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Utility of Intraoperative Cystoscopy in Detecting Ureteral Injury During Vaginal Hysterectomy

Anand, Mallika MD*; Casiano, Elizabeth R. MD, MS; Heisler, Christine A. MD, MS; Weaver, Amy L.§; Borah, Bijan J. PhD; Wagie, Amy E.; Moriarty, James P.; Gebhart, John B.*

Female Pelvic Medicine & Reconstructive Surgery: March/April 2015 - Volume 21 - Issue 2 - p 70–76
doi: 10.1097/SPV.0000000000000157
Original Articles

Objectives The aim of this study was to determine the utility of intraoperative cystoscopy in detecting and managing ureteral injury among women undergoing vaginal hysterectomy.

Methods We performed a secondary analysis of a retrospective cohort study of 593 patients who underwent vaginal hysterectomy for benign indications, with or without additional pelvic floor reconstructive surgery, from January 2, 2004, through December 30, 2005. A logistic regression model determining the propensity to undergo intraoperative cystoscopy was constructed. Comparisons of ureteral injury and cost between patients with and without cystoscopy were adjusted for the cystoscopy propensity score. We further explored the feasibility of using perioperative change in creatinine level to detect ureteral injury.

Results In total, 230 (38.8%) of 593 patients underwent cystoscopy. Six patients (2.6%) in the cystoscopy group and 5 (1.4%) in the no-cystoscopy group had ureteral injuries (odds ratio, 1.92; 95% confidence interval [CI], 0.58–6.36). This association was further attenuated after adjusting for the propensity to undergo cystoscopy (odds ratio, 1.31; 95% CI, 0.19–9.09). Four injuries detected cystoscopically were managed intraoperatively. Adjusted mean-predicted costs for patients undergoing cystoscopy were $10,686 (95% CI, $7500–$13,872) versus $10,217 (95% CI, $6894–$13,540). In the no-cystoscopy group, patients with ureteral injury had a median increase in creatinine level of 0.2 mg/dL, whereas patients without injury had a median decrease of 0.1 mg/dL (P < 0.001).

Conclusions The level of selection for cystoscopy did not significantly increase the mean predicted costs for patients. Reliance on postoperative creatinine level to detect ureteral injury, while highly sensitive, is limited by a low positive predictive value and variable range.

Screening cystoscopy does not increase the cost of vaginal hysterectomy.

From the *Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN; †Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX; ‡Department of Obstetrics and Gynecology, Spectrum Health Medical Group, Grand Rapids, MI; §Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN; and ║Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN.

Reprints: John Gebhart, MD, Division of Gynecologic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail:

Presented at the annual meeting of the American Urogynecologic Society, Chicago, Ill, October 3–6, 2012, and at the winter meeting of the Society of Urodynamics and Female Urology, New Orleans, La, February 28 to March 3, 2012.

Supported by grant number UL1 TR000135 from the National Center for Advancing Translational Sciences and internal funding from the Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN. The data analysis was supported by funds from the Mayo Foundation for Medical Education and Research.

Economic data were obtained from resources supported by the Rochester Epidemiology Project, which is supported by the National Institute on Aging of the National Institutes of Health under award number R01 AG034676. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The authors have declared they have no conflicts of interest.

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