Cystoscopy reveals ureteral obstruction during various vaginal POP repair procedures
Gustilo-Ashby AM, Jelovsek JE, Barber MD, Yoo EH, Paraiso MF, Walters MD. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol. 2006;194(5):1478–1485.
To determine the rate of ureteral obstruction and ureteral injury during vaginal surgery for POP and the accuracy of using intraoperative cystoscopy to prevent upper urinary tract morbidity, Gustilo-Ashby and colleagues performed a retrospective review study of a large patient cohort.
Cystoscopy with indigo carmine is highly sensitive
The study included 700 patients who underwent vaginal surgery for anterior and/or apical POP. Patients had 1 or more of the following anterior and apical prolapse repair procedures: USLS (51%), distal McCall culdeplasty (26%), proximal McCall culdeplasty (29%), anterior colporrhaphy (82%), and colpocleisis (1.4%). Of note, distal McCall culdeplasty was defined as incorporation of the “vaginal epithelium into the uterosacral plication,” while proximal McCall culdeplasty involved plication of “the uterosacral ligaments in the midline proximal to the vaginal cuff.” All patients were given IV indigo carmine to aid in visualizing ureteral efflux.
The majority of patients had a hysterectomy (56%). When accounting for rare false-positive and negative cystoscopy results, the overall ureteral obstruction rate was 5.1% and the ureteral injury rate was 0.9%. The majority of obstructions occurred with USLS (5.9%), proximal McCall culdeplasty (4.4%), and colpocleisis (4.2%). Ureteral injuries occurred only in 6 cases: 3 USLS and 3 proximal McCall culdeplasty procedures.
Based on these findings, the authors calculated that cystoscopy at the time of vaginal surgery for anterior and/or apical prolapse has a sensitivity of 94.4% and a specificity of 99.5% for detecting ureteral obstruction. The positive predictive value of cystoscopy with the use of indigo carmine for detection of ureteral obstruction is 91.9% and the negative predictive value is 99.7%.
Impact of indigo carmine’s unavailability
This study’s strengths include its large sample size and the variety of surgical approaches used for repair of anterior vaginal wall and apical prolapse. Its retrospective design, however, is a limitation; this could result in underreporting of ureteral injuries if patients received care at another institution after surgery. Furthermore, it is unclear if cystoscopy would be as predictive of ureteral injury without the use of indigo carmine, which is no longer available at most institutions.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
The utility of cystoscopy with IV indigo carmine as a screening test for ureteral obstruction is highlighted by the fact that most obstructions were relieved by intraoperative suture removal following positive cystoscopy. McCall culdeplasty procedures are commonly performed by general ObGyns at the time of vaginal hysterectomy. It is therefore important to note that rates of ureteral obstruction after proximal McCall culdeplasty were only slightly lower than those after USLS.
The utility of cystoscopy with IV indigo carmine as a screening test for ureteral obstruction is highlighted by the fact that most obstructions were relieved by intraoperative suture removal following positive cystoscopy. McCall culdeplasty procedures are commonly performed by general ObGyns at the time of vaginal hysterectomy. It is therefore important to note that rates of ureteral obstruction after proximal McCall culdeplasty were only slightly lower than those after USLS.
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