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The role of intraoperative cystoscopy in prolapse and incontinence surgery
The role of intraoperative cystoscopy in prolapse and incontinence surgery Corrine F. I. Jabs, MD, and Harold P. Drutz, MD Regina, Saskatchewan, and Toronto, Ontario, Canada 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.)
Key words: Cystoscopy, incontinence and prolapse surgery, ureter and bladder injury
Ureteric and bladder injuries have been a known complication of gynecologic surgery for more than a century. Although urinary tract injury is higher in pelvic surgery for malignancy, it also occurs in routine benign gynecologic surgery when injury may not be suspected. It has been recognized since the review of the subject by Sampson1 in 1902 that intraoperative recognition and repair of ureteric injury reduces morbidity. Unrecognized ureteral injury can lead to postoperative complications of unexplained fever, persistent ileus, flank pain, hematuria, urinoma, urinary ascites, and fistula. Loss of renal function and death from infectious complications can also occur.
From the Regina General Hospital and the Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital. Dr Jabs received financial support during her urogynecology fellowship from R. Samuel McLaughlin Foundation, Toronto, Ontario, Canada. Presented at the Twenty-Seventh Annual Meeting of the Society of Gynecologic Surgeons, Orlando, Fla, March 5–7, 2001. Reprints not available from author. Copyright © 2001 by Mosby, Inc. 0002-9378/2001 $35.00 + 0 6/6/119072 doi:10.1067/mob.2001.119072
1368
Surgery performed for incontinence and prolapse frequently involves placing sutures in close proximity to the ureters and near the site of entry of the ureters into the bladder. Retropubic urethropexies, suburethral slings, posterior culdoplasties, and cystocele repairs can distort the ureters and trigone. The purpose of this study was to determine the frequency with which intraoperative cystoscopy during prolapse and incontinence procedures produced a change in intraoperative management to prevent ureteric and bladder injury. Methods We reviewed the charts of all patients who had prolapse and incontinence procedures during a 2-year period (January 1, 1997, to December 31, 1998) in a tertiary care urogynecology unit. Patients who had procedures in which the ureters and bladder were not at risk were excluded. All patients underwent intraoperative transurethral cystoscopy with a 70-degree cystoscope after intravenous injection of 5 mL indigo carmine to document patency and function of the ureters and to rule out bladder injury. Extracted data
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Volume 185, Number 6 Am J Obstet Gynecol
Table II. Previous abdominal and pelvic surgery
Table I. Surgeries performed Vaginal approach Including hysterectomy Including suburethral sling* Including modified urethral sling† Fistula repair Abdominal approach Including hysterectomy Including Burch Including colposacropexy Including internal anterior and/or posterior repair‡ Two-team abdominovaginal sling§ Including hysterectomy Including colposacropexy Including sacrospinous fixation Including internal anterior and/or posterior repair TOTAL
154 68 84 57 7 58 47 54 8 47 12 4 5 2 2 224
*Flood et al2 and Lazarevski.3 †Spence-Jones et al.4 ‡Drutz et al.5 §Drutz et al.6
included demographic data and possible risk factors for intraoperative ureteric and bladder injury. Recorded data included age, parity, weight, maximum grade of prolapse, previous pelvic surgery, hormonal status, and estimated blood loss. Continuous variables were compared with use of the Student t test. Nominal variables were compared with the χ2 test. Results From January 1, 1997, to December 31, 1998, 235 patients underwent urogynecologic procedures that included intraoperative cystoscopy. We excluded 11 patients because they had undergone procedures that did not put the urinary tract at risk, leaving 224 cases to be analyzed. The excluded cases involved 6 cases of posterior repair and sacrospinous vault suspension alone in which the peritoneum was not entered and no culdoplasty was performed. Three other cases involved release of a sling suture above the rectus sheath, 1 patient had an examination under anesthetic plus cystoscopy, and 1 patient had an examination under anesthetic, perineorrhaphy, and urethral dilatation. In these 11 excluded cases the cystoscopy was performed for diagnostic purposes and was not necessarily related to potential injury during the current surgery. The mean age of the patients was 60 ± 12 years (age range, 31 to 86 years), the mean weight was 71 ± 14 kg, and the median parity was 2. Fifty-two women were premenopausal and 172 were postmenopausal. Of the postmenopausal women, 93 were taking systemic or local hormone replacement therapy at the time of initial consultation and 170 were taking systemic or local hormone replacement at the time of operation. The operations performed are listed in Table I.2-6 The previous operations of the patients are listed in Table II.
None Hysterectomy Vaginal hysterectomy Total abdominal hysterectomy Subtotal hysterectomy Vaginal repair (at least 1) Vaginal repair (multiple) Retropubic urethropexy Needle suspension Two-team sling Modified urethral sling Suburethral sling
80 97 39 56 2 64 13 32 10 1 3 2
Primary surgery for prolapse or stress incontinence was performed in 138 patients (62%), whereas 83 patients (38%) underwent revision surgery for recurrent prolapse or stress incontinence. A previous hysterectomy had been performed in 43% of the women, 29% had undergone previous vaginal repair, 14% had undergone at least 1 previous retropubic urethropexy, and 7% had undergone other incontinence procedures. In 12 patients (5.3%), intraoperative management was changed by the findings during the intraoperative cystoscopy. The details of the findings and change in management are described in Table III. Patients with abnormal findings at cystoscopy did not differ from patients with normal intraoperative findings with regard to age, weight, parity, maximum grade of prolapse, estimated blood loss, or previous operations (Table IV). No known complications of intravenous injection of indigo carmine and cystoscopy occurred in the patients studied. Of the patients with normal cystoscopic findings, 38% had not had previous gynecologic surgery. In the 12 patients with abnormal findings, 3 had not had previous pelvic or gynecologic surgery and 4 had undergone previous abdominal hysterectomy or appendectomy only. There would have been no suspicion of technical difficulty on the basis of previous surgical history in 7 of the patients (58%) in whom the cystoscopic findings were abnormal. Preoperative imaging of the urinary tract was available in 88% of cases. Abnormalities were found in 20 of the 224 patients (8.9%; Table V). Most abnormalities detected were benign renal cysts. Three patients had known congenital or surgical absence of a kidney, 1 patient had a horseshoe kidney, and 1 had partial duplication of the upper collecting systems. No changes in management were made based on preoperative imaging of the urinary tract. The 1 woman in whom abnormal renal function was detected after slow excretion of indigo carmine at the time of surgery had normal findings on the preoperative ultrasonography (patient 5 in Table III). In this case the partially functioning left kidney did now show evidence of atrophy during preoperative ultrasonography.
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December 2001 Am J Obstet Gynecol
Table III. Cases with abnormal cystoscopy findings and resulting change in management Patient No.
Age (y)
Operation
1
43
VH, A2PE, SSVS, mod sling
RPU
2 3 4 5
55 53 73 77
A2PE, SSVS TAHBSO, C, RPU A2P, SSVS A2PE, SSVS
TAHBSO None TAHBSO TAHBSO
Mod sling stitches seen under bladder mucosa Right ureter blocked Right ureter blocked Both ureters blocked Slow efflux left ureter
6
60
VH, A2PE, mod sling, SSVS
None
Right ureter blocked
7 8 9 10
58 66 53 50
VH, A2PE A2P, SSVS, mod sling A2P, SSVS TAHBSO, C, RPU
Appendectomy A1P TAHBSO, RPU (2) None
Right ureter blocked Left ureter blocked Left ureter blocked Both ureters kinked
11
78
58
VH and A1, A1P, A1E, RPU; total of 4 previous procedures TAHBSO, RPU
Thin area of detrusor detected
12
2 team sling, Martius graft, repair of unintentional cystotomy A2P, mod sling, SSVS, Martius graft
Previous operation
Cystoscopic findings
Bladder laceration detected
Change in management Sling repositioned BN stitch replaced RPU stitch replaced BN stitch replaced Intraoperative stent placed; postoperative intravenous pyelogram and renal nuclear scan showed decreased function left kidney BN and anterior repair stitches replaced BN stitch replaced BN stitch replaced BN stitch replaced Stents passed; uterosacral plication stitches replaced Detrusor reinforced
Sling repositioned; laceration repaired intraoperatively; Foley left in for 3 days
VH, Vaginal hysterectomy; A2, anterior repair with suburethral sling (2) with or without Lazarevski procedure (3); P, posterior repair; E, enterocele repair including culdoplasty; SSVS, sacrospinous vault suspension; mod sling, modified urethral sling (4); RPU, Burch retropubic urethropexy; TAH, total abdominal hysterectomy; BSO, bilateral salpingo-oophorectomy; BN, bladder neck; C, culdoplasty; A1, anterior repair.
Table IV. Characteristics of patients with normal cytoscopy findings
Age (mean ± SD; y) Estimated blood loss (mean ± SD; mL) Weight (mean ± SD; kg) Prolapse grade (median) Parity (median) Menopausal women* No previous surgery*
Cystoscopy abnormal (n = 12)
Cystoscopy normal (n = 212)
60.5 ± 11 758 ± 489 73.3 ± 19.5 3 2 11 of 12 (92%) 3 of 12 (25%)
59.6 ± 12 598 ± 385 70.9 ± 13.6 3 2 161 of 212 (76%) 78 of 212 (37%)
Statistical significance P = .82 P = .29 P = .68 P = .18 P = .42
*No. of patients.
Comment Ureteric and bladder injury is a known complication during gynecologic operations and causes significant morbidity and mortality. Intraoperative detection of injury allows for an immediate search for a cause, and often ureteric blockage can be reversed by removal and replacement of the offending suture or repair of the injury during the same surgery. The incidence of ureteric and bladder injury during gynecologic surgery may vary depending on the type of surgery included, whether the study is of a prospective or retrospective design, and whether intraoperative ureteric visualization is used. The bladder may be visualized with standard transurethral cystoscopy or through an abdomi-
nal approach. Cystotomy or the use of a scope through the bladder dome can be used at the time of abdominal or laparoscopic surgery without repositioning the patient.7-9 Use of intraoperative cystoscopy and teloscopy during urogynecologic procedures has shown an incidence of urinary tract injury of 2.6% to 8%,8-11 whereas its use in all major benign gynecologic procedures discovered otherwise undetected injury in 0.4%.12 Without the use of intraoperative cystoscopy, ureteral obstruction is found in 0.33% to 1.5% of major gynecologic surgical procedures.13-15 There are 4 locations described where the ureter is known to be at risk during gynecologic surgery. From proximal to distal, these sites are (1) along the lateral pelvic sidewall above the uterosacral ligament, (2) near
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Volume 185, Number 6 Am J Obstet Gynecol
Table V. Urinary tract abnormalities on preoperative imaging Benign renal cysts Congenital or surgical absence of kidney Horseshoe kidney Mild bilateral hydronephrosis Partial upper tract duplication Renal echogenic focus Bladder abnormalities Wall thickening Distortion due to stress Fistula Diverticula TOTAL
8 3 1 2 1 1 1 1 1 1 20
the infundibulopelvic ligament, (3) at the base of the broad ligament where the ureter passes underneath the uterine vessels, and (4) through the tunnel in the cardinal ligament where the ureter turns medially anterior to the vaginal fornix to enter the bladder. Intra-abdominal surgery allows for direct visualization and palpation of the pelvic ureter during dissection. It is considerably more difficult to ensure protection of the portion of the ureter below the level of the uterine vessels. During vaginal surgery, it is more difficult but not impossible to palpate the ureter but, again, the most distal portion of the ureters may not be palpable and therefore may be at risk. Vaginal procedures performed for prolapse can distort the anatomy of the bladder base, trigone, and ureters and can lead to inadvertent kinking and blockage of the ureters. Culdoplasty sutures and bladder neck procedures have been shown to cause a significant number of injuries that lead to ureteral obstruction.10 Preoperative intravenous pyelography has not been helpful in the prevention of ureteric injury.14,16,17 The only factors associated with an increased incidence of preoperative abnormalities shown by intravenous pyelography were patients with a uterine size of 12 weeks or greater or an ovarian cyst of 4 cm or larger. It was questionable whether the results of the intravenous pyelogram led to reduced injury in these cases in which risk was already known to be higher and dissection would be carried out with more care to identify the ureter. Preoperative urinary tract imaging in our series did not assist in intraoperative management because the cases of absent or nonfunctioning kidney were either known by history or, in the case of the patient with abnormal cystoscopic findings, not detected by preoperative ultrasonography. Intraoperative visualization of the bladder and excreted indigo carmine from the ureters is an effective and low-risk method of detecting bladder and ureteric injury. The use of this technique at the time of bladder neck and prolapse surgery is important to detect and repair potential urinary tract injury. The use of routine cystoscopy in benign gynecologic surgery that does not involve the
bladder neck remains controversial, although the threshold for use of intraoperative cystoscopy should be very low when dissection is difficult or when risk factors for ureteral injury are present. We encourage training programs for gynecologic surgery to include training in diagnostic cystoscopy or transvesical teloscopy to allow the liberal use of this technique to reduce the frequency of serious sequelae from urinary tract injury. In view of the 5.3% incidence of prevention of potential ureteric or bladder damage reported in this series, we recommend the routine use of intraoperative cystoscopy for all patients undergoing incontinence and prolapse surgery.
REFERENCES
1. Sampson JA. Ligation and clamping of the ureter as complications of surgical operations. Am Med 1902;4:693. 2. Flood CG, Drutz HP, Waja L. Anterior colporrhaphy reinforced with marlex mesh for the treatment of cystoceles. Int Urogynecol J Pelvic Floor Dysfunct 1998;9:200-4. 3. Lazarevski MB. Suburethral duplication of the vaginal wall: an original operation for urinary stress incontinence in women. Int Urogynecol J Pelvic Floor Dysfunct 1995;6:73-9. 4. Spence-Jones C, DeMarco E, Lemieux MC, Drutz HP. Modified urethral sling for the treatment of genuine stress incontinence and latent incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1994;5:69-75. 5. Drutz HP, Baker KR, Lemieux MC. Retropubic colpourethropexy with transabdominal anterior and/or posterior repair for the treatment of genuine stress urinary incontinence and genital prolapse. Int Urogynecol J Pelvic Floor Dysfunct 1991;2:201-7. 6. Drutz HP, Buckspan M, Flax S, Mackie L. Clinical and urodynamic re-evaluation of combined abdominalvaginal Marlex sling operations for recurrent stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1990;1:70-3. 7. Pace J, Ballard CA, Klutke J, Klutke C, Kobak W. Intraoperative transvesical cystoscopy for urogynecologic procedures. Int Urogynecol J Pelvic Floor Dysfunct 1997;8:265-9. 8. Tulikangas PK, Weber AM, Larive AB, Walters MD. Intraoperative cystoscopy in conjunction with anti-incontinence surgery. Obstet Gynecol 2000;95:794-6. 9. Shoemaker ES, Wilkinson PD. Teloscopy after bladder neck suspension. J Am Assoc Gynecol Laparosc 1998;5:261-3. 10. Pettit PD, Petrou SP. The value of cystoscopy in major vaginal surgery. Obstet Gynecol 1994;84:318-20. 11. Harris RL, Cundiff GW, Theofrastous JP, Yoon H, Bump RC, Addison WA. The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery. Am J Obstet Gynecol 1997;177:1367-9. 12. Wiskind AK, Thompson JD. Should cystoscopy be performed at every gynecologic operation to diagnose unsuspected ureteral injury? J Pelvic Surg 1995;1:134-7. 13. Stanhope CR, Wilson TO, Utz WJ, Smith LH, O’Brien PC. Suture entrapment and secondary ureteral obstruction. Am J Obstet Gynecol 1991;164:1513-9. 14. Mann WJ, Arato M, Patsner B, Stone ML. Ureteral injuries in and obstetrics and gynecology training program: etiology and management. Obstet Gynecol 1988;72:82-5. 15. Daly JW, Higgins KA. Injury to the ureter during gynecologic surgical procedures. Surg Gynecol Obstet 1988;167:19-22. 16. Symmonds RE. Ureteral injuries associated with gynecologic surgery: prevention and management. Clin Obstet Gynecol 1976;19:623-44. 17. Piscatelli JT, Simel DL, Addison WA. Who should have intravenous pyelograms before hysterectomy for benign disease? Obstet Gynecol 1987;69;541-5.
1372 Jabs and Drutz
Discussion DR ROBERT L. SUMMITT, JR. Intraoperative injury to the lower urinary tract is a well-recognized complication of major gynecologic surgery, particularly surgery for genuine stress incontinence and pelvic organ prolapse. In an obstetrics and gynecology residency training program, Mann et al1 noted 17 urethral injuries among 3815 (0.5%) major gynecologic cases, 16 of which were recognized intraoperatively. Among women undergoing urogynecologic and reconstructive pelvic surgeries, Harris et al2 documented an injury rate of 4.0% when cystoscopy was performed at the time of surgery. Although the incidence of lower urinary tract injury is low, failure to recognize it can lead to devastating outcomes. Obviously, early recognition of ureteral obstruction and bladder injury has the potential to allow prevention of postoperative morbidity. Drs Jabs and Drutz describe a retrospective review of 235 urogynecologic and prolapse surgeries in which intraoperative cystoscopy was performed to recognize intraoperative injury to the lower urinary tract. The primary objective of the study was to determine the frequency with which intraoperative cystoscopy produced a change in the surgical management after recognition of a lower urinary tract injury. Drs Jabs and Drutz are to be commended for their detail in the assessment of risk factors that could potentially influence the outcome and incidence of lower urinary tract injury, particularly noting that maximum grade of prolapse, estimated blood loss, preoperative radiologic studies, and the combinations of surgeries performed did not affect the frequency of injuries. I submit the following questions and comments to Drs Jabs and Drutz: 1. Of the 12 patients with abnormal cystoscopic findings, the majority with ureteral obstructions occurred with an anterior repair. The resolution involved replacement of a bladder neck stitch. Please explain why this procedure was associated with obstruction and what the replacement achieved. 2. In other studies of cystoscopy performed at the time of urogynecologic surgery, culdoplasty was associated with ureteral obstruction.2,3 Were culdoplasties performed in this study group and, if so, how was obstruction prevented? 3. Drs Jabs and Drutz stated that preoperative imaging was performed in 88% of their cases but found that no particular imaging study affected the ultimate outcome of their patients. In addition, information about congenitally absent or nonfunctioning kidneys was gleaned from the histories of the patients. This seems to be a very high incidence of preoperative imaging, and in many of our patients a history of congenitally missing kidney may not be related to us. With this in mind, can Drs Jabs and Drutz document what type of imaging was typically performed in their patients? When imaging is not commonly performed before an operation and when the preoperative his-
December 2001 Am J Obstet Gynecol
tory is unremarkable, do Drs Jabs and Drutz believe it is ever necessary to perform cystoscopy at the beginning of surgery to document normal ureteral function? 4. As noted earlier, a number of previous studies have investigated the frequency of lower urinary tract injury at the time of urogynecologic surgery with use of intraoperative cystoscopy and have shown the value of its utility. What new information, if any, does this current study provide? I appreciate being invited to discuss this paper and enjoyed reviewing it. I look forward to the responses of Drs Jabs and Drutz. REFERENCES
1. Mann WJ, Arato M, Patsner B, Stone ML. Ureteral injuries in an obstetrics and gynecology training program: etiology and management. Obstet Gynecol 1988;72:82-5. 2. Harris RL, Cundiff GW, Theofrastous JP, Yoon H, Bump RC, Addison WA. The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery. Am J Obstet Gynecol 1997;177:1367-9. 3. Pettit PD, Petrou SP. The value of cystoscopy in major vaginal surgery. Obstet Gynecol 1994;84:318-20.
DR JABS (Closing). Dr Summitt’s first question relates to injuries with anterior repair and bladder neck sutures. Dr Drutz is very experienced with synthetic mesh in the anterior compartment and uses a stitch at the bladder neck that builds up the tissue between the bladder neck and the mesh itself. This suture was often the culprit and required removal and replacement. There are several places where the ureter can become obstructed and kinked, and I think relatively small changes in standard operative procedure put either more or less risk on the urinary tract. For example, with a culdoplasty stitch, some surgeons will go slightly more lateral and others will stay more medial, and the difference of a centimeter can make a large difference in the rate of injury. This can also happen with changes in technique of anterior repair in which the technique used can produce more or less distortion of the trigone. The next question concerned how we avoided injury with culdoplasty sutures. In our center, vaginal culdoplasties were performed at the time of vaginal hysterectomies, but it was not the main technique used for vaginal vault support if there was significant apical or posterior prolapse. We frequently used sacrospinous vault suspension, and this would often not require entry into the cul-de-sac and was simply performed through the posterior repair. We found that preoperative imagining did not affect outcome. In our center, which is our tertiary care center in Ontario, Canada, almost all of the patients that were to undergo a surgical procedure had ultrasonography if we did not already have this information. I am now in a much smaller center and I do not routinely order preoperative ultrasonography for all patients. All urogynecologic patients in my practice undergo cystoscopy as part of their preoperative investigations, and this will document the presence of two ureteric orifices. Ultra-
Volume 185, Number 6 Am J Obstet Gynecol
sonagraphy would be useful in patients who have undergone previous pelvic surgery to rule out asymptomatic atrophic kidney, although we have shown that normal ultrasonography does not entirely rule out a dysfunctional kidney. What new information does this add? This article adds to the handful of other articles that have looked at the incidence of ureteric injuries discovered with intraoperative cystoscopy, and I think this is an important message that has not yet been fully implemented. I do not think
Jabs and Drutz 1373
any of us have to look very far to see surgeons without cystoscopy privileges who do have privileges to do anterior repair, vaginal hysterectomy, or Burch retropubic urethropexies and, if we want to make these procedures safe, it is important to use cystoscopy with indigo carmine and take the 5 minutes required to rule out injury. Cystoscopy is not a difficult procedure compared with the urogynecologic surgical procedure itself. We should promote the use of cystoscopy and the privileging of our residents and colleagues for this procedure.
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Key words: Cystoscopy, incontinence and prolapse surgery, ureter and bladder injury
Ureteric and bladder injuries have been a known complication of gynecologic surgery for more than a century. Although urinary tract injury is higher in pelvic surgery for malignancy, it also occurs in routine benign gynecologic surgery when injury may not be suspected. It has been recognized since the review of the subject by Sampson1 in 1902 that intraoperative recognition and repair of ureteric injury reduces morbidity. Unrecognized ureteral injury can lead to postoperative complications of unexplained fever, persistent ileus, flank pain, hematuria, urinoma, urinary ascites, and fistula. Loss of renal function and death from infectious complications can also occur.
From the Regina General Hospital and the Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital. Dr Jabs received financial support during her urogynecology fellowship from R. Samuel McLaughlin Foundation, Toronto, Ontario, Canada. Presented at the Twenty-Seventh Annual Meeting of the Society of Gynecologic Surgeons, Orlando, Fla, March 5–7, 2001. Reprints not available from author. Copyright © 2001 by Mosby, Inc. 0002-9378/2001 $35.00 + 0 6/6/119072 doi:10.1067/mob.2001.119072
1368
Surgery performed for incontinence and prolapse frequently involves placing sutures in close proximity to the ureters and near the site of entry of the ureters into the bladder. Retropubic urethropexies, suburethral slings, posterior culdoplasties, and cystocele repairs can distort the ureters and trigone. The purpose of this study was to determine the frequency with which intraoperative cystoscopy during prolapse and incontinence procedures produced a change in intraoperative management to prevent ureteric and bladder injury. Methods We reviewed the charts of all patients who had prolapse and incontinence procedures during a 2-year period (January 1, 1997, to December 31, 1998) in a tertiary care urogynecology unit. Patients who had procedures in which the ureters and bladder were not at risk were excluded. All patients underwent intraoperative transurethral cystoscopy with a 70-degree cystoscope after intravenous injection of 5 mL indigo carmine to document patency and function of the ureters and to rule out bladder injury. Extracted data
Jabs and Drutz 1369
Volume 185, Number 6 Am J Obstet Gynecol
Table II. Previous abdominal and pelvic surgery
Table I. Surgeries performed Vaginal approach Including hysterectomy Including suburethral sling* Including modified urethral sling† Fistula repair Abdominal approach Including hysterectomy Including Burch Including colposacropexy Including internal anterior and/or posterior repair‡ Two-team abdominovaginal sling§ Including hysterectomy Including colposacropexy Including sacrospinous fixation Including internal anterior and/or posterior repair TOTAL
154 68 84 57 7 58 47 54 8 47 12 4 5 2 2 224
*Flood et al2 and Lazarevski.3 †Spence-Jones et al.4 ‡Drutz et al.5 §Drutz et al.6
included demographic data and possible risk factors for intraoperative ureteric and bladder injury. Recorded data included age, parity, weight, maximum grade of prolapse, previous pelvic surgery, hormonal status, and estimated blood loss. Continuous variables were compared with use of the Student t test. Nominal variables were compared with the χ2 test. Results From January 1, 1997, to December 31, 1998, 235 patients underwent urogynecologic procedures that included intraoperative cystoscopy. We excluded 11 patients because they had undergone procedures that did not put the urinary tract at risk, leaving 224 cases to be analyzed. The excluded cases involved 6 cases of posterior repair and sacrospinous vault suspension alone in which the peritoneum was not entered and no culdoplasty was performed. Three other cases involved release of a sling suture above the rectus sheath, 1 patient had an examination under anesthetic plus cystoscopy, and 1 patient had an examination under anesthetic, perineorrhaphy, and urethral dilatation. In these 11 excluded cases the cystoscopy was performed for diagnostic purposes and was not necessarily related to potential injury during the current surgery. The mean age of the patients was 60 ± 12 years (age range, 31 to 86 years), the mean weight was 71 ± 14 kg, and the median parity was 2. Fifty-two women were premenopausal and 172 were postmenopausal. Of the postmenopausal women, 93 were taking systemic or local hormone replacement therapy at the time of initial consultation and 170 were taking systemic or local hormone replacement at the time of operation. The operations performed are listed in Table I.2-6 The previous operations of the patients are listed in Table II.
None Hysterectomy Vaginal hysterectomy Total abdominal hysterectomy Subtotal hysterectomy Vaginal repair (at least 1) Vaginal repair (multiple) Retropubic urethropexy Needle suspension Two-team sling Modified urethral sling Suburethral sling
80 97 39 56 2 64 13 32 10 1 3 2
Primary surgery for prolapse or stress incontinence was performed in 138 patients (62%), whereas 83 patients (38%) underwent revision surgery for recurrent prolapse or stress incontinence. A previous hysterectomy had been performed in 43% of the women, 29% had undergone previous vaginal repair, 14% had undergone at least 1 previous retropubic urethropexy, and 7% had undergone other incontinence procedures. In 12 patients (5.3%), intraoperative management was changed by the findings during the intraoperative cystoscopy. The details of the findings and change in management are described in Table III. Patients with abnormal findings at cystoscopy did not differ from patients with normal intraoperative findings with regard to age, weight, parity, maximum grade of prolapse, estimated blood loss, or previous operations (Table IV). No known complications of intravenous injection of indigo carmine and cystoscopy occurred in the patients studied. Of the patients with normal cystoscopic findings, 38% had not had previous gynecologic surgery. In the 12 patients with abnormal findings, 3 had not had previous pelvic or gynecologic surgery and 4 had undergone previous abdominal hysterectomy or appendectomy only. There would have been no suspicion of technical difficulty on the basis of previous surgical history in 7 of the patients (58%) in whom the cystoscopic findings were abnormal. Preoperative imaging of the urinary tract was available in 88% of cases. Abnormalities were found in 20 of the 224 patients (8.9%; Table V). Most abnormalities detected were benign renal cysts. Three patients had known congenital or surgical absence of a kidney, 1 patient had a horseshoe kidney, and 1 had partial duplication of the upper collecting systems. No changes in management were made based on preoperative imaging of the urinary tract. The 1 woman in whom abnormal renal function was detected after slow excretion of indigo carmine at the time of surgery had normal findings on the preoperative ultrasonography (patient 5 in Table III). In this case the partially functioning left kidney did now show evidence of atrophy during preoperative ultrasonography.
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December 2001 Am J Obstet Gynecol
Table III. Cases with abnormal cystoscopy findings and resulting change in management Patient No.
Age (y)
Operation
1
43
VH, A2PE, SSVS, mod sling
RPU
2 3 4 5
55 53 73 77
A2PE, SSVS TAHBSO, C, RPU A2P, SSVS A2PE, SSVS
TAHBSO None TAHBSO TAHBSO
Mod sling stitches seen under bladder mucosa Right ureter blocked Right ureter blocked Both ureters blocked Slow efflux left ureter
6
60
VH, A2PE, mod sling, SSVS
None
Right ureter blocked
7 8 9 10
58 66 53 50
VH, A2PE A2P, SSVS, mod sling A2P, SSVS TAHBSO, C, RPU
Appendectomy A1P TAHBSO, RPU (2) None
Right ureter blocked Left ureter blocked Left ureter blocked Both ureters kinked
11
78
58
VH and A1, A1P, A1E, RPU; total of 4 previous procedures TAHBSO, RPU
Thin area of detrusor detected
12
2 team sling, Martius graft, repair of unintentional cystotomy A2P, mod sling, SSVS, Martius graft
Previous operation
Cystoscopic findings
Bladder laceration detected
Change in management Sling repositioned BN stitch replaced RPU stitch replaced BN stitch replaced Intraoperative stent placed; postoperative intravenous pyelogram and renal nuclear scan showed decreased function left kidney BN and anterior repair stitches replaced BN stitch replaced BN stitch replaced BN stitch replaced Stents passed; uterosacral plication stitches replaced Detrusor reinforced
Sling repositioned; laceration repaired intraoperatively; Foley left in for 3 days
VH, Vaginal hysterectomy; A2, anterior repair with suburethral sling (2) with or without Lazarevski procedure (3); P, posterior repair; E, enterocele repair including culdoplasty; SSVS, sacrospinous vault suspension; mod sling, modified urethral sling (4); RPU, Burch retropubic urethropexy; TAH, total abdominal hysterectomy; BSO, bilateral salpingo-oophorectomy; BN, bladder neck; C, culdoplasty; A1, anterior repair.
Table IV. Characteristics of patients with normal cytoscopy findings
Age (mean ± SD; y) Estimated blood loss (mean ± SD; mL) Weight (mean ± SD; kg) Prolapse grade (median) Parity (median) Menopausal women* No previous surgery*
Cystoscopy abnormal (n = 12)
Cystoscopy normal (n = 212)
60.5 ± 11 758 ± 489 73.3 ± 19.5 3 2 11 of 12 (92%) 3 of 12 (25%)
59.6 ± 12 598 ± 385 70.9 ± 13.6 3 2 161 of 212 (76%) 78 of 212 (37%)
Statistical significance P = .82 P = .29 P = .68 P = .18 P = .42
*No. of patients.
Comment Ureteric and bladder injury is a known complication during gynecologic operations and causes significant morbidity and mortality. Intraoperative detection of injury allows for an immediate search for a cause, and often ureteric blockage can be reversed by removal and replacement of the offending suture or repair of the injury during the same surgery. The incidence of ureteric and bladder injury during gynecologic surgery may vary depending on the type of surgery included, whether the study is of a prospective or retrospective design, and whether intraoperative ureteric visualization is used. The bladder may be visualized with standard transurethral cystoscopy or through an abdomi-
nal approach. Cystotomy or the use of a scope through the bladder dome can be used at the time of abdominal or laparoscopic surgery without repositioning the patient.7-9 Use of intraoperative cystoscopy and teloscopy during urogynecologic procedures has shown an incidence of urinary tract injury of 2.6% to 8%,8-11 whereas its use in all major benign gynecologic procedures discovered otherwise undetected injury in 0.4%.12 Without the use of intraoperative cystoscopy, ureteral obstruction is found in 0.33% to 1.5% of major gynecologic surgical procedures.13-15 There are 4 locations described where the ureter is known to be at risk during gynecologic surgery. From proximal to distal, these sites are (1) along the lateral pelvic sidewall above the uterosacral ligament, (2) near
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Table V. Urinary tract abnormalities on preoperative imaging Benign renal cysts Congenital or surgical absence of kidney Horseshoe kidney Mild bilateral hydronephrosis Partial upper tract duplication Renal echogenic focus Bladder abnormalities Wall thickening Distortion due to stress Fistula Diverticula TOTAL
8 3 1 2 1 1 1 1 1 1 20
the infundibulopelvic ligament, (3) at the base of the broad ligament where the ureter passes underneath the uterine vessels, and (4) through the tunnel in the cardinal ligament where the ureter turns medially anterior to the vaginal fornix to enter the bladder. Intra-abdominal surgery allows for direct visualization and palpation of the pelvic ureter during dissection. It is considerably more difficult to ensure protection of the portion of the ureter below the level of the uterine vessels. During vaginal surgery, it is more difficult but not impossible to palpate the ureter but, again, the most distal portion of the ureters may not be palpable and therefore may be at risk. Vaginal procedures performed for prolapse can distort the anatomy of the bladder base, trigone, and ureters and can lead to inadvertent kinking and blockage of the ureters. Culdoplasty sutures and bladder neck procedures have been shown to cause a significant number of injuries that lead to ureteral obstruction.10 Preoperative intravenous pyelography has not been helpful in the prevention of ureteric injury.14,16,17 The only factors associated with an increased incidence of preoperative abnormalities shown by intravenous pyelography were patients with a uterine size of 12 weeks or greater or an ovarian cyst of 4 cm or larger. It was questionable whether the results of the intravenous pyelogram led to reduced injury in these cases in which risk was already known to be higher and dissection would be carried out with more care to identify the ureter. Preoperative urinary tract imaging in our series did not assist in intraoperative management because the cases of absent or nonfunctioning kidney were either known by history or, in the case of the patient with abnormal cystoscopic findings, not detected by preoperative ultrasonography. Intraoperative visualization of the bladder and excreted indigo carmine from the ureters is an effective and low-risk method of detecting bladder and ureteric injury. The use of this technique at the time of bladder neck and prolapse surgery is important to detect and repair potential urinary tract injury. The use of routine cystoscopy in benign gynecologic surgery that does not involve the
bladder neck remains controversial, although the threshold for use of intraoperative cystoscopy should be very low when dissection is difficult or when risk factors for ureteral injury are present. We encourage training programs for gynecologic surgery to include training in diagnostic cystoscopy or transvesical teloscopy to allow the liberal use of this technique to reduce the frequency of serious sequelae from urinary tract injury. In view of the 5.3% incidence of prevention of potential ureteric or bladder damage reported in this series, we recommend the routine use of intraoperative cystoscopy for all patients undergoing incontinence and prolapse surgery.
REFERENCES
1. Sampson JA. Ligation and clamping of the ureter as complications of surgical operations. Am Med 1902;4:693. 2. Flood CG, Drutz HP, Waja L. Anterior colporrhaphy reinforced with marlex mesh for the treatment of cystoceles. Int Urogynecol J Pelvic Floor Dysfunct 1998;9:200-4. 3. Lazarevski MB. Suburethral duplication of the vaginal wall: an original operation for urinary stress incontinence in women. Int Urogynecol J Pelvic Floor Dysfunct 1995;6:73-9. 4. Spence-Jones C, DeMarco E, Lemieux MC, Drutz HP. Modified urethral sling for the treatment of genuine stress incontinence and latent incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1994;5:69-75. 5. Drutz HP, Baker KR, Lemieux MC. Retropubic colpourethropexy with transabdominal anterior and/or posterior repair for the treatment of genuine stress urinary incontinence and genital prolapse. Int Urogynecol J Pelvic Floor Dysfunct 1991;2:201-7. 6. Drutz HP, Buckspan M, Flax S, Mackie L. Clinical and urodynamic re-evaluation of combined abdominalvaginal Marlex sling operations for recurrent stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1990;1:70-3. 7. Pace J, Ballard CA, Klutke J, Klutke C, Kobak W. Intraoperative transvesical cystoscopy for urogynecologic procedures. Int Urogynecol J Pelvic Floor Dysfunct 1997;8:265-9. 8. Tulikangas PK, Weber AM, Larive AB, Walters MD. Intraoperative cystoscopy in conjunction with anti-incontinence surgery. Obstet Gynecol 2000;95:794-6. 9. Shoemaker ES, Wilkinson PD. Teloscopy after bladder neck suspension. J Am Assoc Gynecol Laparosc 1998;5:261-3. 10. Pettit PD, Petrou SP. The value of cystoscopy in major vaginal surgery. Obstet Gynecol 1994;84:318-20. 11. Harris RL, Cundiff GW, Theofrastous JP, Yoon H, Bump RC, Addison WA. The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery. Am J Obstet Gynecol 1997;177:1367-9. 12. Wiskind AK, Thompson JD. Should cystoscopy be performed at every gynecologic operation to diagnose unsuspected ureteral injury? J Pelvic Surg 1995;1:134-7. 13. Stanhope CR, Wilson TO, Utz WJ, Smith LH, O’Brien PC. Suture entrapment and secondary ureteral obstruction. Am J Obstet Gynecol 1991;164:1513-9. 14. Mann WJ, Arato M, Patsner B, Stone ML. Ureteral injuries in and obstetrics and gynecology training program: etiology and management. Obstet Gynecol 1988;72:82-5. 15. Daly JW, Higgins KA. Injury to the ureter during gynecologic surgical procedures. Surg Gynecol Obstet 1988;167:19-22. 16. Symmonds RE. Ureteral injuries associated with gynecologic surgery: prevention and management. Clin Obstet Gynecol 1976;19:623-44. 17. Piscatelli JT, Simel DL, Addison WA. Who should have intravenous pyelograms before hysterectomy for benign disease? Obstet Gynecol 1987;69;541-5.
1372 Jabs and Drutz
Discussion DR ROBERT L. SUMMITT, JR. Intraoperative injury to the lower urinary tract is a well-recognized complication of major gynecologic surgery, particularly surgery for genuine stress incontinence and pelvic organ prolapse. In an obstetrics and gynecology residency training program, Mann et al1 noted 17 urethral injuries among 3815 (0.5%) major gynecologic cases, 16 of which were recognized intraoperatively. Among women undergoing urogynecologic and reconstructive pelvic surgeries, Harris et al2 documented an injury rate of 4.0% when cystoscopy was performed at the time of surgery. Although the incidence of lower urinary tract injury is low, failure to recognize it can lead to devastating outcomes. Obviously, early recognition of ureteral obstruction and bladder injury has the potential to allow prevention of postoperative morbidity. Drs Jabs and Drutz describe a retrospective review of 235 urogynecologic and prolapse surgeries in which intraoperative cystoscopy was performed to recognize intraoperative injury to the lower urinary tract. The primary objective of the study was to determine the frequency with which intraoperative cystoscopy produced a change in the surgical management after recognition of a lower urinary tract injury. Drs Jabs and Drutz are to be commended for their detail in the assessment of risk factors that could potentially influence the outcome and incidence of lower urinary tract injury, particularly noting that maximum grade of prolapse, estimated blood loss, preoperative radiologic studies, and the combinations of surgeries performed did not affect the frequency of injuries. I submit the following questions and comments to Drs Jabs and Drutz: 1. Of the 12 patients with abnormal cystoscopic findings, the majority with ureteral obstructions occurred with an anterior repair. The resolution involved replacement of a bladder neck stitch. Please explain why this procedure was associated with obstruction and what the replacement achieved. 2. In other studies of cystoscopy performed at the time of urogynecologic surgery, culdoplasty was associated with ureteral obstruction.2,3 Were culdoplasties performed in this study group and, if so, how was obstruction prevented? 3. Drs Jabs and Drutz stated that preoperative imaging was performed in 88% of their cases but found that no particular imaging study affected the ultimate outcome of their patients. In addition, information about congenitally absent or nonfunctioning kidneys was gleaned from the histories of the patients. This seems to be a very high incidence of preoperative imaging, and in many of our patients a history of congenitally missing kidney may not be related to us. With this in mind, can Drs Jabs and Drutz document what type of imaging was typically performed in their patients? When imaging is not commonly performed before an operation and when the preoperative his-
December 2001 Am J Obstet Gynecol
tory is unremarkable, do Drs Jabs and Drutz believe it is ever necessary to perform cystoscopy at the beginning of surgery to document normal ureteral function? 4. As noted earlier, a number of previous studies have investigated the frequency of lower urinary tract injury at the time of urogynecologic surgery with use of intraoperative cystoscopy and have shown the value of its utility. What new information, if any, does this current study provide? I appreciate being invited to discuss this paper and enjoyed reviewing it. I look forward to the responses of Drs Jabs and Drutz. REFERENCES
1. Mann WJ, Arato M, Patsner B, Stone ML. Ureteral injuries in an obstetrics and gynecology training program: etiology and management. Obstet Gynecol 1988;72:82-5. 2. Harris RL, Cundiff GW, Theofrastous JP, Yoon H, Bump RC, Addison WA. The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery. Am J Obstet Gynecol 1997;177:1367-9. 3. Pettit PD, Petrou SP. The value of cystoscopy in major vaginal surgery. Obstet Gynecol 1994;84:318-20.
DR JABS (Closing). Dr Summitt’s first question relates to injuries with anterior repair and bladder neck sutures. Dr Drutz is very experienced with synthetic mesh in the anterior compartment and uses a stitch at the bladder neck that builds up the tissue between the bladder neck and the mesh itself. This suture was often the culprit and required removal and replacement. There are several places where the ureter can become obstructed and kinked, and I think relatively small changes in standard operative procedure put either more or less risk on the urinary tract. For example, with a culdoplasty stitch, some surgeons will go slightly more lateral and others will stay more medial, and the difference of a centimeter can make a large difference in the rate of injury. This can also happen with changes in technique of anterior repair in which the technique used can produce more or less distortion of the trigone. The next question concerned how we avoided injury with culdoplasty sutures. In our center, vaginal culdoplasties were performed at the time of vaginal hysterectomies, but it was not the main technique used for vaginal vault support if there was significant apical or posterior prolapse. We frequently used sacrospinous vault suspension, and this would often not require entry into the cul-de-sac and was simply performed through the posterior repair. We found that preoperative imagining did not affect outcome. In our center, which is our tertiary care center in Ontario, Canada, almost all of the patients that were to undergo a surgical procedure had ultrasonography if we did not already have this information. I am now in a much smaller center and I do not routinely order preoperative ultrasonography for all patients. All urogynecologic patients in my practice undergo cystoscopy as part of their preoperative investigations, and this will document the presence of two ureteric orifices. Ultra-
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sonagraphy would be useful in patients who have undergone previous pelvic surgery to rule out asymptomatic atrophic kidney, although we have shown that normal ultrasonography does not entirely rule out a dysfunctional kidney. What new information does this add? This article adds to the handful of other articles that have looked at the incidence of ureteric injuries discovered with intraoperative cystoscopy, and I think this is an important message that has not yet been fully implemented. I do not think
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any of us have to look very far to see surgeons without cystoscopy privileges who do have privileges to do anterior repair, vaginal hysterectomy, or Burch retropubic urethropexies and, if we want to make these procedures safe, it is important to use cystoscopy with indigo carmine and take the 5 minutes required to rule out injury. Cystoscopy is not a difficult procedure compared with the urogynecologic surgical procedure itself. We should promote the use of cystoscopy and the privileging of our residents and colleagues for this procedure.
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