Evaluation of the Morbidity of Routine Cystoscopy Performed Intraoperatively During Total Laparoscopic Hysterectomies.

STUDY
OBJECTIVES: The primary objective is to determine the rate of morbid events (urinary tract infection, hematuria, urinary retention, false positive, incidental finding) associated with routine cystoscopies performed intraoperatively during total laparoscopic hysterectomies (TLH). The secondary objectives are 1) to determine the rate of urinary complications during TLHs in our centers and 2) to determine the detection rate of urinary complications using cystoscopy during TLHs.
METHOD: Descriptive retrospective multicenter study. The study took place in Obstetrics & Gynecology departments of 2 university centers in Montreal. Patients underwent a routine cystoscopy during their TLH for a benign reason in our centers. Five hundred thirty-one charts from January 1, 2012 to January 31, 2018 were reviewed.
RESULTS: The morbidity rate of routine cystoscopies during TLHs is 4.19% (22/524 cases) in our centers. Our urinary complication rate is 2.45% (13/531 cases). Of these 13 complications, 4 were detected by cystoscopy.
CONCLUSION: The usefulness of routine cystoscopies performed intraoperatively during TLHs is questionable due to the number of morbid events and the low rate of urinary trauma in our centers. However, it is hard to establish a direct causality link between certain morbid events and cystoscopy. More studies should be conducted on this subject.

INTRODUCTION

Laparoscopic surgery has been gaining popularity in the field of gynecology since the 1990’s. This approach presents numerous advantages for hysterectomies compared to laparotomies, including reduced morbidity, hospitalization length of stay, and recovery time.[1] However, it is also recognized that a laparoscopic approach increases the risk of urinary traumas.[1] A delay in detecting these traumas can increase morbidity for the patients, increases readmission and reintervention risks, and presents medical-legal issues.[2] Thus, performing a routine intraoperative diagnostic cystoscopy during total laparoscopic hysterectomies (TLH) is a widely used practice in North-American centers in order to detect these traumas. Certain scholarly organizations, such as the American Association of Gynecologic Laparoscopists, have stated their position in favor of routine intraoperative cystoscopies during TLHs.[3]

The use of routine intraoperative cystoscopies during TLHs is currently debated for several reasons.[4] Indeed, a systematic review of 79 studies published in 2015 questions the usefulness of this procedure.5 In addition, routine cystoscopy could lead to morbid events. Currently, only one study, conducted in 2003 in the US, addressed morbidity associated with routine cystoscopies during hysterectomies.[6] It is a retrospective observational study of 101 hysterectomy cases, of which 20 were laparoscopy-assisted vaginal hysterectomies.

The objective of this study is primarily to determine the rate of morbid events associated with the use of routine intraoperative cystoscopy during TLHs. Secondary objectives are to determine the rate of urinary complications associated with TLHs as well as to determine the detection rate of these complications by routine cystoscopy.

SUBJECTS & METHODS

Our study consists of a descriptive retrospective multicenter study. The primary objective is to determine the rate of morbid events associated with routine cystoscopies performed intraoperatively during TLHs for benign conditions in our 2 university centers. The morbid events of interest are urinary tract infections, hematuria, urinary traumas, urinary retention, incidental findings, and unnecessary investigations or false positives.

Our study includes 2 secondary objectives, the first one being to determine the rate of urinary complications associated with TLHs for benign conditions in our centers. The second objective is to determine the detection rate of urinary complications by routine cystoscopy during TLHs.

Included in our study are TLHs for benign conditions (fibroids, abnormal uterine bleeding, endometriosis, etc.) during which a routine cystoscopy has been performed. Our exclusion criteria were TLHs for neoplasia as well as concurrent surgeries for prolapse correction or urinary incontinence correction. We have also not considered urinary complications that happened over 30 days post-surgery.

Collected demographic data were body mass index, age, medications, previous surgeries, and comorbidities. Collected clinical data were surgery indication, uterus weight, presence of adhesions, operating time, and blood losses. Institutional Review Board approval was received on May 1, 2019 for both centers.

RESULTS

In total, 531 charts from 2 university centers were reviewed for this study. The considered TLHs were performed between January 1, 2012 and January 31, 2018. summarizes demographic characteristics of the subjects.

Regarding the primary objective, there were 18 morbid events identified out of 524 reviewed cases, for a morbidity rate of 3.44%. To note, we use the denominator 524 because 7 charts were excluded for the primary objective as there was no cystoscopy performed. Of these 22 morbid events, there were 13 false positives, 4 urinary infections, and 1 urinary retention. presents the details of the morbid events identified in these cases.

For the first secondary objective, there were 13 urinary complications out of 531 cases reviewed, for a rate of 2.45% in our 2 centers. Four of these were ureteral microtraumas, 4 were cystotomies, 3 ureteral entrapments, 1 foreign body, and 1 uretero-vaginal fistula. presents the details of urinary complications identified during TLHs.

The other secondary objective was to determine the detection rate of urinary complications by routine cystoscopy during TLHs. Out of 13 urinary complications, cystoscopy proved to be useful in 4 situations (31%). Seven of the 13 urinary complications were noticed before cystoscopy (cases removed for the calculation of the denominator of the primary objective). There were 2 instances where a cystoscopy was performed but gave a false negative result.

DISCUSSION

As mentioned in the introduction, a number of studies report that routine cystoscopy during TLHs increases surgical morbidity. Indeed, cystoscopies are relatively invasive procedures and are associated with a higher number of urinary infections, urinary bleeding, vesical traumas, and urinary retention.[7] Possible causes of retention include swelling obstructing the flow of urine, or bladder distention leading to subsequent temporary weakening of the voiding muscles. In previous studies, the risk of urinary tract infection was found to be between 5% and 8%.[8]

In our study, the rate of morbid event occurrence is 3.44%. However, it is important to mention that the causality link with cystoscopy is hard to prove in the case of urinary tract infection and urinary retention. ().

If we consider as morbid only the false positive cases, which have led to additional investigations or unnecessary surgical procedures, there are 13 false positives out of 524 cases (2.48%). These events are the only cases for which a causal relation with cystoscopy can be definitely established.

Regarding the first secondary objective, we have identified 13 urinary complications for a rate of 2.45% (). This within the range of the complication rate of 0.73%–4% that is found in the literature.[9-11]

It should be noted that for the two objectives mentioned so far, we have to consider losses to follow-up. Indeed, 84% of the study patients were seen postoperatively. The remaining 16% have either not been seen again or the information was missing. A number of them were seen in another center or in a private office for which data is not accessible. In addition, since some of the surgeries were performed several years ago, certain charts have been destroyed. The possibility that some patients have sought medical attention in another center for urinary complications should be acknowledged. Centralized patient charts available in Quebec cannot currently be used for research purposes, which is a barrier to tracking data from other centers.

In the literature, the detection rate by cystoscopies is 90% for unsuspected ureteral lesions and 85% for vesical lesions.[12] In our study, 7 urinary complications were identified before a cystoscopy was even performed. Out of the 6 remaining urinary complications, 4 were detected by cystoscopy and 2 were not. Certain types of urinary traumas are sometimes not identified by cystoscopy, such as traumas of thermic origin secondary to devascularization or those caused by a suture leading to necrosis. One of the 2 false negative cases was indeed a microtrauma. The second, however, was a complete transection of the ureter, and this kind of trauma should have been detected by cystoscopy.

In addition, in most previous studies addressing detection rate, cystoscopies were performed using indigo carmine in order to properly visualize ureteral jet flow.[5,11,12] Since a few years it has been impossible to access this product in our hospitals in Canada. Thus, we no longer use coloring solution during our routine cystoscopies, which is a hypothesis that could explain why our detection rate is inferior to that reported in the literature.

Finally, in the analysis of the relevance of routine cystoscopies during TLHs, it is necessary to discuss the costs versus benefits of this procedure. As a matter of fact, performing a routine cystoscopy during a TLH increases operating time and represents an additional cost during the surgery. A 2019 study reported that routine cystoscopies during TLHs are only cost-effective if the rate of vesical traumas is superior to 47% and the rate of ureteral trauma is superior to 37%.[13] These rates are much higher than those observed in our centers.

Considering the financial aspect in addition to the extra morbidity, the usefulness of routine cystoscopy is questionable in our centers. However, the only morbid events that can be directly associated to cystoscopy are the false positives which led to unnecessary investigations or procedures. In these situations, laparoscopy allows direct visualization of the ureter if a ureteral trauma is suspected. This meticulous visualization could avoid an unnecessary cannulation in the false positive cases, consequently reducing morbidity. Cystoscopy; however, remains the gold standard when a vesical trauma is suspected.

The strengths of our study are the number of reviewed charts and the fact that few studies have addressed this subject in the past. Its limitations are the retrospective design, the losses to follow-up and the absence of a control group.

CONCLUSION

The usefulness of routine intraoperative cystoscopies during TLHs is questionable due to the number of morbid events and the low rate of urinary trauma in our centers. However, it is hard to establish a direct causal relation between certain morbid events and cystoscopies. Additional studies should investigate this topic.

Table 1.

Demographic and Clinical Data

Age
Mean	45 years
Range	21–78 years
Mean body mass index	29
Comorbidity rate	82%
Previous laparotomies	29%
Indications for surgery
Fibroids	30%
Bleeding	23%
Other	47%
Operating time
Mean	148 minutes
Range	35–465 minutes
Uterus weight
Mean	194 g
Range	22–1280 g
Mean blood losses	143 ml

Table 2.

Morbid Events Associated with Routine Cystoscopies During Total Laparoscopic Hysterectomy

	Morbid Event Type	Clinical History
1	False positiveUnnecessary investigation	Absence of left ureteral flowUrology consultationImpossible retrograde cannulationFluoroscopyImaging reveals a hypoplasic left kidney
2	False positiveUnnecessary investigation	Absence of unilateral ureteral flowUrology consultationRetrograde pyelogramAbsence of trauma
3	Urinary infection	Emergency room visit on postoperative day #9Antibiotherapy
4	False positiveUnnecessary investigation	Absence of unilateral ureteral flowUrology consultationIntraoperative investigationAbsence of trauma
5	False positiveUnnecessary investigation	Weak ureteral flow bilaterallyNormal pyeloscan postoperative day #1
6	False positiveUnnecessary investigation	Absence of bilateral ureteral flowUrology consultationNormal bilateral cannulation
7	False positiveUnnecessary investigationUrinary infection	Absence of ureteral flowUrology consultationNormal bilateral cannulationAntibiotherapy
8	False positiveUnnecessary investigation	Absence of ureteral flowUrology consultationNormal bilateral cannulation
9	False positiveUnnecessary investigation	Absence of ureteral flowUrology consultationNormal bilateral cannulation
10	False positive	Absence of unilateral ureteral flowNo postoperative complications
11	False positive	Absence of left ureteral flowUrology consultationObstruction seen on retrograde pyelogramUnsuccessful Cannulation attemptImaging reveals absence of right kidney
12	Urinary infection	Postoperative pyelonephritis on day #10
13	False positiveUnnecessary investigation	Absence of unilateral ureteral flowUreterolysis - Sutures evaluated far from the ureter Repeat cystoscopy – Ureteral flow identified
14	False positiveUnnecessary investigation	Absence of bilateral ureteral flowUreterolysis - Sutures evaluated far from the ureter Repeat cystoscopy and Lasix given – Ureteral flow identified
15	Urinary infection	Cystitis within 30 days postoperation
16	Urinary retention	Urinary retention on postop day #2Discharge with home catheterResolved eventually
17	False positiveUnnecessary investigation	Absence of unilateral ureteral flowUreterolysis - sutures evaluated far from the ureter Repeat cystoscopy – Ureteral flow identified

Table 3.

Urinary Complications Related to TLHs

	Urinary Complication	Clinical History
1	Microtrauma	EndometriosisUreter difficult to visualizeUrology consultation for insertion of a PollackInsertion of a double J-stent due to proximity to dissection area
2	Uretero-vaginal fistula	Normal cystoscopyPostoperative painComplete transection seen on imagingPercutaneous nephrostomy while waiting for reimplantationReimplantation left ureter
3	Ureteral pinch	Absence of ureteral jet on one sideUrology consultationRemoval of a suture on the vaultLaparoscopic ureterolysisNo ureteral trauma – Double J-stent for caution
4	Microtrauma	Cauterization near ureterUrology consultationInsertion of a double J-stent
5	Cystotomy	Prior caesarean sections x 2Vesical adhesions - cystotomyUrology consultationLaparoscopic repair then conversion to laparotomy
6	Cystotomy	Vesical adhesionsCystotomyLaparotomy repair
7	Cystotomy	Vesical adhesionsCystotomyLaparoscopic repairUrology consultationBladder catheter for seven days
8	Cystotomy	Vesical adhesionsCystotomyLaparoscopic repair
9	Foreign body	Indentation/curve seen on cystoscopyRemoval of the hemoclip that was placed during the procedure
10	Microtrauma	Cauterization near ureterUrology consultationInsertion of a double J-stent
11	Microtrauma	Suspicion of ureteral trauma during surgeryUrology consultationCystoscopy and cannulation with pollack – judged normalEmergency department consultation PO#9 for painTrauma to uretero-vesical junction on imagingInsertion of a double J-stent
12	Ureteral pinch	Cystoscopy - Absence of ureteral flow on one sideRemoval of a suture on the vaultJets visualized bilaterally afterwards
13	Ureteral pinch	Cystoscopy - Absence of ureteral flow on right sideCannulation with resistanceRemoval of a suture – Ureteral flow visualized afterwardsSuspected delayed ureteral traumaUrology consultationUreterolysis and insertion of a J-stent Absence of trauma