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 , Obstetrics and Gynecology, Urogynecology Department of Obstetrics and Gynecology, and Reconstructive Pelvic Surgery; Associate Duke University School of Medicine, Professor of Surgery, Division of ; 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 for benign gynecologic diagnosis of ureteral and/or bladder inju- conditions, including fibroids, menorrhagia, ries is associated with increased morbidity, and (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 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

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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

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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 post–universal cystoscopy group. prior cystoscopy training also were proctored The study period was 7 years, and data on in the operating room for 3 sessions and were complications were abstracted for 1 year

28 OBG Management | October 2018 | Vol. 30 No.10 mdedge.com/obgyn after the completion of the study period. WHAT THIS EVIDENCE MEANS FOR PRACTICE The primary outcome had 3 components: • the rate of urologic injury before and after Instituting a universal cystoscopy policy for hysterectomy was the policy associated with a significant decrease in delayed postoperative • the cystoscopy detection rate of urologic urinary tract complications and an increase in the intraoperative injury detection rate of urologic injuries. Intraoperative detection and • the adherence rate to the policy. repair of a urinary tract injury is cost-effective compared with a The overall rate of bladder and ureteral delayed diagnosis. injury was 2.1%; the rate of injury during pre–universal screening was 2.6%, and dur- ing post–universal screening was 1.8%. The intraoperative detection rate of injury nearly Study had many strengths doubled, from 24% to 47%, when intraopera- This study evaluated aspects of implement- tive cystoscopy was utilized. In addition, the ing quality initiatives after proper training percentage of delayed urologic complica- and proctoring of a procedure. The authors tions decreased from 28% to 5.9% (P = .03) compared very large cohorts from a busy following implementation of the universal academic medical center in which surgeon cystoscopy policy. With regard to surgeon adherence with routine cystoscopy was adherence, cystoscopy was documented in high. The majority of patient outcomes were 86.1% of the hysterectomy cases after the pol- tracked for an extended period following icy was implemented compared with 35.7% surgery, thereby minimizing the risk of miss- of cases before the policy. ing delayed urologic injuries. Notably, how- The investigators performed a cost anal- ever, there was shorter follow-up time for ysis and found that hospital costs were nearly the post–universal cystoscopy group, which FAST twice as much if a delayed urologic injury could result in underestimating the rate of TRACK was diagnosed. delayed urologic injuries in this cohort. The percentage of delayed urologic complications decreased from Cystoscopy reveals ureteral 28% to 5.9% (P = .03) following obstruction during various implementation of a universal vaginal POP repair procedures cystoscopy policy

Gustilo-Ashby AM, Jelovsek JE, Barber MD, Yoo EH, Cystoscopy with indigo carmine Paraiso MF, Walters MD. The incidence of ureteral ob- is highly sensitive struction and the value of intraoperative cystoscopy The study included 700 patients who under- during vaginal surgery for pelvic organ prolapse. Am J went vaginal surgery for anterior and/or Obstet Gynecol. 2006;194(5):1478–1485. apical POP. Patients had 1 or more of the fol- lowing anterior and apical prolapse repair o determine the rate of ureteral procedures: USLS (51%), distal McCall cul- obstruction and ureteral injury dur- deplasty (26%), proximal McCall culdeplasty T ing vaginal surgery for POP and the (29%), anterior colporrhaphy (82%), and accuracy of using intraoperative cystoscopy colpocleisis (1.4%). Of note, distal McCall to prevent upper urinary tract morbidity, culdeplasty was defined as incorporation of Gustilo-Ashby and colleagues performed a the “vaginal epithelium into the uterosac- retrospective review study of a large patient ral plication,” while proximal McCall culde- cohort. plasty involved plication of “the uterosacral

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ligaments in the midline proximal to the vag- used for repair of anterior vaginal wall and inal cuff.” All patients were given IV indigo apical prolapse. Its retrospective design, carmine to aid in visualizing ureteral efflux. however, is a limitation; this could result in The majority of patients had a hysterec- underreporting of ureteral injuries if patients tomy (56%). When accounting for rare false- received care at another institution after sur- positive and negative cystoscopy results, the gery. Furthermore, it is unclear if cystoscopy overall ureteral obstruction rate was 5.1% would be as predictive of ureteral injury with- and the ureteral injury rate was 0.9%. The out the use of indigo carmine, which is no majority of obstructions occurred with USLS longer available at most institutions. (5.9%), proximal McCall culdeplasty (4.4%), and colpocleisis (4.2%). Ureteral injuries occurred only in 6 cases: 3 USLS and 3 proxi- mal McCall culdeplasty procedures. Based on these findings, the authors cal- WHAT THIS EVIDENCE culated that cystoscopy at the time of vaginal MEANS FOR PRACTICE surgery for anterior and/or apical prolapse The utility of cystoscopy with IV indigo has a sensitivity of 94.4% and a specificity of carmine as a screening test for ureteral 99.5% for detecting ureteral obstruction. The obstruction is highlighted by the fact that positive predictive value of cystoscopy with most obstructions were relieved by intra- the use of indigo carmine for detection of operative suture removal following positive ureteral obstruction is 91.9% and the nega- cystoscopy. McCall culdeplasty proce- tive predictive value is 99.7%. dures are commonly performed by general ObGyns at the time of vaginal hysterec- FAST tomy. It is therefore important to note that TRACK Impact of indigo carmine’s rates of ureteral obstruction after proximal unavailability McCall culdeplasty were only slightly lower For detecting This study’s strengths include its large sample than those after USLS. ureteral size and the variety of surgical approaches obstruction, the authors calculated that cystoscopy at the time of vaginal surgery for Sodium fluorescein and anterior and/or apical prolapse 10% dextrose provide clear visibility has a sensitivity of 94.4% and of ureteral jets in cystoscopy specificity of 99.5% Espaillat-Rijo L, Siff L, Alas AN, et al. Intraoperative Study compared 4 media cystoscopic evaluation of ureteral patency: a random- The investigators enrolled 176 participants ized controlled trial. Obstet Gynecol. 2016;128(6):1378– (174 completed the trial) and randomly 1383. assigned them to receive 1 of 4 modali- ties: 1) normal saline as a bladder disten- n a multicenter randomized controlled tion medium (control), 2) 10% dextrose as a trial, Espaillat-Rijo and colleagues com- bladder distention medium, 3) 200 mg oral I pared various methods for visualizing ure- phenazopyridine given 30 minutes prior to teral efflux in participants who underwent cystoscopy, or 4) 50 mg IV sodium fluores- gynecologic or urogynecologic procedures in cein at the start of cystoscopy. Indigo car- which cystoscopy was performed. mine was not included in this study because

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it has not been routinely available since 2014. urinary tract infection was 24.1% and did not Surgeons were asked to categorize the differ between groups. ureteral jets as “clearly visible,” “somewhat visible,” or “not visible.” The primary outcome was subjective vis- Results are widely ibility of the ureteral jet with each modality dur- generalizable ing cystoscopy. Secondary outcomes included This was a well-designed randomized multi- surgeon satisfaction, adverse reactions to the center trial that included both benign gyne- modality used, postoperative urinary tract cologic and urogynecologic procedures, infection, postoperative urinary retention, and thus strengthening the generalizability of delayed diagnosis of ureteral injury. the study. The study was timely since proven Visibility assessment results. Overall, ure- methods for visualization of ureteral patency teral jets were “clearly visible” in 125 cases became limited with the withdrawal of com- (71%) compared with “somewhat visible” in mercially available indigo carmine, the previ- 45 (25.6%) and “not visible” in 4 (2.3%) cases. ous gold standard. There was a statistically significant differ- ence between the 4 groups. Use of sodium fluorescein and 10% dextrose resulted in WHAT THIS EVIDENCE significantly better visualization of ureteral MEANS FOR PRACTICE jets (P<.001 and P = .004, respectively) com- pared with the control group. Visibility with Intravenous sodium fluorescein and 10% phenazopyridine was not significantly differ- dextrose as bladder distention media can ent from that in the control group or in the both safely be used to visualize ureteral ef- flux and result in high surgeon satisfaction. 10% dextrose group (FIGURE). FAST Although 10% dextrose has been associ- TRACK Surgeon satisfaction was highest with ated with higher rates of postoperative 10% dextrose and sodium fluorescein. In urinary tract infection,11 this was not found Use of sodium 6 cases, the surgeon was not satisfied with fluorescein and to be the case in this study. Preoperative visualization of the ureteral jets and relied administration of oral phenazopyridine was 10% dextrose on fluorescein (5 times) or 10% dextrose no different from the control modality with in cystoscopy (1 time) to ultimately see efflux. No signifi- regard to visibility and surgeon satisfaction. resulted in cant adverse events occurred; the rate of significantly better visualization FIGURE Ratings of modalities used in cystoscopy of ureteral jets for visualization of ureteral jets12 compared with the control group 100 90 Clearly visible

80 Somewhat visible

70 Not visible

60

50

40 % of patients 30

20

10

0 10% dextrose Phenazopyridine Sodium uorescein Saline

32 OBG Management | October 2018 | Vol. 30 No.10 mdedge.com/obgyn The cost-effectiveness consideration

The debate around universal cystoscopy following benign gynecologic surgery is ongoing. The studies discussed in this Update demonstrate that cystoscopy following hysterectomy for benign indications: • is superior to visualizing ureteral peristalsis • increases detection of urinary tract injuries, and • decreases delayed urologic injuries. Although these articles emphasize the importance of detecting urologic injury, the picture would not be complete without mention of cost-effectiveness. Only one study, from 2001, has evaluated the cost-effectiveness of universal cystoscopy.1 Those authors concluded that universal cystoscopy is cost-effective only when the rate of urologic injury is 1.5% to 2%, but this conclusion, admittedly, was limited by the lack of data on medicolegal settlements, outpatient expenses, and nonmedical-related economic loss from decreased productivity. Given the extensive changes that have occurred in medical practice over the last 17 years and the emphasis on quality metrics and safety, an updated analysis would be needed to make definitive conclusions about cost-effectiveness. While this Update cannot settle the ongoing debate of universal cystoscopy in gynecology, it is important to remember that the American College of Obstetricians and Gynecologists and the American Urogynecologic Society recommend cystoscopy following all surgeries for pelvic organ prolapse and stress urinary incontinence.2

References 1. Visco AG, Taber KH, Weidner AD, Barber MD, Myers ER. Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy. Obstet Gynecol. 2001;97(5 pt 1):685–692. 2. ACOG Committee on Practice Bulletins–Gynecology and the American Urogynecologic Society. Urinary incontinence in women. Female Pelvic Med Reconstr Surg. 2015;21(6):304–314.

References 1. Ibeanu OA, Chesson RR, Echols KT, Nieves M, Busangu F, Development Pelvic Floor Disorders Network. Comparison of Nolan TE. Urinary tract injury during hysterectomy based on 2 transvaginal surgical approaches and perioperative behav- universal cystoscopy. Obstet Gynecol. 2009;113(1):6–10. ioral therapy for apical vaginal prolapse: the OPTIMAL ran- 2. ACOG Committee on Practice Bulletins–Gynecology and the domized trial. JAMA. 2014;311(10):1023–1034. American Urogynecologic Society. Urinary incontinence in 8. Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis women. Female Pelvic Med Reconstr Surg. 2015;21(6):304– and management of ureteric injury: an evidence-based anal- 314. ysis. BJU Int. 2004;94(3):277–289. 3. Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson 9. Kwon CH, Goldberg RP, Koduri S, Sand PK. The use of intra- HB. Hysterectomy in the United States, 1988–1990. Obstet operative cystoscopy in major vaginal and urogynecologic Gynecol. 1994;83(4):549–555. surgeries. Am J Obstet Gynecol. 2002;187(6):1466–1471. 4. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epi- 10. Adams-Piper ER, Guaderrama NM, Chen Q, Whitcomb EL. demiology of surgically managed pelvic organ prolapse and Impact of surgical training on the performance of proposed urinary incontinence. Obstet Gynecol. 1997;89(4):501–506. quality measures for hysterectomy for pelvic organ prolapse. 5. Mäkinen J, Johansson J, Tomás C, et al. Morbidity of Am J Obstet Gynecol. 2017;216(6):588.e1–588.e5. 10,110 hysterectomies by type of approach. Hum Reprod. 11. Siff LN, Unger CA, Jelovsek JE, Paraiso MF, Ridgeway BM Bar- 2001;16(7):1473–1478. ber MD. Assessing ureteral patency using 10% dextrose cys- 6. Gilmour DT, Dwyer PL, Carey MP. Lower urinary tract injury toscopy fluid: evaluation of urinary tract infection rates. Am J during gynecologic surgery and its detection by intraopera- Obstet Gynecol. 2016;215(1):74.e1–74.e6. tive cystoscopy. Obstet Gynecol. 1999;94(5 pt 2):883–889. 12. Espaillat-Rijo L, Siff L, Alas AN, et al. Intraoperative cysto- 7. Barber MD, Brubaker L, Burgio KL, et al; Eunice Kennedy scopic evaluation of ureteral patency: a randomized con- Schriver National Institute of Child Health and Human trolled trial. Obstet Gynecol. 2016;128(6):1378–1383.

 Update on minimally invasive WATCH gynecologic surgery FOR... Arnold P. Advincula, MD

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