Universal Cystoscopy Research Articles

Implementation of a policy of universal cystoscopy at the time of hysterectomy for benign indications: A retrospective comparative study.

Lower urinary tract injury (LUTI) is a serious complication of major gynaecologic surgery. Although intra-operative cystoscopy can facilitate timely diagnosis and treatment of LUTI, the optimal approach to cystoscopy at the time of benign hysterectomy remains debatable. To assess whether implementation of a policy of universal cystoscopy at the time of benign hysterectomy was associated with a difference in intra-operative detection and rates of LUTI. Retrospective cohort study at a large regional teaching hospital where a policy of universal cystoscopy at the time of benign hysterectomy was implemented on 30 September 2019. Hysterectomies performed from 1 November 2016 to 31 March 2021 were included and categorised into the 'pre-policy' and 'post-policy' groups. Primary outcomes included the intra-operative detection and overall rates of LUTI. Secondary outcome was the policy adherence rate. Multivariate analysis was used to examine the effect of this policy on the outcomes. There were 584 hysterectomies identified, including 325 in the pre-policy group and 259 in the post-policy group. Cystoscopy was performed in 55.1% in the pre-policy group and 97.7% in the post-policy group (P < 0.01). Adjusted for age, indication and route of hysterectomy, there were no significant differences in the intra-operative cystoscopic detection of LUTI (42.9% vs 25.0%, P=0.55) or the rate of LUTI (2.2% vs 1.5%, P=0.25) after implementation of the policy. The practice of universal cystoscopy at the time of benign hysterectomy has not been associated with a significant change in the intra-operative detection and rates of LUTI at our institution.

Technique for cost effective cystoscopy following laparoscopic hysterectomy

The objectives of this video are (1) review the incidence of lower urinary tract injury (2) summarize the evidence of cost effectiveness of cystoscopy following hysterectomy and (3) demonstrate a technique for cystoscopy following laparoscopic hysterectomy utilizing only instruments using during hysterectomy without use of a cystoscopy tray. We demonstrate a technique for post hysterectomy cystoscopy utilizing the 5mm 30-degree laparoscope, suction irrigator, and foley without the use of a cystoscopy tray. The demonstrated technique allows for efficient use of time and resources thereby allowing a cost-effective approach to universal cystoscopy.

Intraoperative ultrasound assessment of ureteral patency during pelvic surgery.

Ureteral injuries probably represent the most feared complication of benign hysterectomies. Lack of proper intraoperative detection causes diagnostic delay, which results in additional hospitalization, prolonged catheterization, and multiple additional procedures. However, the policy of universal cystoscopy is still under debate, owing to costs, increased operative time, lack of proper training, and risk of trauma. Intraoperative ultrasound assessment can offer a valid alternative for evaluating ureteral patency. After intravenous administration of 300ml of saline solution and 10mg of furosemide, the bladder is filled with 300ml of saline solution. Transabdominal ultrasound bladder scans are obtained with a convex 3.5-MHz probe in transverse planes. The power Doppler field size is set to include the entire posterior wall of the bladder, at the level of the ureterovesical junctions. Ureteral patency test is considered normal if jets are present on both sides. It is considered abnormal when either absent or comparatively diminished on one side. It is considered nondiagnostic when neither side is visualized. Cystoscopy should be performed in the case of abnormal or nondiagnostic sonographic findings. Intraoperative transabdominal power Doppler ultrasound represents a feasible, non-invasive, and inexpensive diagnostic tool for assessing ureteral patency during gynecological surgery.

A Structured, Hybrid Cystoscopy Simulation Curriculum for Obstetrics/Gynecology Residents.

This study aimed to assess the subjective and objective cystoscopy skills of gynecology residents before and after implementation of a comprehensive simulation curriculum. Residents in an obstetrics/gynecology program at a single academic institution participated in a 6-week cystoscopy simulation course. Residents attended an initial orientation and didactic presentation, and then weekly 20- to 30-minute training sessions using a water balloon model and a virtual reality simulator. Pretesting and posttesting were performed, including (1) subjective self-assessments, (2) a written quiz, and (3) objective structured assessment of technical skills. Paired t test was used to assess the differences in residents' objective assessment scores before and after simulation training. A total of 16 residents were recruited. Residents reported significant subjective improvements in comfort, confidence, and proficiency in performing cystoscopy after completing the curriculum. Their overall objective assessment improved, including written quiz scores (mean score, 49% vs 78%; P < 0.001), efficiency in cystoscope assembly (means score, 0 vs 4; P < 0.001), overall bladder survey score (56% vs 86%, P < 0.001), and global rating score (mean score, 15 vs 24; P < 0.001). Residents tended to prefer the water-balloon model compared with the virtual reality simulator (75% vs 25%). Obstetrics/gynecology residents demonstrated significant improvements in subjective and objective measures of skill after completion of a 6-week cystoscopy simulation training course using a combination of low- and high-fidelity models. Although universal cystoscopy at the time of hysterectomy for benign indications remains controversial, cystoscopy simulation should remain an important part of resident training.

Cost-effectiveness Analysis of Universal Cystoscopy at the Time of Benign Laparoscopic Hysterectomy

To estimate the rate of lower urinary tract injury (LUTI) and percentage of LUTI needing to be recognized intraoperatively to make universal cystoscopy cost-effective and cost-saving during laparoscopic hysterectomy. A decision tree model was used to estimate the costs and quality-adjusted life years associated with delayed or intraoperative recognition of LUTI at the time of laparoscopic hysterectomy. Probabilities and utilities were estimated from published literature. Costs were estimated from Medicare national reimbursement schedules. Threshold analyses estimated the LUTI rate and cystoscopy sensitivity that would make universal cystoscopy cost-effective or cost-saving. Monte Carlo simulations were performed. US healthcare system. Individuals undergoing laparoscopic hysterectomy for benign indications. Theoretic implementation of a universal cystoscopy policy. The total direct medical costs of laparoscopic hysterectomy under usual care were $8831 to $9149 and under universal cystoscopy were $8944 to $9068. When low LUTI rates (0.44%; estimated using sample-weighted estimates of retrospective and prospective data) were assumed, universal cystoscopy was only cost-effective in 17.1% of the simulations; the incremental cost was estimated to be $111 to $131. With median LUTI rates (2.3%) or high LUTI rates (4.0%; estimated using only prospective data with universal screening), the universal cystoscopy strategy was cost-effective in 93.9% and 99.6% of the simulations, respectively, and potentially cost-saving if the sensitivity of intraoperative cystoscopy for ureteral injury exceeded 65% or 31%, respectively. The estimated potential savings were $18 to $95 per hysterectomy. In threshold analysis assuming the average cystoscopy sensitivity rate, universal cystoscopy is estimated to be cost-effective when the LUTI rate exceeds 0.80%. In our model, universal cystoscopy is the preferred approach for laparoscopic hysterectomy and is estimated to be cost-effective in contemporary clinical settings where the LUTI rate is estimated to be 1.8% and potentially cost-saving among higher-risk populations, including those with endometriosis or pelvic organ prolapse. If the LUTI rates are less than 0.75%, the estimated incremental costs are modest-up to $131 per case. Administrators and providers should consider the local LUTI rates and practice patterns when planning implementation of a universal cystoscopy policy.

Impact of Retained Cystoscopy Fluid after Laparoscopic Hysterectomy: A Randomized Controlled Trial

To investigate the impact of retained cystoscopy fluid after laparoscopic hysterectomy on time to spontaneous void, time to discharge, urinary retention, bladder discomfort, and patient satisfaction. Single-blind randomized controlled trial. An academic medical center. One hundred and twenty patients who underwent laparoscopic hysterectomy with universal cystoscopy for benign indications, excluding pelvic organ prolapse and urinary incontinence indications. From October 10, 2018, to October 17, 2019, we compared 200 mL retained cystoscopy fluid and complete bladder emptying after laparoscopic hysterectomy with universal cystoscopy. A total of 120 patients were enrolled and randomized (59 in the retained cystoscopy fluid group and 61 in the emptied fluid group). The primary outcome was time to first spontaneous void. The secondary outcomes were time to discharge, urinary retention rates, bladder discomfort, and patient satisfaction. A sample size of 120 was calculated to detect a 57-minute difference in time to spontaneous void. There were minimal differences in baseline demographics and surgical characteristics between the groups. There was an apparent, although not significant, difference in time to void of 25 minutes (143 minutes vs 168 minutes, p = .20). Time to discharge and urinary retention rates did not differ (199 minutes vs 214 minutes, p = .40, and 13.6% vs 8.2%, p = .51, respectively). There was no difference in postoperative bladder discomfort and patient satisfaction. Retained cystoscopy fluid after laparoscopic hysterectomy did not significantly affect time to first spontaneous void, time to discharge, urinary retention, bladder discomfort, or patient satisfaction.

Impact of Retained Cystoscopy Fluid Following Laparoscopic/Robotic Hysterectomy: A Randomized Controlled Trial [OP02-5B

INTRODUCTION: Spontaneous voiding is an important postoperative milestone following hysterectomy. We investigated the impact of retained cystoscopy fluid following laparoscopic and robotic hysterectomy with universal cystoscopy on time to spontaneous void and patient satisfaction. METHODS: This was an IRB approved, single-blind, randomized, controlled trial from October 2018 to October 2019 comparing 200-mL retained cystoscopy fluid and complete bladder emptying following laparoscopic and robotic hysterectomy for benign indications, excluding prolapse and incontinence. The primary outcome was time to spontaneous void. Secondary outcomes were urinary retention rates, length of stay, bladder discomfort, and patient satisfaction. A sample size of 120 was calculated to achieve 80% power (alpha = .05) to detect a 57 minute difference in time to spontaneous void. RESULTS: A total of 120 patients were randomized (59 in the retained fluid arm, 61 in the empty arm). There were no differences in baseline demographics or surgery characteristics between groups. There was an apparent although not statistically significant difference in time to spontaneous void (143 minutes vs 168 minutes, P=.20). Urinary retention rates and length of stay did not differ (13.6% vs 8.2%, P=.51 and 199 minutes vs 214 minutes, P=.40). There was no difference in postoperative bladder discomfort and patient satisfaction. CONCLUSION: Retained cystoscopy fluid following laparoscopic and robotic hysterectomy did not significantly impact time to spontaneous void, urinary retention, length of stay, bladder discomfort, and patient satisfaction. Despite no differences, recovery nurses feel patients void faster with retained fluid. Our next step will be to perform a qualitative study of recovery nurse perceptions.

27: Costs of delayed vs intraoperative recognition of lower urinary tract injury at the time of laparoscopic hysterectomy

To evaluate the direct medical costs associated with delayed versus immediate recognition of lower urinary tract injury (LUTI) at the time of laparoscopic hysterectomy and estimate the relative costs and savings associated with universal cystoscopy (UC) as compared to selective cystoscopy (SC). A decision tree model was used to estimate the costs associated with delayed vs intraoperative recognition of LUTI at the time of laparoscopic hysterectomy for benign indications. Probability distributions of injury and its associated complications were drawn from published literature. Where multiple published probabilities were available, a sample-size-weighted average was used with a PERT distribution. Healthcare payer costs were drawn from 2016 Centers for Medicare and Medicaid Services national reimbursement schedules and included estimated physician fees, anesthesia fees, facility fees, imaging fees and pathology fees, using Current Procedural Terminology or Diagnosis Related Group codes as appropriate. The payer cost of cystoscopy was estimated using bundled outpatient reimbursement rates, as it is not separately billed at the time of hysterectomy. Total costs were estimated under both SC and UC. SC assumed an average 25% cystoscopy rate based on published literature. A three-way threshold analysis was performed to determine the proportion of LUTI with delayed diagnosis that would need to be diagnosed intraoperatively to favor UC under three scenarios: low injury rates (0.5%; estimated using pooled retrospective and prospective data), high injury rates (4%; estimated using prospective data with universal screening), and moderate injury rates (2.2%). Probabilistic sensitivity analysis was used to assess the robustness of the findings. Given insufficient data, no other healthcare system costs, such as malpractice liability, differential operating room time, or out-of-pocket expenses were included. The SC estimated cost of laparoscopic hysterectomy, inclusive of LUTI complications, ranged from $8,807 to $9,132, while the UC cost ranged from $8,962 to $9,034. Assuming high LUTI rates, UC can be cost saving with ureteral injury detection rates above 50% or bladder injury detection rates above 96%; maximal estimated costs savings were $98 per hysterectomy. UC does not achieve cost savings to the payer assuming low injury rates with a median incremental cost of $143 per hysterectomy (incremental cost to prevent one delayed diagnosis $113,186). Moderate injury rates were estimated to be cost neutral. Estimated UC costs vary based on LUTI rates, and UC policy has the potential to be cost saving through increased intraoperative diagnosis of LUTI. When not cost saving, the incremental costs of UC are modest and may still be outweighed by other health system and malpractice liability costs not accounted for within this model.

Barriers to Universal Cystoscopy After Hysterectomy

Abstract Objective: The goal of this study was to identify logistical reasons that preclude the adoption of universal cystoscopy after hysterectomy among practicing gynecologic surgeons at an acade...

Universal cystoscopy at the time of benign hysterectomy: a debate

Injury to the bladder and/or ureters is the cause of significant morbidity, and efforts to reduce these injuries are important. This debate presents arguments that both support, and refute, the value of routine cystoscopy at the time of benign hysterectomy. Proponents of routine cystoscopy state that injuries are more likely to be detected and repaired when cystoscopy is routinely performed. Dissenters counter that the available evidence does not support routine cystoscopy at the current rates of lower urinary tract injury, and the cystoscopy should be performed only when injury is suspected or when performing hysterectomy with concurrent procedures that increase the risk of lower urinary tract injury.

Phenazopyridine for Evaluation of Ureteral Patency: A Randomized Controlled Trial

(Abstracted from Obstet Gynecol 2016;128:348–355) There is increased risk of urinary tract injury with use of pelvic reconstructive and incontinence procedures compared with other gynecologic procedures. The incidence of injury ranges from 0.6% to 11% and has led to recommendations for use of universal cystoscopy after all urogynecologic procedures.

Is Universal Cystoscopy After Benign Hysterectomy Warranted

Urologic injuries following benign hysterectomy can cause significant morbidity; thus, a U.S. medical center instituted a policy of universal

Resident experiences with and post-training plans for cystoscopy at the time of hysterectomy.

To determine OB/GYN residents' experience with and opinions toward cystoscopy at the time of hysterectomy. An internet survey of OB/GYN residents assessed utilization of cystoscopy at the time of hysterectomy, familiarity with literature regarding universal versus selective cystoscopy, and plans post residency. Cystoscopy was performed universally in the minority of cases of vaginal hysterectomy (12%), laparoscopically assisted vaginal hysterectomy (14%), supracervical hysterectomy (0%), total abdominal hysterectomy (2%), laparoscopic supracervical hysterectomy (9%), total laparoscopic hysterectomy (27%), and hysterectomy with adnexa removal (5%). Residents planned universal cystoscopy post-training more frequently for all hysterectomy types. Cystoscopy at the time of hysterectomy was performed universally in the minority for all hysterectomy categories. For all hysterectomy types, residents planned post-graduation to utilize universal cystoscopy at the time of hysterectomy more often than occurred in training.

Survey of Cytoscopy Performance at the Time of Hysterectomy [10

OBJECTIVE: To determine third-year and fourth-year obstetrics and gynecology residents' current experience with and opinion toward cystoscopy at the time of hysterectomy. METHODS: A nine-part questionnaire was designed to assess the utilization of cystoscopy at the time of hysterectomy. Respondents were queried regarding their familiarity with literature regarding selective compared with universal cystoscopy, the number of cystoscopies they have done, how often cystoscopy has been performed for the specific types of hysterectomy they have participated in, and their plans regarding the performance of selective compared with universal cystoscopy for specific types of hysterectomy after they complete their training. The online survey, created on www.surveymonkey.com, was sent to third-year and fourth-year obstetrics and gynecology residents in accredited U.S. programs. RESULTS: Fifty-six third-year and fourth-year obstetrics and gynecology residents completed the survey. Fifty-nine percent reported familiarity with literature regarding selective compared with universal cystoscopy. Seventy-nine percent had been involved with a hysterectomy having a bladder or ureter injury. The average number of cystoscopies performed was 44. Residents reported that cystoscopy was performed in more than 90% of the following types of hysterectomy: vaginal hysterectomy (VH) 12%, laparoscopically assisted vaginal hysterectomy (LAVH) 14%, supracervical hysterectomy (SCH) 0%, total abdominal hysterectomy (TAH) 2%, laparoscopically assisted supracervical hysterectomy (LASH) 7%, total laparoscopic hysterectomy (TLH) 29%, and those including removal of adnexa 5%. Postresidency, universal cystoscopy was planned during 34% of VHs, 34% of LAVHs, 13% of SCHs, 16% of TAHs, 21% of LASHs, 48% of TLHs, and 14% of hysterectomies with removal of adnexa. CONCLUSION: Universal cystoscopy was performed in the minority for all types of hysterectomy. Residents plan to perform universal cystoscopy more frequently than occurred in their training.

Findings of universal cystoscopy at incontinence surgery and their sequelae

The purpose of this study was to report the frequency of abnormal cystoscopy at incontinence surgery and to identify risk factors and sequelae of injury. Findings of cystoscopy were collected prospectively in 3 multicenter surgical trials. Clinical, demographic, and procedure characteristics and surgeon experience were analyzed for association with iatrogenic injury and noninjury abnormalities. Impact of abnormalities on continence outcomes and adverse events during 12 months after the procedure were assessed. Abnormal findings in the bladder or urethra were identified in 95 of 1830 women (5.2%). Most injuries (75.8%) were iatrogenic. Lower urinary tract (LUT) injury was most common at retropubic urethropexy and retropubic midurethral sling (MUS) procedures (6.4% each), followed by autologous pubovaginal sling procedures (1.7%) and transobturator MUS (0.4%). Increasing age (56.9 vs 51.9 years; P = .04), vaginal deliveries (3.2 vs 2.6; P = .04), and blood loss (393 vs 218 mL; P = .01) were associated with LUT injury during retropubic urethropexy; however, only age (62.9 vs 51.4 years; P = .02) and smoking history (P = .04) were associated for pubovaginal sling procedures. No factors correlated with increased risk of injury at retropubic and transobturator MUS. Notably, previous incontinence surgery, concomitant procedures, anesthesia type, and trainee participation did not increase LUT injury frequency. Although discharge with an indwelling catheter was more common after trocar perforation compared with the noninjury group (55.6% vs 18.5%; P < .001), they did not differ in overall success, voiding dysfunction, recurrent urinary tract infections, or urge urinary incontinence. Universal cystoscopy at incontinence surgery detects abnormalities in 1 in 20 women. Urinary trocar perforations that are addressed intraoperatively have no long-term adverse sequelae.

Utility of Cystoscopy During Hysterectomy

To estimate the incidence of cystoscopy use at time of hysterectomy and its use to detect urinary tract injury. This was a retrospective cohort study in a tertiary care academic center of 1982 patients who underwent a hysterectomy for any indication (excluding obstetric) between January 2009 and December 2010. Medical records were reviewed for baseline and perioperative characteristics, cystoscopy use, and information about bladder or ureteral injury related to hysterectomy. Two hundred fifty-one women (12.66%, 95% confidence interval [CI] 11.23-14.21%) underwent a cystoscopy at the time of hysterectomy with no reported complications resulting from the cystoscopy procedure. Cystoscopy was most frequently used by low-volume surgeons and in cases involving prolapse or vaginal mode of access. Fourteen patients (0.71%, 95% CI 0.39-1.19%) experienced bladder injury and five patients (0.25%, 95% CI 0.08-0.58%) sustained ureteral injury. None of these complications were detected by cystoscopy; cystoscopy was either normal at the time of hysterectomy or was omitted. The presence of adhesions was significantly associated with bladder injury at the time of hysterectomy (P=.006). Low-volume surgeon and laparoscopic or robotic mode of access were both significantly associated with ureteral injury (P=.023 and P=.042, respectively). Our data support selective rather than universal cystoscopy at the time of hysterectomy.

Cost Savings of Using Laparoscope for Cystoscopy Following Hysterectomy

Cost Savings of Using Laparoscope for Cystoscopy Following Hysterectomy

Cost-Effective Analysis of Universal Cystoscopy in Identification of Urinary Tract Injury by Hysterectomy Route

Cost-Effective Analysis of Universal Cystoscopy in Identification of Urinary Tract Injury by Hysterectomy Route

Intra-operative cystoscopy in gynaecological surgery: A brief overview

Recent studies using universal cystoscopy have demonstrated a higher rate of urinary tract injury at major gynaecological procedures than previously thought. These injuries are associated with significant medical and medico-legal implications. The sensitivity of visual inspection is low and cystoscopic screening with intravenous dye improves detection. We review the evidence for intra-operative cystoscopy in gynaecology, with emphasis on rates of urinary tract injury and the use of intravenous contrast dye.

Universal cystoscopy for timely detection of urinary tract injuries during pelvic surgery

This review discusses recently published and relevant data that help understand the role of intraoperative cystoscopy at the time of benign gynecologic surgery. Given the consequences, urinary tract injury at the time of benign gynecologic surgery remains a major concern to the pelvic surgeon. Timely diagnosis of injuries is associated with lower morbidity, litigation, and costs. Recent studies that involved the role of intraoperative cystoscopy at time of benign gynecologic surgery provided a clearer understanding of injury rates, cost-effectiveness, and associated morbidity. The routine use of cystoscopy at the time of gynecologic surgery allows for timely diagnosis of urinary tract injuries in a cost-effective and cost-saving manner.