The value of intra-operative cystoscopy at the time of laparoscopic hysterectomy

Human Reproduction, Jul 1999

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.

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The value of intra-operative cystoscopy at the time of laparoscopic hysterectomy

Human Reproduction 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 corrective action. 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. Uterine myoma Pelvic pain (endometriosis) Endometrial hyperplasia Endometrial carcinoma 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. Results 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. Discussion 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 series. 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 laparoscopic procedures. 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 .


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Sergio Ribeiro, Harry Reich, Jay Rosenberg, Enrica Guglielminetti, Andrea Vidali. The value of intra-operative cystoscopy at the time of laparoscopic hysterectomy, Human Reproduction, 1999, 1727-1729, DOI: 10.1093/humrep/14.7.1727