Cystoscopy after total or subtotal laparoscopic hysterectomy: the value of a routine procedure

Abstract

Ureteral injury during hysterectomy is one of the most troubling complications gynecologists need to be aware of. In various studies, such injury occurred in laparotomy, laparoscopy, and vaginal hysterectomy. The objective of our study was to assess the necessity, efficiency, and cost-effectiveness of cystoscopy at the end of total or subtotal laparoscopic hysterectomy (TLH/STLH). This is a retrospective analysis of 7 years’ experience in a university-affiliated hospital. All hysterectomies were performed on an overnight basis by experienced surgeons. Out of 338 patients, 106 patients underwent TLH, and 232 underwent STLH. Four cases (1.18%) of ureter injury were noted (one after TLH and three after STLH). Diagnosis was clinically made by postoperative vaginal sonography and was confirmed by intravenous pyelography. A cystoscopy was performed after intravenous indigo carmine injection. The study period consisted of two phases. In the first phase, we used bipolar cautery to occlude the uterine artery; consequently, a nearby thermal injury could be misdiagnosed. In the second phase we clipped the uterine artery with a new hemoclip called Hem-o-lok (Weck Closure Systems, USA), which forced an exact uterine artery closure. As a result, in the second phase no cases of ureteral injury were noted. In view of the fact that the equipment for cystoscopy is used during surgery for TLH/STLH and is sterile and available, the only additional cost of the cystoscopy is an ampule of indigo carmine. Therefore, we conclude that cystoscopy at the end of surgery for TLH/STLH is an important evaluation and provides the following significant advantages: In patients presenting with postoperative flank pain, cystoscopy may prevent the need for further evaluation and expensive testing, and cystoscopy increases the surgeon’s and the patient’s confidence in the integrity of the urinary tract during the recovery period.