Intravenous Indigo Carmine Research Articles

Indigo carmine dye for detecting urinary track damage during vaginal surgery

ObjectiveUnrecognized ureteral and bladder injury increase morbidity and mortality in gynecologic surgery. The primary objective of this study is to analyze the efficiency of a systematic intra-venous (IV) injection of carmine indigo to detect bladder injury in gynecologic vaginal surgery for benign disease. The secondary objective is to analyze the cost and use of carmine indigo. Study designA retrospective, monocentric study was conducted in a tertiary hospital between January 2018 and October 2021. All patients undergoing a vaginal surgery of hysterectomy for benign disease or anterior prolapse were systematically included. Patients can be systematically included by the automatic coding of surgery. After anesthesia, during the patient's installation, an intravenous injection of 5 mL of intravenous indigo carmine (Carmyne®) diluted in 100 mL of physiological serum was systematically administered by the anesthesia team. Intraoperative cystoscopy was performed only in cases of suspected associated ureteral injury. ResultsWe recorded 443 vaginal hysterectomies for benign disease and 95 vaginal anterior prolapse surgeries. There were 6 (1,4%) bladder injuries during vaginal hysterectomies and 1 (1,1%) bladder injury during vaginal prolapse surgery. All bladder injuries were diagnosed intraoperatively. No ureteral injury was diagnosed in this series of patients. No complication related to IV indigo carmine injection was found. In this tertiary hospital, 1085 ampoules of carmine indigo were ordered during the same period, approximatively 270 per year. The total cost to the gynecology and obstetrics department was 19,600 euros, or about 4,900 euros per year. Half of the carmine indigo was used in vaginal surgery and half in laparotomy, caesarean section and endometriosis surgery for suspected bladder or ureteral injury.

A Randomized Clinical Trial Evaluating Indigo Carmine as a Visualization Aid for Evaluating Ureteral Patency

ObjectivesTo determine whether intravenous indigo carmine provides a visualization advantage compared to saline in the evaluation of ureteral patency in a randomized, controlled clinical trial. MethodsPatients undergoing urological or gynecological surgical procedures in which the patency of the ureter was to be assessed received a saline injection and were randomized to receive 2.5 mL or 5.0 mL of indigo carmine. Blinded video assessments were conducted by independent reviewers using a conspicuity scale ranked 1 (poorest) to 5 (best), and subjects with scores ≥ 3 and at least a +1-point difference from saline were considered responders. Time to visualization was recorded for indigo carmine. A responder analysis evaluated whether indigo carmine showed improved visualization. ResultsThere were 96 ureters evaluated with the 5.0 mL dose of indigo carmine, 92 with the 2.5 mL dose, and 180 with saline. Most ureters were scored a 4 or higher on the conspicuity scale following indigo carmine; both doses were significantly better than saline (p<0.0001). Overall, 92.3% of patients were rated as a responder for either ureter. The median time to visualization of blue color was not significantly different (6.0 minutes in the 5.0 mL group and 5.9 minutes in the 2.5 mL group). There were no adverse events related to indigo carmine use. ConclusionsBoth dose levels of indigo carmine were significantly better than saline as a visualization aid for ureter patency.

Cost-effectiveness of agents used for evaluation of ureteral patency during intraoperative cystoscopy in gynecologic and urogynecologic surgery

Intraoperative evaluation of ureteral patency is often performed in gynecologic and urogynecologic surgery. Many agents are used to help assess the patency, each with its own associated cost, ease of use, and adverse reactions. Some agents, such as dextrose, are used as an instillation fluid to create a viscosity difference and aid the visualization of a ureteral jet. Others, such as oral phenazopyridine or the intravenous use of sodium fluorescein and indigo carmine, cause a color change of the urine to directly aid the visualization of ureteral jets. Recently, numerous studies have examined the efficacy and surgeon satisfaction of these agents. The studies have also emphasized certain options as associated with a lower cost. However, there have not been any cost studies comparing these agents. To compare the cost-effectiveness of the following 4 agents that are commonly used in assessing ureteral patency intraoperatively: oral phenazopyridine, dextrose instillation, intravenous sodium fluorescein, and intravenous indigo carmine. We constructed a decision-analytic model to compare cystoscopy using oral phenazopyridine, dextrose instillation, intravenous sodium fluorescein, and intravenous indigo carmine. Failure to see efflux resulted in work-ups for ureteral obstruction. The probabilities were obtained from published studies, and the probability of successfully seeing efflux ranged from 0.92 with oral phenazopyridine to 0.99 with intravenous indigo carmine. The costs of the agents, adverse effects, and ureteral obstruction work-ups were obtained from the University of North Carolina at Chapel Hill Department of Pharmacy, the Healthcare Cost and Utilization Project 2016 database and the FAIR Health Consumer database. The cost of a ureteral obstruction work-up used in our model ranged from $9755 for intraoperative evaluation with retrograde pyelograms and stents to $29,034 for hospitalization. Our primary outcome was the incremental cost-effectiveness ratio per unnecessary work-up for ureteral obstruction avoided. Sensitivity analyses were performed to identify the key uncertainties. Oral phenazopyridine, followed by an intravenous agent if needed, had a mean cost of $110 per patient. Dextrose averaged $151 more per patient, with only a slight improvement in avoiding unnecessary ureteral obstruction work-ups and a higher cost associated with adverse reactions (incremental cost-effectiveness ratio, $62,000). Intravenous agents cost approximately $1000 more per patient and were less effective at preventing unnecessary work-ups. Sensitivity analyses did not identify any thresholds that would significantly change the outcomes. Our model suggests that oral phenazopyridine and dextrose instillation are the least expensive and the most effective agents to aid in the visualization of ureteral patency during intraoperative cystoscopy, although dextrose is associated with higher costs owing to a higher rate of adverse reactions (primarily urinary tract infections). Intravenous sodium fluorescein and indigo carmine are historically popular first-choice agents. However, they were found to be more expensive and less effective as primary agents in our model and should likely be reserved for use as secondary agents in the event that the visualization of ureteral jets is unclear with the initial use of phenazopyridine or dextrose.

Risk of Urinary Tract Infection Symptoms after Posthysterectomy Cystoscopy with 50% Dextrose as Compared with Saline Cystoscopy with Indigo Carmine

Compare odds of postoperative urinary symptoms in women who had cystoscopy after benign laparoscopic hysterectomy with 50% dextrose and with normal saline solution with intravenous indigo carmine. Retrospective cohort study. Two tertiary care centers. All women who underwent benign laparoscopic hysterectomy and intraoperative cystoscopy carried out by a single surgeon. We compared postoperative urinary symptoms in patients who received 50% dextrose cystoscopy fluid (January 2016-June 2017) with those who received saline cystoscopy with intravenous indigo carmine (November 2013-April 2014). A total of 96 patients had cystoscopy with 50% dextrose and 104 with normal saline with intravenous indigo carmine. Differences in baseline characteristics of the two groups of participants mainly reflected institutional population diversity: age (45.2 vs 41.9, p = .01), body mass index (26.9 vs 33.4, p <.01), race, current smoking status (1% vs 7.8%, p = .04), diabetes (2.1% vs 11.5%, p = .01), history of abdominal surgery (53.1% vs 74%, p <.01), hysterectomy type, receipt of intraoperative antibiotics (92.7% vs 100%, p <.01), recatheterization (10.4% vs 0%, p <.01), and removal of catheter on postoperative day 0 (66.7% vs 12.5%, p <.01). Urinary symptoms were similar for 50% dextrose and saline (12.5% vs 7.7%, p = .19). After adjusting for age, body mass index, race, diabetes, and day of catheter removal, there remained no significant differences in urinary symptoms between the groups (odds ratio 3.19 [95% confidence interval, 0.82-12.35], p = .09). One immediate bladder injury was detected in the saline group and 1 delayed lower urinary tract injury in the 50% dextrose group. Overall, most women experienced no urinary symptoms after benign laparoscopic hysterectomy. There were no significant differences in postoperative urinary symptoms or empiric treatment of urinary tract infection after the use of 50% dextrose cystoscopy fluid as compared with normal saline. The previous finding of increased odds of urinary tract infection after dextrose cystoscopy may be due to use in a high-risk population.

Assessing ureteral patency using 10% dextrose cystoscopy fluid: evaluation of urinary tract infection rates

Intravenous indigo carmine has routinely been used to confirm ureteral patency after urogynecologic surgery. Recent discontinuation of the dye has altered clinical practice. In the absence of indigo carmine, we have used 10% dextrose in sterile water (D10) as cystoscopic fluid to evaluate ureteral patency. Glucosuria has been associated with urinary tract infection (UTI) invivo and significantly enhanced bacterial growth invitro. The concern is that the use of D10 would mimic a state of glucosuria albeit transient and increase the risk of postoperative UTI. The objectives of this study were to compare the rates of postoperative UTI and lower urinary tract (LUT) injuries between patients who underwent instillation of D10 vs normal saline at the time of intraoperative cystoscopy after urogynecological surgery. This was a retrospective cohort study of all women who underwent cystoscopic evaluation of ureteral patency at the time of urogynecological surgery from May through December 2014 at a tertiary care referral center. We compared patients who received D10 cystoscopy fluid vs those who used normal saline. Outcomes included UTI and diagnosis of ureteral or LUT injuries. UTI was diagnosed according to Centers for Disease Control and Prevention guidelines by symptoms alone, urine dipstick, urinalysis, or urine culture. Descriptive statistics compared the rates of UTI between the 2 groups, and a multivariable model was fit to the data to control for potential confounders and significant baseline differences between the groups. A total of 303 women were included. D10 was used in 113 cases and normal saline (NS) was used in 190. The rate of UTI was higher in the D10 group than the NS group: 47.8% (95% confidence interval [CI], 38.3-57.4) vs 25.9% (95% CI, 19.8-32.8, P < .001). After adjusting for age, pelvic organ prolapse stage, use of perioperative estrogen, days of postoperative catheterization, menopausal status, diabetes mellitus, and history of recurrent UTI, the UTI rate remained significantly higher with the use of D10 (adjusted odds ratio, 3.4 [95% CI, 1.6-7.5], P= .002) compared with NS. Overall, 3 cases of transient ureteral kinking (1.0%) and one cystotomy (0.3%) were identified intraoperatively. However, ureteral and LUT injuries were not different between groups. No unidentified injuries presented postoperatively. Although the use of D10 cystoscopy fluid has been successful in identifying ureteral patency in the absence of indigo carmine, it is associated with an increased rate of postoperative UTI compared with NS.

The values shown on optical technology-based patient monitors must be cautiously interpreted: intravenous dye-induced errors.

Intravenous dyes such as indocyanine green (ICG), indigo carmine, and methylene blue are commonly used during various surgical procedures. The intraoperative administration of intravenous dyes can result in misreadings of the actual values measured by optical technology-based patient monitors (i.e., cerebral oximeters and pulse oximeters) because they interfere with the amount of the specific infrared or red wavelength detected by each device. Therefore, clinicians would benefit from a narrow review of the effects of intravenously administered dyes on regional cerebral tissue oxygen saturation and percutaneous oxygen saturation readings. The pulse oximeter was developed based on the fact that oxygenated and reduced hemoglobin have different rates of absorption of red and infrared light (Lambert-Beer law). Oxyhemoglobin absorbs more infrared light (990 nm), whereas deoxyhemoglobin absorbs more red light (660 nm). The device detects the difference in the extent of absorption of two wavelengths of light (660 and 925 nm) in arterial blood. The value is automatically calculated as an absorption ratio (extent of light detected at 660 nm/extent of light detected at 925 nm) and is represented as the arterial oxygen saturation (SaO2). Similar to pulse oximetry, cerebral near-infrared spectrometry measures the absorption ratio of two different wavelengths of near-infrared light (730 and 805 nm) in venous, capillary, and arterial blood and represents the value as the regional cerebral tissue oxygen saturation (SctO2). In clinical practice, intraoperative ICG is commonly used during neurosurgery to confirm the patency of the anastomosed vessels after middle cerebral artery-superficial temporal artery bypass surgery or carotid endarterectomy and the completeness of the secured aneurysm after cerebral aneurysmal clipping. The peak absorption wavelength of ICG is 805 nm [1]. A clinical study published in this issue of the Korean Journal of Anesthesiology demonstrates that the intravenous injection of ICG can produce false increases in SctO2 readings in a dosedependent fashion [2]. This finding can be partly explained by an increase in the absorption ratio of two different wavelengths of light: 730 and 805 nm. In other words, ICG absorbs light with a wavelength of 805 nm, falsely decreasing the amount of 805 nm light detected by the cerebral oximeter; this light is displaced as an increased SctO2 reading. Another recent study showed that intravenous ICG administration caused a false decrease in SaO2 readings [2,3]. ICG acts similarly to deoxyhemoglobin in arterial blood; this falsely decreases the absorption ratio of red and infrared wavelengths detected by the pulse oximeter, resulting in a decreased SaO2 reading. Indigo carmine is commonly used during urologic surgical procedures to identify the ureteral orifices in the bladder. Indigo carmine is a blue dye with peak absorption at around 620 nm [1]. Therefore, intravenous indigo carmine administration, like ICG injection, causes a false decrease in SaO2 readings by decreasing the amount of red light (660 nm) detected by the pulse oximeter. In contrast to ICG, however, indigo carmine administration results in a false reduction in SctO2 readings by decreasing the amount of light with a wavelength of 730 nm detected by the cerebral oximeter [4]. Methylene blue, which is used to treat vasoplegic syndrome in clinical practice [5,6], has an absorption peak at 668 nm and shows a dose-dependent effect on plasma light absorbance, resulting in falsely low values on pulse oximeters and cerebral oximeters [7,8]. In conclusion, clinicians should be aware that the intraoperative administration of various dyes can cause misreadings of the actual values measured by optical technology-based patient monitors, including cerebral oximeters and pulse oximeters, by interfering with the amount of the specific infrared or red wavelength detected by each device.

Cardiac arrest from intravenous indigo carmine during laparoscopic surgery -A case report-

Indigo carmine (sodium indigotindisulfonate) is a safe, biologically inactive blue dye routinely administered intravascularly during urologic and gynecologic procedures to localize the ureteral orifices and to identify severed ureters and fistulous communications. We report a case of hypotension, cardiac arrest, and cerebral ischemia after the administration of indigo carmine in a patient under total laparoscopic hysterectomy.

The role of preoperative oral vitamin B in the cystoscopic assessment of ureteric patency

The objective of this study is to determine whether oral vitamin B can be used as a marker of ureteric patency at cystoscopy, and thereby reduce the need for intraoperative intravenous indigo carmine. Patients scheduled for cystoscopy, or for an operation likely to require a cystoscopy, were given three tablets of vitamin B complex orally 1-4 h prior to their operation. The time of administration, time of operation, and time of cystoscopy were recorded. The time taken for ureteric jets to be visualized was also recorded. The color of the urine was graded by the operator as being clear (negative) or bright yellow (positive), indicating ureteric patency and that no indigo carmine was required. Sixty-nine women in total were given vitamin B prior to their cystoscopy. One case was cancelled because of presumed but unproven aspiration. In 49 of the remaining 68 cases (72.1%), yellow urine was seen at both ureteric orifices. In 19 (27.9%) cases, yellow urine was not seen at both ureteric orifices; however, unilateral yellow, clear, or turbulent jets were seen in all but one case. The mean time from dose to cystoscopy was 162 min and the mean time for visualization of both ureteric jets was 2.2 min with no significant difference between groups. Indigo carmine was used in only two cases (2.9%). The results of this study show that oral vitamin B administration preoperatively has the potential to be used to reduce the requirement for intravenous indigo carmine administration. This would have advantages in reducing the cost and toxicity of intravenous indigo carmine administration. Vitamin B warrants further investigation and refinement as a marker of ureteric patency at cystoscopy.

Laparoscopic Utero-Sacral Plication Addressing Apical Vaginal Prolapse: Nothing New!

Study Objective: To describe and lend further support to a simple, effective, safe and minimally invasive surgical technique (laparoscopic uterosacral ligament plication), used to address apical vaginal prolapse. To report objective clinical data that demonstrate successful outcome. Design: Describe technique, report data on a case series from retrospective chart review and clinical interview. Setting: Antrim Area Hospital, Department of Gynaecology, Northern Ireland. Patients: 10 patients with apical vaginal prolapse underwent laparoscopic uterosacral ligament plication either as a primary procedure or as an adjunct to laparoscopic paravaginal repair or total laparoscopic hysterectomy. Intervention: The ureters are first identified and releasing incisions made medially on the uterosacral ligaments. Non-absorbable, monofilament, sutures 0 (Monosof™) are then run continuously from a posterior position, anteriorly onto the pubo-cervical fascia. Extra-corporeal sutures are then tied and tightened to shorten the uterosacral ligament, elevating the vaginal apex. Cystoscopy is performed using intravenous indigo carmine to ensure there is no ureteric injury, occlusion or kinking. Measurements and Main Results: Pelvic organ prolapse quantification (POP-Q) assessments were made pre and post operatively and at 3 months post surgery, providing an objective measurement of the surgical result. POP-Q demonstrated immediate improvement in prolapse staging of all patients. Three months to 1 year after initial operation 2 patients required further surgery to address middle compartment prolapse. These women had chosen to retain their uteri and went on to have a hysterectomy. Subjectively 8/10 (80%) patients reported a “satisfactory to excellent” result from the procedure. There were no major complications or ureteric injuries. Conclusion: This small case series demonstrates the safety and effectiveness of a laparoscopic equivalent to the vaginal apical support technique originally described by McCall in 1957.

A Case of Vesicocutaneous Fistula to the Thigh

We report a case of vesicocutaneous fistula to the thigh that developed 7 years after an injury to the pelvis. A 34-year-old male patient was referred to our hospital because of a water-soluble yellow exudate from his left thigh. A urinary fistula was suggested by the results of an intravenous indigo carmine injection. Intravenous pyelography and computed tomography revealed the presence of a bladder deformation and a fistula originating at the ventral bladder wall and leading down to the left thigh. The patient underwent fistulectomy and partial cystectomy. To the best of our knowledge, no previous reports of vesicocutaneous fistula to the thigh have been published.

The Safety of Intravenous Indigo Carmine to Assess Ureteric Patency During Transvaginal Uterosacral Suspension of the Vaginal Vault

In Brief Objective: There is approximately a 0.6% to 10.9% risk of intraoperative ureteric injury with transvaginal uterosacral suspension of the vaginal vault. Indigo carmine (indigotridisulfonate sodium) is a blue dye used primarily in urological and gynecological surgery in combination with cystoscopy to assess ureteric patency. Manufacturers warn that mild pressor effects may be encountered in some patients and serious adverse reactions to the drug have been reported. This study evaluates the hemodynamic responses to indigo carmine during gynecological surgery. Methods: The effect of indigo carmine on blood pressure and heart rate was reviewed retrospectively in a series of 71 patients who underwent transvaginal high uterosacral ligament fixation between January 2007 and April 2008 at Weston General Hospital, United Kingdom. Results: Indigo carmine was shown to induce a statistically significant increase in both systolic and diastolic blood pressure with a maximum response observed at 5 minutes. In addition, a statistically significant fall in heart rate was seen with a maximum difference at 10 minutes. One critical incident was encountered in our patient group within 1 hour after the administration of indigo carmine. This is unlikely to have occurred as a direct result of indigo carmine administration. Conclusions: In our experience, intravenous indigo carmine is a safe method for assessing ureteric patency during gynecological surgery. However, our results support existing evidence that indigo carmine induces an increase in blood pressure, together with a fall in heart rate, and as a result caution should be taken during its use in patients with cardiovascular disease. The effect of intravenous indigo carmine on blood pressure and heart rate was studied in a series of 71 women undergoing transvaginal high uterosacral ligament fixation. Only 1 patient in our series experienced a critical incident within 1 hour of indigo carmine administration and it is unlikely that this occurred as a direct result of the drug. Therefore, in our experience intravenous indigo carmine appears to be a safe method for assessing ureteric patency during gynecological surgery. However, our results support existing evidence that indigo carmine induces changes in patients’ hemodynamic status by increasing blood pressure and decreasing heart rate. It would be prudent to administer caution during its use in patients with cardiovascular disease, and further investigation of its hemodynamic effects in these patients over shorter time intervals may be of interest.

The Effect of Intravenous Indigo Carmine on Near-Infrared Cerebral Oximetry

The effects of IV-administered dyes on pulse oximetry have been well described. However, the effects on near-infrared cerebral oximetry have not been well documented. We report a series of four patients undergoing radical prostatectomy who were monitored with cerebral oximetry during surgery. After the administration of indigo carmine, intraoperative desaturations were observed for an extended period. Because clinical use of near-infrared cerebral oximetry is increasing, anesthesiologists should be aware of this issue.

Intravenous indigo carmine might cause cerebral ischemia

Acta Anaesthesiologica ScandinavicaVolume 51, Issue 6 p. 776-777 Intravenous indigo carmine might cause cerebral ischemia Y. Kawaguchi, Corresponding Author Y. KawaguchiY. Kawaguchi Department of AnesthesiologyUniversity of Hirosaki School of MedicineHirosaki 036–8563Japane-mail: my405maru@yahoo.co.jpSearch for more papers by this authorH. Hashimoto, H. HashimotoSearch for more papers by this authorM. Kitayama, M. KitayamaSearch for more papers by this authorK. Hirota, K. HirotaSearch for more papers by this author Y. Kawaguchi, Corresponding Author Y. KawaguchiY. Kawaguchi Department of AnesthesiologyUniversity of Hirosaki School of MedicineHirosaki 036–8563Japane-mail: my405maru@yahoo.co.jpSearch for more papers by this authorH. Hashimoto, H. HashimotoSearch for more papers by this authorM. Kitayama, M. KitayamaSearch for more papers by this authorK. Hirota, K. HirotaSearch for more papers by this author First published: 26 April 2007 https://doi.org/10.1111/j.1399-6576.2007.01320.xCitations: 5Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume51, Issue6July 2007Pages 776-777 RelatedInformation

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

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.

Life-threatening reaction to indigo carmine – A sulfa allergy?

Indigo carmine is commonly used during cystoscopy when evaluating for lower urinary tract safety after gynecologic surgery. We report a case of severe hypotension and bradycardia following intravenous indigo carmine injection in a patient with known sulfa allergy.

The use of intraoperative cystoscopy in major vaginal and urogynecologic surgeries

Objective: Our purpose was to examine the frequency of significant intraoperative cystoscopic findings during major vaginal reconstructive and urogynecologic surgeries. Study Design: The records of 526 consecutive women who underwent routine cystoscopy with intravenous injection of indigo carmine at the time of their urogynecologic and major vaginal reconstructive procedures between January 1, 1997, and April 20, 2001, were reviewed. We determined the incidence of significant cystoscopic findings and their effect on intraoperative management. Two-tailed t tests and logistic regression analyses were used to compare characteristics between the groups with and without significant cystoscopic findings. Results: During the 526 operations, 26 significant findings (4.9%) were unsuspected before cystoscopy and 15 (2.9%) of these findings were operative injuries that required intervention. Seventy-nine subjects (15.0%) had no anti-incontinence operation performed. Of these patients, there was one partial ureteral obstruction from an anterior colporrhaphy (1.3%). Seven of 184 Burch procedures (3.8%) resulted in injuries to the lower urinary tract, of which 3 (1.6%) required intervention that were unrecognized before cystoscopy. Seven of the 15 cases resulting in changes in intraoperative management were caused by anterior colporrhaphy sutures (2.0% of all anterior colporrhaphies). There were no unrecognized injuries that caused morbidity after surgery. There were no significant differences between patients with abnormal and normal cystoscopic findings in regard to mean age, weight, parity, estimated blood loss, previous surgery, or previous incontinence surgeries. No complications or morbidity occurred as a direct result of intraoperative cystoscopy. Conclusion: Intraoperative cystoscopy with intravenous indigo carmine is a safe and effective way to detect injury of the lower urinary tract. Cystoscopy detected unsuspected operative injuries in 2.9%. In cases that did not involve anti-incontinence procedures, the rate of injury was 1.3%. With a significant rate of detection, cystoscopy allows for immediate recognition and easier repair of lower urinary tract injury, lowering the patient's risk for morbidity. Anterior colporrhaphy was the most common cause of unrecognized ureteral compromise. (Am J Obstet Gynecol 2002;187:1466-72.)

Extreme Hypotension Followed by an Intravenous Indigo Carmine Injection during a Radical Prostatectomy: A case report

Indigo carmine (sodium indigotin disulfonate) is a blue dye that is generally regarded as a safe and inactive material. It is widely used in urology and gynecology to identify the ureteral orifice. Occasionally it causes high blood pressure, bradycardia, nausea and vomiting as side effects. Though rare, it can cause a skin rash, pruritus, and bronchospasm as well. However, it is known that hypotension is extremely uncommon. We report an experience of extreme hypotension that happened immediately after an intravenous indigo carmine injection during a radical prostatectomy under general anesthesia.

The role of intraoperative cystoscopy in prolapse and incontinence surgery

Objective: Unrecognized ureteral and bladder injury are a known source of morbidity and mortality in gynecologic surgery. The objective of this study was to determine the frequency that intraoperative cystoscopy during prolapse and incontinence procedures produced a change in intraoperative management to prevent ureteric and bladder injury. Study Design: This study reviewed the charts and operative reports of 235 cases of routine intraoperative cystoscopy during prolapse and incontinence surgery during a 2-year period in a tertiary care urogynecology unit. Demographic data and potential risk factors for intraoperative urinary tract injury were recorded. Cases that involved a change in management brought about by intraoperative cystoscopy with intravenous indigo carmine were compared with cases in which intraoperative cystoscopy was normal. Variables were compared with use of the Student t test and the χ2 test. Results: Of 235 cases, 11 were excluded. Of the 224 remaining cases, 12 (5.3%) underwent changes in intraoperative management as a result of cystoscopic findings. Eight cases involved ureteric blockage. Patients with abnormal cystoscopies did not differ from patients with normal intraoperative findings with regard to age, weight, parity, maximum grade of prolapse, estimated blood loss, or previous surgery. In 58% of patients with abnormal cystoscopies, there was no suspicion of technical difficulty on the basis of previous surgical history. Preoperative renal imaging did not predict cases with abnormal cystoscopy. There were no cases of complications caused by the intraoperative cystoscopy. Conclusion: Intraoperative cystoscopy with intravenous injection of indigo carmine is a safe technique that can detect otherwise undetected intraoperative compromise of the urinary tract during prolapse and incontinence surgery. It is recommended that cystoscopy be used liberally to reduced the frequency of serious sequelae from urinary tract injury. (Am J Obstet Gynecol 2001;185:1368-73.)

The routine use of cystoscopy with the Burch procedure

Objective: We sought to determine the incidence of unsuspected injury to the lower urinary tract as detected by intraoperative cystoscopy when the Burch procedure is performed. Study Design: We reviewed the records of 181 women who underwent pelvic surgery, which included a Burch retropubic urethropexy for genuine stress urinary incontinence, between Jan 1, 1998, and Dec 31, 1999. All patients underwent intraoperative cystoscopy at the completion of the Burch procedure after the administration of intravenous indigo carmine dye. Results: There were 6 (3.3%) injuries to the lower urinary tract. Five of the injuries were cystotomies that had been recognized during operation. One obstructed left ureter was detected by cystoscopy and relieved by the release of left paravaginal repair sutures. No unsuspected injuries that were detected by cystoscopy were attributable to the Burch procedure. Conclusions: The lower urinary tract injury rate was 3.3%. All but one injury was recognized before cystoscopy. The one injury was attributed to concomitant paravaginal repair and not to the Burch procedure. (Am J Obstet Gynecol 2001;185:345-48.)

Intraoperative Cystoscopy in Conjunction With Anti-Incontinence Surgery

The authors investigated the frequency of bladder and ureteral injuries in antiincontinence surgery as detected by routine intraoperative cystoscopy. A review of medical records from 1995 to 1998 identified 347 women who underwent antiincontinence surgery with intraoperative cystotomy. Charts were reviewed, and pertinent data were recorded for analysis. Intraoperative cystoscopy was started after the antiincontinence procedure. After administration of intravenous indigo carmine, the bladder was examined transurethrally with an 70-degree cystoscope or suprapubically through a cystotomy in the dome using a 30-degree cystoscope. Both ureteral orifices were checked for free-flowing indigo carmine–stained urine, and the bladder was examined for intravesical injuries. The 347 patients underwent more than 1000 procedures, with nearly all of the patients having more than one procedure performed. Nine injuries were detected in the 347 cases. Four of 48 women undergoing a laparoscopic Burch procedure sustained a bladder injury that was recognized before cystoscopy was performed. The procedure was converted to laparotomy and the cystotomy repaired. During cystoscopy, four instances of sutures in the bladder were detected. All of them occurred during 161 pubovaginal sling procedures, yielding an injury rate of 2.5 percent with a 95% confidence interval of 0.7 to 6.2. They were removed and replaced, and the patients experienced a normal recovery. In one woman, who was undergoing an open Burch procedure, intravesical sutures from a prior needle urethropexy were detected by cystoscopy. They were removed by cystotomy. In all, five injuries were detected during cystoscopy, a rate of 1.5 percent with a 95% confidence interval of 0.5 to 3.4. No new unrecognized injuries during Burch procedures (48 laparoscopic and 138 open) were detected during cystoscopy. In two women polypoid lesions in the bladder mucosa were discovered, and biopsy samples were obtained. No ureteral injuries occurred in this series. One woman had an apparent transient ureteral spasm that impeded the flow of urine from her left ureter until it was opened by passage of a 25-cm stent. There was no apparent suture injury in this patient. Statistical analyses identified no variables associated with preoperative or intraoperative injury. Obstet Gynecol 2000;95:794–796