Making cystoscopy accessible in gynecology

Intraoperative cystoscopy

Reported rates of ureteral and bladder injury during gynecologic procedures have varied by study, type of injury, and complexity of surgery.

In an early report on the usefulness of intra-operative cystoscopy, Dr. Sergio Ribeirio and his colleagues reported that the procedure enabled early recognition and treatment of ureteral injuries in four of a series of 118 patients (3.4%) undergoing total laparoscopic hysterectomy with vault suspension (Hum Reprod. 1999 Jul;14[7]:1727-9.)

A review of 236,392 patients who underwent various laparoscopic gynecologic operations during 1994-2000 showed a urinary tract injury rate ranging from 0.02% to 1.7% (Clin Obstet Gynecol. 2002 Jun;45[2]:469- 80.). And, in another review specifically of ureteral injury in laparoscopic pelvic surgery, incidences of injury ranged from less than 1% to 2% (Obstet Gynecol Surv. 2003 Dec;58[12]:794-9.).

Other studies on the use of cystoscopy have reported injury rates up to and above 3%. In most cases, such reports include the incidence of bladder injury, which is less uncommon. Intraoperative bladder perforation occurs in 3%-9% of cases of midurethral retropubic sling procedures, for instance, according to ACOG’s opinion paper.

In a recent chart review of almost 1,000 women who underwent uterosacral colpopexy for pelvic organ prolapse, on the other hand, the intraoperative bladder injury rate was only 1%, and the rate of ureteral kinking/obstruction requiring stitch removal was significantly higher at 4.5% (Am J Obstet Gynecol. 2015;212:603.e1-7.).

Urinary tract injuries can have serious implications in terms of morbidity and litigation. When an injury is detected intraoperatively, the surgeon can repair it immediately and reduce the risk of complications and readmissions. The ureteral kinking detected in the previously mentioned study would not have been diagnosed without routine cystoscopy; nor would most cases of inadvertent suture or mesh placement in the bladder or urethral lumen.

The advisability of performing cystoscopy routinely in all gynecologic surgical procedures has been debated and should be studied further. However, given the advantages of early detection and the new availability of relatively simple and inexpensive cystoscopy, it is now possible – and will likely be beneficial – to move toward more routine use.

Currently, cystoscopy is performed in only a minority of indicated cases. In the 2003 review cited above from Obstetrical & Gynecological Survey, the ureteral injuries that occurred were identified intraoperatively in only 8.6% of the cases. And in an additional systematic literature review of urinary tract injury from gynecologic surgery, only 17 of the 47 studies included in the review employed routine intraoperative cystoscopy (Obstet Gynecol. 2006 Jun;107[6]:1366-72.).

A survey of ob.gyn residents presented at the ACOG meeting in May 2015 similarly showed that for hysterectomy, universal cystoscopy (defined as being performed in more than 90% of cases) was performed in the residents’ training settings for only a fraction of various types of hysterectomies, from vaginal hysterectomy to total laparoscopic hysterectomy.

Yet, in looking toward their future practice, the residents indicated in the survey that they plan to perform universal cystoscopy more frequently. The majority of them – almost 80% – had been involved with a hysterectomy having a bladder or ureter injury, according to the survey.

The Cystosure system facilitates a complete check of ureteral patency and bladder integrity. The system’s three-way catheter can be placed once and used for multiple passes of the cystoscope as well as for intraoperative retrograde fill of the bladder, postoperative drainage, and IV-based hands-free backfill voiding trials prior to discharge. The catheter’s red balloon port accepts the standard 5 cc syringe, and the blue inflow port provides a universal IV/cysto tubing fitting. The yellow drainage port may be attached to a standardized urinary drainage bag.

With Cystosure, a postoperative voiding trial thus becomes simpler and more efficient than it has in the past. Our nurses can clamp the outflow port, attach the IV bag to the inflow port, and briefly turn their attention elsewhere while the bladder fills hands free. The catheter is then removed, and the patient is allowed to void.

In the office

In the office, Cystosure can similarly make the evaluation of conditions like overactive bladder, urinary incontinence, incomplete bladder emptying, and recurrent urinary tract infections much easier and less expensive, enabling more gynecologists to take the lead in diagnosis.

Currently, there are various methods for performing cystometric testing. One technique, sometimes called “poor man’s cystometry,” involves placing a Foley red rubber catheter in the bladder, attaching a large syringe with the plunger removed, filling the bladder by pour technique, and monitoring the patient’s described sensations of bladder fullness and urge to urinate. This basic test can provide useful information about bladder functioning; patients with overactive bladder feel sensation at much smaller volumes than do patients with neurogenic bladder, for instance.