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Cystoscopy and Ureteral Stents for the Gynecologic Surgeon (Didactic)

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Cystoscopy and Ureteral Stents for the Gynecologic Surgeon (Didactic) Cystoscopy and Ureteral Stents for the Gynecologic Surgeon (Didactic) PROGRAM CHAIR Paul D. Pettit, MD Anita Chen, MD Robert G. Ferrigni, MD Barry K. Jarnagin, MD Sponsored by AAGL Advancing Minimally Invasive Gynecology Worldwide Professional Education Information Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME. Table of Contents Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 3 Importance of Cystoscopy in Gynecologic Surgery P.D. Pettit ..................................................................................................................................................... 5 Basics of Cystoscopy B.K. Jarnagin ............................................................................................................................................... 13 Common Benign Cystoscopic Findings A. Chen ....................................................................................................................................................... 20 Normal Cystoscopic Findings and Reasons for Referral to Urology R.G. Ferrigni ................................................................................................................................................ 27 Surgical Management of Gyn Surgical Injury to Ureter and Bladder R.G. Ferrigni, P.D. Pettit ............................................................................................................................. 46 Cultural and Linguistics Competency ......................................................................................................... 61 PG 107 Cystoscopy and Ureteral Stents for the Gynecologic Surgeon (Didactic) Paul D. Pettit, Chair Faculty: Anita Chen, Robert G. Ferrigni, Barry K. Jarnagin Course Description Cystoscopy, like laparoscopy, is a technology that should benefit our patients and not isolate a specialty. Cystoscopy should be a component of any pelvic surgery when the lower urinary tract is at risk for injury. The cystoscope has become essential for patient safety with increased utilization of laparoscopy and robotic surgery. The cystoscope is not a substitute for surgical technique or judgment. This course is designed to give the participants the cystoscopic means to be sure of technique, allow adjustment for distorted anatomy and to correct potential or actual surgical injury at the primary operation. The morning session will be a didactic discussions; including basic and advance information necessary to carry out the technical challenges of cystoscopy. Course Objectives At the conclusion of this course, the participant will be able to: 1) Review relevant lower urinary tract anatomy; 2) identify bladder landmarks and common benign findings; 3) identify bladder pathology that should be referred to a urologist; 4) assemble and perform ridged and flexible cystoscopy; 5) select and utilize the four basic types of stents (open end, single j, double j, acorn tip); 6) recognize bladder and ureteral injury Intraoperatively; 7) place stents during laparotomy via cystotomy; 8) select appropriate pre-op and post-op diagnostic testing to define preoperative anatomy and know when it is safe to remove stents; and 9) manage postop complication of ureteral and bladder injury. Course Outline 8:00 Welcome, Introductions and Course Overview P.D. Pettit 8:05 Importance of Cystoscopy in Gynecologic Surgery P.D. Pettit 8:45 Basics of Cystoscopy B.K. Jarnagin 9:15 Common Benign Cystoscopic Findings A. Chen 9:45 Questions & Answers All Faculty 10:00 Break 10:15 Normal Cystoscopic Findings and Reasons for Referral to Urology R.G. Ferrigni 10:45 Surgical Management of Gyn Surgical Injury to Ureter and Bladder R.G. Ferrigni, P.D. Pettit 1 11:15 Post-Surgical Management and Stent Complications – PowerPoint Case Presentations All Faculty 11:45 Questions & Answers All Faculty 12:00 Course Evaluation 2 PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other: Lecturer - Olympus, Lecturer - Karl Storz Endoscopy-America SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties - CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium - Ethicon Endo-Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy-America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor - Intuitve Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Paul D. Pettit* Anita Chen* Robert G. Ferrigni* Barry K. Jarnagin Grants/Research Support: Coloplast 3 Asterisk (*) denotes no financial relationships to disclose. 4 Paul D. M. Pettit, M.D. Disclosure Cystoscopy In • I have no financial relationships to Gyn Surgery disclose. mayo mayo 02112K deg:PMP 1 02112K deg:PMP 2 Should be a part of all GYN surgery Objective when unable to ensure the integrity of the lower urinary tract This lecture will highlight how cystoscopy is a valuable safeguard for all pelvic surgery! mayo mayo 02112K deg:PMP 3 02112K deg:PMP 4 Unrecognized Urinary Tract Genitourinary FistulasFistulas-- Etiology InjuryInjury Radiation Therapy TTrraumaauma 4%4% 6%6% OBOB • Fistula 8%8% 85% GYN Surgery • Obstruction • Loss of renal function • Any combination mayo Lee et al Obstet Gyn 72:313, 1988 mayo 02112K deg:PMP 5 02112K deg:PMP 6 5 Genitourinary FistulasFistulas-- Reason Vesicovaginal Fistula for Surgeryfor Surgery Malignant 14% >90% 12%12%??12% ? 74%74%74% Benign Benign Surgery benign conditions conditioncondition (70% TAH) Lee et al Obstet Gyn 72:313, 1988 Lee et al Obstet Gyn 72:313, 1988 mayo mayo 02112K deg:PMP 7 02112K deg:PMP 8 Surgical Etiology of Fistula Pelvic Surgery Safeguards Identification and mobilization of all contiguous structures • Sharp dissection • Unrecogggnized gross in jyjury • Traction and counter traction • Inadvertent placement of suture • Retroperitoneal spaces • Necrosis from hematoma, infection or • Intentional cystotomy devascularization • Ureteral catheters • Suction drainage • Antibiotics Symmonds RE: JCE OB/GYN, 21:13, 1979 • Foley mayo mayo 02112K deg:PMP 9 • Cystoscopy 02112K deg:PMP 10 Specific Abdominal Surgery Identify ureters above level of Safeguards pathologypathology • Identify ureters above level of pathology • Identify and protect throughout their course • Sharply
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