The value of intra-operative cystoscopy at the time of laparoscopic hysterectomy
The value of intra-operative cystoscopy at the time of laparoscopic hysterectomy
Sergio Ribeiro 0 2 3 4
Harry Reich 0 2 3
Jay Rosenberg 0 2 3
Enrica Guglielminetti 0 1 2
Andrea Vidali 0 1 2 3
0 Columbia University College of Physicians and Surgeons , New York, New York , USA
1 Division of Reproductive Endocrinology, Columbia Presbyterian Medical Center
2 Obstetrics and Gynecology , 622 W 168th Street PH-16, New York, NY 10032 , USA
3 Division of Advanced Laparoscopic Surgery
4 Hospital das Clinicas da FMUSP, Rua Eneas de Carvalho Aguiar , 255, 10 andar, sala 10167, Sa o Paulo, Brasil CEP 05403-000
The aim of this study was to determine the usefulness of routine intra-operative cystoscopy in documenting ureteral injury during total laparoscopic hysterectomy with vault suspension and to document the incidence of this complication in a large series. The charts of 118 patients who underwent laparoscopic hysterectomy with vault suspension from January 1992 to January 1998 were retrospectively reviewed. The patients underwent intra-operative cystoscopic evaluation to verify ureteral permeability and bladder integrity. Intra-operative ureteral obstruction occurred in four patients (3.4%). All complications were immediately fixed and there were no postoperative ureteral problems. No late ureteral complications were observed. Intra-operative cystoscopy allows for early recognition and treatment of obstructive ureteral injuries and may reduce the rate of late postoperative complications during advanced laparoscopic procedures.
The prevention and reporting of complications has become
one of the major issues of debate in laparoscopic surgery
(Chapron et al., 1998). A knowledge of anatomy combined with
surgical skills is necessary to prevent surgical complications.
However, even the most experienced surgeons cannot prevent
all complications and when they do occur, immediate diagnosis
is essential (Witters and Cornelissen et al., 1986).
Ureteral injury in gynaecological procedures continues to
be a problem that frequently warrants additional corrective
surgery and increases morbidity and mortality (Saidi et al.,
1996). The risk of damage increases when the normal course
of the ureter is either altered by primary gynaecological
pathological factors or is inadequately visualized during
intraoperative complications, such as bleeding (Wiskind and
Thompson, 1995). Early detection and repair of intra-operative
ureteral injuries can restore normal function and avoid
postoperative complication (Selzman et al., 1995).
The aim of this study was to determine the usefulness of
intra-operative cystoscopy in documenting the complication
and therefore allowing the surgeon to proceed with immediate
Materials and methods
The charts of 278 patients who underwent laparoscopic hysterectomy
with McCall vault suspension from January 1992 to January 1998
were retrospectively studied. The same surgical team operated on all
the patients. A total of 118 patients had a routine transurethral
cystoscopy after the vault suspension to verify ureteral permeability
and bladder integrity.
The main preoperative diagnoses (Table I) were symptomatic
fibroids (70.3%) and pelvic pain with endometriosis (18.6%).
Under general anaesthesia with endotracheal intubation, the patient
was placed in a low dorsolithotomic position with both legs and feet
supported by Allens stirrups (Allen Medical, Mayfield, OH, USA).
A Valtchev uterine mobilizer (Conkin Surgical Instruments, Toronto,
Ontario, Canada) was inserted into the uterine cavity to antevert the
uterus and delineate the posterior vagina. A 10 mm laparoscope was
inserted through the umbilical trocar sleeve in a vertical
intraumbilical incision. Two 5 mm supra-pubic trocar sleeves were placed,
lateral to the rectus abdominalis muscle and inferior epigastric
vessels. After complete exploration of the abdomen, bilateral ureteral
dissection was performed early in the operation, before the pelvic
sidewall peritoneum became oedematous and/or opaque from irritation
by CO2 or aquadissection. In some patients with a very large uterus,
early identification and isolation of the uterine artery was achieved,
especially if ovarian preservation was desired. In these cases, the
ureters were not isolated.
Each uterine vessel pedicle was suture-ligated with 0-Vicryl on a
blunt-tip needle, using extracorporeal knot technique. The upper
uterine blood supply was ligated using 20 Vicryl, either on a
curved needle or a free ligature, which was placed around the
infundibulopelvic ligament (when oophorectomy was indicated or
desired) or around the uteroovarian ligament (when ovarian
preservation was possible and desired). A spoon electrode divided
the broad ligament and the round ligament just lateral to the utero
ovarian artery anastomosis. After dividing the round ligaments at
their midportion, scissors or a spoon electrode was used to separate
the vesico uterine peritoneal fold and the bladder was mobilized free
from the uterus and upper vagina. The cardinal ligaments on each
side were divided and the vagina was entered posteriorly, near the
cervicovaginal junction. A 4 cm vaginal delineator was placed in
the vagina, identifying anterior cervicovaginal junction and the
lateral fornices. They were incised using a CO2 laser to complete
the circumferential culdotomy.
The uterus was morcellated, if necessary, and pulled out of the
vagina. A vaginal delineator was placed back into the vagina for
closure of the vaginal cuff. A High McCall culdoplasty was performed.
Pelvic pain (endometriosis)
Cervical carcinoma stage 1
Laparoscopic-assisted vaginal hysterectomy
Total laparoscopic hysterectomy
Total laparoscopic hysterectomy 1 unilateral salpingo-oophorectomy
Total laparoscopic hysterectomy 1 bilateral salpingo-oophorectomy
Laparoscopic supracervical hysterectomy
Laparoscopic hysterectomy with lymphadenectomy
Laparoscopic radical hysterectomy with lymphadenectomy
A rectal probe was used to ease the identification of the rectum and
the left and the right uterosacral ligaments. A 0-Vicryl suture was
placed through the left uterosacral and then through the left cardinal
ligament with a few cells of the posterolateral vagina just below the
uterine vessels, and along the posterior vaginal epithelium with a few
bites over the right side. Finally, the same suture was used to fix the
right posterolateral vagina and right cardinal ligaments to the right
uterosacral ligament. When necessary, a second or third suture was
used in the same fashion through the uterosacral ligaments to avoid
any peritoneal gap, which might result in a future enterocele formation.
At this point, 5 ml of indigo carmine dye was administered to the
patient. A transurethral cystoscopy was routinely done after cuff
closure to verify ureteral permeability and bladder integrity. If a
cystoscope was not available, a 30 hysteroscope was used. At the
close of each operation, an underwater examination was used to
detect bleeding from vessels and viscera tamponaded during the
procedure by the increased intraperitoneal pressure of the CO2
pneumoperitoneum. At least 2 l of lactated Ringers solution was left
in the peritoneal cavity. The umbilical incision was closed with a
single 40 Vicryl suture opposing deep fascia and skin dermis, with
the knot buried beneath the fascia. The lower quadrant incisions were
loosely approximated with a Javid vascular clamp (V. Mueller,
McGraw Park, IL, USA) and covered with collodion to allow drainage
of excess lactated Ringers solution.
The types of laparoscopic technique carried out on the 118 patients
were simply modifications of the more extensive procedure described
above. All types of procedures done are presented in Table II. If
laparoscopic lymphadenectomy was indicated, it was performed at
the beginning of the surgery and the technique was essentially the
same used for pelvic lymphadenectomy carried out by laparotomy.
The detailed description of that technique may be found elsewhere
(Neuman et al., 1991).
This study was performed in compliance with the Institutional
Review Board regulations. Patients were followed up at 6 weeks and
6 months with office visits.
All procedures were successfully performed through the
laparoscopic approach. Ureteral obstruction was verified in four of
Left ureter occlusion
Right ureter occlusion
Left ureter occlusion
Right ureter occlusion
the 118 patients (3.39%) (Table III). The intra-operative
cystoscopy showed no flow through the ureter in these patients
(two left and two right ureters). These ureters were then
dissected and a misplaced suture occluding the ureter distally,
overlying the uterine artery, was found in three cases; it was
immediately removed. In one case, a fibrotic band was found
and removed. It was decided not to leave an indwelling stent
in any patient. Postoperatively, there were no complications.
Ureteral damage may occur with any gynaecological surgery.
According to the literature available, incidence of ureteral
injury after gynaecological procedures varies from 0.5 to 2.5%
for routine pelvic operation to as high as 30.0% for radical
procedures for malignant conditions (Reich, 1998). However,
it is difficult to be certain of the true incidence of ureteral
injury after hysterectomy, or any pelvic surgery from previous
large reviews because cystoscopy was not routinely performed,
precluding the recognition of possible silent cases (Meirow
et al., 1994; Goodno et al., 1995).
As far as we know, this study is the first one to consider the
usefulness of detection of ureteral damage after laparoscopic
hysterectomy using intra-operative cystoscopy to assess
ureteral permeability in a large series. A misplaced suture
during the uterine artery ligature was responsible for three
cases of ureteral occlusion in this group. One patient had a
fibrotic band. All these patients had a distortion of the anatomy
caused by severe uterosacral endometriosis and a large
uterus (Table III). The intra-operative cystoscopy enabled the
recognition of all cases of ureteral occlusion, avoiding the
delay of 221 days in recognition. We agree with other authors
that it is best to find out about ureteral obstruction at the time
of the initial surgery (Grainger et al., 1990). The early
intraoperative diagnosis and repair of these complications explain
the absence of postoperative ureteral complications in our
Some authors have observed that endo-urological techniques
are highly successful in treating ureterovaginal fistulae
(Selzman et al., 1995). In a series of seven ureterovaginal
fistulae treated with a ureteral stent for 48 weeks, six healed
completely without stricture. One stricture developed after 2
months after the stent was removed but conservative
management with endo-urological techniques by cutting, dilating and
stenting the ureter for 6 weeks resulted in complete resolution
of the stricture.
The incidence of intra-operative ureteral obstruction found
in our selected group of patients (3.4%) was similar to that
found by others (4%; Harris et al., 1997) suggesting a
comparable incidence of ureteral injuries at the time of either
major operative laparoscopic or traditional open gynaecological
surgeries. Intra-operative cystoscopy allows early recognition
and treatment of all obstructive ureteral injuries and may
reduce the postoperative rate of complications during advanced
Chapron , C. , Querleu , D. , Bruhat , M.A. et al. ( 1998 ) Surgical complications of diagnostic and operative gynaecological laparoscopy: a series of 29 966 cases . Hum. Reprod., 13 , 867 - 872 .
Goodno Jr , J.A., Powers , T.W. and Harris , V.D. ( 1995 ) Ureteral injury in gynecologic surgery: a ten-year review in a community hospital . Am. J. Obstet. Gynecol. , 172 , 1817 - 1822 .
Grainger , D.A. , Soderstrom , R.M. , Diamond , M.P. et al. ( 1990 ) Ureteral injuries at laparoscopy: insights into diagnosis , management, and prevention. Obstet. Gynecol., 75 , 838 - 843 .
Harris , R.L. , Cundiff , G.W. , Theofrastous , J.P. et al. ( 1997 ) The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery . Am. J. Obstet. Gynecol. , 177 , 1367 - 1371 .
Meirow , D. , Moriel , E.Z. , Zilberman , M. et al. ( 1994 ) Evaluation and treatment of iatrogenic injuries during obstetric and gynecologic operations for nonmalignant conditions . J. Am. Coll. Surg. , 178 , 144 - 148 .
Neuman , M. , Eidelman , A. , Langer , R. et al. ( 1991 ) Iatrogenic injuries to the ureter during gynecologic and obstetric operations . Surg. Gynecol. Obstet. , 173 , 268 - 272 .
Reich , H. ( 1998 ) Laparoscopic pelvic lymphadenectomy . In Hulka, J.F. and Reich , H. (eds), Textbook of Laparoscopy , 3rd edn. Saunders, Philadelphia, Pennsylvania, pp. 443 - 449 .
Saidi , M.H. , Sadler , R.K. , Vancaillie , T.G. et al. ( 1996 ) Diagnosis and management of serious urinary complications after major operative laparoscopy . Obstet. Gynecol., 87 , 272 - 276 .
Selzman , A.A. , Spirnak , J.P. and Kursh , E.D. ( 1995 ) The changing management of ureterovaginal fistulas . J. Urol. , 153 , 626 - 628 .
Wiskind , A.K. and Thompson , J.D. ( 1995 ) Should cystoscopy be performed at every gynecologic operation to diagnose unsuspected ureteral injury ? J. Pelvic Surg., 3 , 134 - 137 .
Witters , S. , Cornelissen , M. and Vereecken , M. ( 1986 ) Iatrogenic ureteral injury: aggressive or conservative treatment . Am. J. Obstet. Gynecol. , 155 , 582 - 584 .