Experts recommend selective use of cystoscopy

Although many researchers have recommended cystoscopy as a universal screening tool to detect injury at the time of hysterectomy, new research recommends selective use of cystoscopy based on the low absolute risk of urinary tract injury.

A retrospective cohort study of 1982 patients at Brigham and Women’s Hospital in Boston, Massachusetts, who underwent a hysterectomy for any indication (excluding obstetric) between January 2009 and December 2010 was the basis for the researchers’ conclusions. The study appeared in the December 2012 issue of Obstetrics 
& Gynecology.

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 cystoscopy. The procedure 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 5 patients (0.25%, 95% CI 0.08–0.58%) sustained ureteral injury. None of these complications was 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).

These data support selective rather than universal cystoscopy at the time of hysterectomy, stated the researchers. They also wrote “ … in cases involving low-volume surgeons, significant pelvic pathology, or both, cystoscopy should be performed liberally. Surgeons should also be aware that a normal cystoscopy does not negate the possibility of urinary tract injury and maintain vigilance during the postoperative period.”

 Commentary from Deputy Editor Jon I. Einarsson, MD, MPH: In this retrospective study of 1982 patients, the incidence of urinary tract injury at the time of hysterectomy was 0.96%, which is similar to what has been reported in prior studies. However, cystoscopy was not helpful in detecting these injuries, most likely because the majority of the injuries were thermal in nature. As the laparoscopic approach becomes the main mode of access for hysterectomy, the nature of urinary tract injury may change and become predominantly thermal. While liberal use of cystoscopy is still encouraged, this study highlights that a normal cystoscopy does not necessarily equate to an intact urinary tract at the time of hysterectomy.