine, Professor of Surgery, Division of Urology; Durham, North Carolina. Program Director of the Female Pelvic Medicine and Reconstructive Surgery Fellowship; Program Director of K12 Multidisciplinary Urologic Research Scholars Program; Program Director of BIRCWH, Duke University Medical Center. The authors report no financial relationships relevant to this article. “To cysto or not to cysto?” that is the ongoing question surrounding the role of cystoscopy following benign gyn surgery. These authors review data on the procedure’s ability to detect injury, an ideal method for visualizing IN THIS ureteral efflux, and how universal cystoscopy can affect the ARTICLE rate of injury. Universal cystoscopy policy sing cystoscopy to evaluate ureteral ranges from 0.02% to 2% for ureteral injury page 28 efflux and bladder integrity following and from 1% to 5% for bladder injury.5,6 U benign gynecologic surgery increases In a recent large randomized controlled the detection rate of urinary tract injuries.1 trial, the rate of intraoperative ureteral Detecting ureteral Currently, it is standard of care to perform a obstruction following uterosacral ligament obstruction cystoscopy following anti-incontinence pro- suspension (USLS) was 3.2%.7 Vaginal vault page 29 cedures, but there is no consensus among suspensions, as well as other vaginal cuff ObGyns regarding the use of universal cys- closure techniques, are common procedures Media for efflux toscopy following benign gynecologic sur- associated with urinary tract injury.8 Addi- visualization 2 gery. A number of studies, however, have tionally, ureteral injury during surgery for page 30 suggested potential best practices for evalu- POP occurs in as many as 2% of anterior vagi- ating urinary tract injury during pelvic sur- nal wall repairs.9 gery for benign gynecologic conditions. It is well documented that a delay in Pelvic surgeries for benign gynecologic diagnosis of ureteral and/or bladder inju- conditions, including fibroids, menorrhagia, ries is associated with increased morbidity, and pelvic organ prolapse (POP), are com- including the need for additional surgery mon. More than 500,000 hysterectomies are to repair the injury; in addition, significant performed annually in the United States, and delay in identifying an injury may lead to up to 11% of women will undergo at least one subsequent sequela, such as renal injury and surgery for POP or urinary incontinence in fistula formation.8 their lifetime.3,4 During gynecologic surgery, A large study in California found that the urinary tract is at risk, and the injury rate 36.5% of hysterectomies performed for POP mdedge.com/obgyn Vol. 30 No. 10 | October 2018 | OBG Management 25 UPDATE pelvic floor dysfunction were performed by general gynecologists.10 by cystoscopy, including a bladder survey General ObGyns performing these surgeries and ureteral efflux evaluation. When should therefore must understand the risk of urinary a cystoscopy be performed, and what is the tract injury during hysterectomy and recon- best method for visualizing ureteral efflux? structive pelvic procedures so that they can Can instituting universal cystoscopy for all appropriately identify, evaluate, and repair gynecologic procedures make a difference in injuries in a timely fashion. the rate of injury detection? In this Update, The best way to identify urinary tract we summarize the data from 4 studies that injury at the time of gynecologic surgery is help to answer these questions. About 30% of urinary tract injuries identified prior to cystoscopy at hysterectomy (which detected 5 of 6 injuries) Vakili B, Chesson RR, Kyle BL, et al. The incidence of terectomy (59%), 31% had a vaginal hysterec- FAST urinary tract injury during hysterectomy: a prospective tomy, and 10% had a laparoscopic-assisted TRACK analysis based on universal cystoscopy. Am J Obstet Gy- vaginal hysterectomy or total laparoscopic necol. 2005;192(5):1599–1604. hysterectomy. At hysterectomy, Rate of urinary tract injuries. The total uri- the total urinary akili and colleagues conducted a mul- nary tract injury rate detected by cystoscopy tract injury rate ticenter prospective cohort study of was 4.8%. The ureteral injury rate was 1.7%, detected by V women undergoing hysterectomy and the bladder injury rate was 3.6%. A com- cystoscopy was for benign indications; cystoscopy was per- bined ureteral and bladder injury occurred in 4.8%, with the formed in all cases. The 3 hospitals involved 2 women. ureteral injury were all part of the Louisiana State University Surgery for POP significantly increased rate 1.7% and Health system. The investigators’ goal was to the risk of ureteral injury (7.3% vs 1.2%; the bladder injury determine the rate of urinary tract injury in P = .025). All cases of ureteral injury during rate 3.6% this patient population at the time of intraop- POP surgery occurred during USLS. There erative cystoscopy. was a trend toward a higher rate of blad- der injury in the group with concurrent anti-incontinence surgery (12.5% vs 3.1%; Intraoperative cystoscopy P = .049). Regarding the route of hysterec- beats visual evaluation tomy, the vaginal approach had the high- Four hundred and seventy-one women est rate of ureteral injury; however, when underwent hysterectomy and had intraop- prolapse cases were removed from the erative cystoscopy, including evaluation of analysis, there were no differences between ureteral patency with administration of intra- the abdominal, vaginal, and laparoscopic venous (IV) indigo carmine. Patients under- approaches for ureteral or bladder injuries. went abdominal, vaginal, or laparoscopic Injury detection with cystoscopy. Impor- hysterectomy, and 54 (11.4%) had concur- tantly, the authors found that only 30% of rent POP or anti-incontinence procedures. injuries were identified prior to perform- The majority underwent an abdominal hys- ing intraoperative cystoscopy. The majority CONTINUED ON PAGE 28 26 OBG Management | October 2018 | Vol. 30 No.10 mdedge.com/obgyn UPDATE pelvic floor dysfunction CONTINUED FROM PAGE 26 of these were bladder injuries. In addition, WHAT THIS EVIDENCE despite visual confirmation of ureteral peri- MEANS FOR PRACTICE stalsis during abdominal hysterectomy, when intraoperative cystoscopy was per- The rate of urinary tract injury, including formed with evaluation for ureteral efflux, 5 both bladder and ureteral injuries, was of 6 ureteral injury cases were identified. The more than 4% at the time of hysterectomy authors reported 1 postoperative vesicovagi- for benign conditions. Using intraoperative nal fistula and concluded that it was likely peristalsis or normal ureteral caliber could due to an unrecognized bladder injury. No result in a false sense of security since other undetected injuries were identified. these are not reliable signs of ureteral in- Notably, no complications occurred as a tegrity. The majority of urinary tract injuries result of cystoscopy. will not be identified without cystoscopic evaluation. Multiple surgical indications The study is limited by the inability to reflect real-world scenario blind surgeons, which may have resulted in The study included physicians from 3 differ- the surgeons altering their techniques and/ ent hospitals and all routes of hysterectomy or having a heightened awareness of the uri- for multiple benign gynecologic indications nary tract. However, their rates of ureteral as well as concomitant pelvic reconstructive and bladder injuries were slightly higher than procedures. While this enhances the gener- previously reported rates, suggesting that the alizability of the study results, all study sites procedures inherently carry risk. The study is were located in Louisiana at hospitals with further limited by the lack of a retrospective FAST resident trainee involvement. Additionally, comparison group of hysterectomy without TRACK this study confirms previous retrospective routine cystoscopy and a longer follow-up studies that reported higher rates of injury period that may have revealed additional The majority with pelvic reconstructive procedures. missed delayed urologic injuries. of urinary tract injuries during hysterectomy will not be identified without Universal cystoscopy policy proves cystoscopic evaluation protective, surgeon adherence is high Chi AM, Curran DS, Morgan DM, Fenner DE, Swenson required to demonstrate competency with CW. Universal cystoscopy after benign hysterectomy: bladder survey, visualizing ureteral efflux, examining the effects of an institutional policy. Obstet and urethral assessment. Indigo carmine was Gynecol. 2016;127(2):369–375. used to visualize ureteral efflux. n a retrospective cohort study, Chi and colleagues evaluated urinary tract inju- Detection of urologic I ries at the time of hysterectomy before and injury almost doubled with after the institution of a universal cystoscopy cystoscopy policy. At the time of policy implementation A total of 2,822 hysterectomies were at the University of Michigan, all faculty who included in the study, with 973 in the performed hysterectomies attended a cystos- pre–universal cystoscopy group and 1,849 copy workshop. Attending physicians without in the
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