Should a Cystoscopy be always performed after laparoscopic hysterectomy?
Evidence is emerging that laparoscopic hysterectomy is the treatment of choice if a vaginal hysterectomy is not feasible. Injuries of the ureters or the bladder are uncommon after Laparoscopic Hysterectomy. In the recently published LACE trial, we reported a 1.5% intraoperative bladder injury rate and a 0.6% intraoperative ureteric injury rate at Total Laparoscopic Hysterectomy (TLH) for endometrial cancer. If you are a gynaecologist and don’t know what your rate of viscus injury is, check out www.surgicalperformance.com.
There is always a reason why an injury happens. Complex pelvic surgery can be challenging especially when the pelvic anatomy is distorted, hysterectomy is performed for large uterine fibroids, surgery to obese patients or significant blood loss for whatever reason. In those cases the risk of intraoperative visceral injury to the bowel, bladder and ureter is higher.
Last month the American Association of Gynaecological Laparoscopy published a guideline to suggest that a cystoscopy should be performed after all laparoscopic hysterectomies. The committee suggested that the rate of injury to the ureter and the bladder is higher with laparoscopic than with open or vaginal hysterectomy in some studies. In the LACE Trial the incidence of intraoperative injuries was similar in the laparoscopic and the open arm.
Irrespective, injures to the bladder and the ureter are hardly ever diagnosed intraoperatively. Patients will get pretty sick first before a diagnosis of an injury to bladder or ureter is made, which is the ideal soil for civil litigation. The patient will require a number of procedures, hospital stay and costs, may face the real chance of urinary incontinence or a fistula or even the need for a nephrectomy.
There are four sites of likely injuries are:
- At the level of the IP ligament where the ureter crosses the common external iliac artery;
- At the level of the broad ligament;
- At the level of the crossing of uterine artery and ureter; and
- If the ureter does not deviate lateral once it has passed beneath the uterine artery but stays medial and has to direct anteriorly to find the bladder base.
Potential types of injury: The ureter can be divided or ligated (in an attempt to secure haemostasis). Alternatively the ureter can suffer from an avascular necrosis (delayed diathermy injury) and leak 7 to 10 days after surgery.
Will a cystoscopy pick up all ureteric and bladder injuries? A recently published study suggested that the surgeon detected only one in four urinary tract injuries intraoperatively, whereas a cystoscopy before waking the patient up detected more than 90% of these injuries. However, delayed diathermy injuries will not be picked up.
Is there harm doing a cystoscopy? Inserting a catheter/cystoscope brings along a 7% risk of urinary tract infection (UTI). I do approximately 150 to 200 TLH per year and I would create some 50 to 70 unnecessary UTIs per year. I find that a bit too much. The AAGL guideline also suggested to use i.v. contrast (Indigocarmine) to demonstrate a urinary jet from at cystoscopy. Usually, I can see a urinary jet easily busing water Some hospitals would not have Indigocarmine available and Methylene Blue would be used instead. I am aware of case reports on anaphylactic reactions to Methylene Blue that resulted in patients’ deaths.
I conduct cystoscopies intraoperatively only in selected cases or high risk situations: Patients with distortion of the pelvic anatomy (endometriosis), or whenever there is doubt about the course of the pelvic ureter, large fibroids or pelvic masses, morbidly obese patients or whenever the intraoperative blood loss is higher for whatever reasons.
In addition, I recommend a cystoscopy for patients who have had a hysterectomy previously and who now require surgery for a pelvic mass if I was unable to dissect the ureters. These operations might be sometimes difficult to perform.
I do not recommend a cystoscopy following all routine laparoscopic operations.
I only use Indigocarmine if I am unsure if I could see a urinary jet from one of the ureteric orifices at cystoscopy.
Obermair et al: Improved surgical safety after laparoscopic compared to open surgery for apparent early stage endometrial cancer: results from a randomised controlled trial. Eur J Cancer 2012: 48: 1147-53.