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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:

  1. At the level of the IP ligament where the ureter crosses the common external iliac artery;
  2. At the level of the broad ligament;
  3. At the level of the crossing of uterine artery and ureter; and
  4. 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 recommend

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.

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Comments

  • Andreas Obermair 01/10/2012 10:41pm (9 years ago)

    Hi Kelvin,
    I was trying to answer your question in this week's blog http://obermair.info/latest-news/blog/total-abdominal-hysterectomy-is-becoming-out-dated/;
    In brief, if surgeons like you have the guts to do a TLH whenever possible, you will have more conversions than someone who offers only a TLH to a patient where it is really easy. A conversion is not a complication. SurgicalPerformance, which will launch next week will allow you to compare your conversion rate with the ones from your colleagues. It will give you an account of how many times you achieved what you wanted to achieve. That will be relevant.
    Thanks again for making the effort to post a comment.

  • Renate 04/09/2012 12:29pm (9 years ago)

    I know this response is a long time in cmonig but for all those following this blog uterine thickening does not usually require a hysterectomy, even with cancer in the family. Uterine cancer is very rarely inherited. An endometiral biopsy can be done in the office, then a Mirena progesterone containing IUD will likely thin the uterine lining and take care of this without hysterectomy. However, hysterectomy should you prefer that route, is a reasonable alternative. I save mesh repairs for the few who fail natural tissue repairs or the very active or very young, and then I recommend abdominal surgery with mesh rather than vaginal mesh as there is more long term safety data. This can be done robotically or laparoscopically by a skilled surgeon.

  • Kelvin Larwood 31/08/2012 4:52pm (9 years ago)

    Hi Andreas. I am liking your blog content and the idea of having a blog.
    I have a question in relation to conversion of TLH to TAH. I am performing TLH whenever possible but have had a run of conversions to TAH. On both occasions I have decided early, after diagnostic laparoscopically essentially. I know that this is technically a conversion but is it a safer conversion to convert early rather than when in trouble with bleeding or injury or am I converting without trying hard enough? One case was previous 4 LSCS and bladder was plastered 2/3 of the way up uterus, she had a 1A1 scc cervix so had to get it out, went open no problems and patient home day 2 (TAP blocks great). The other menorrhagia/fibroid uterus, Hb 80 pre op. After diagnostic laparoscopy large posterior fibroid taking up POD and unable to see USL - given this I went open concerned if I had bleeding with UA would not have good access. Also went home day 2. Your thoughts on these conversions.

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