Although more prospective studies are needed, debaters at this year’s John I. Brewer Memorial Lecture leaned toward universal cystoscopy after hysterectomy performed with reconstructive surgery as opposed to selective cystoscopy.
Lisa M. Peacock, MD, chair and division director of female pelvic medicine and reconstructive surgery in the department of obstetrics & gynecology and urology at LSU Health Sciences Center in New Orleans, took the pro stance during the debate “Routine Cystoscopy at the Time of Hysterectomy.”
Rebecca Rogers, MD, associate chair for clinical integrations and operations, department of women’s health at the Dell Medical School at the University of Texas at Austin, provided evidence against routine cystoscopy. Although Dr. Rogers was on the “con” side, she interpreted the information with caveats.
Dr. Peacock reviewed several studies and programs that examined overall detection rates with universal cystoscopy, including the largest multi-site study, which involved 839 patients. Researchers at Louisiana State University and Tulane University found that prior to cystoscopy, the ureteral injury detection rate was 6.7 percent and the bladder injury detection rate was 37. 5 percent. With cystoscopy, the overall detection rate increased to 97.4 percent.
And after the University of Michigan instituted a universal cystoscopy policy in 2008, “They detected twice as many injuries after they instituted a policy of universal cystoscopy at 47 percent vs. 24 percent,” she said. “Their conclusion was that universal cystoscopy was probably protective for women.”
The estimated fixed cost of cystoscopy was found to be $125 in 1998, according to a study performed almost two decades ago. But that study has limited findings, Dr. Peacock said, because it failed to include outpatient costs, medications, litigation and settlements, and nonmedical costs of economic and productivity losses.
Dr. Peacock argued that universal cystoscopy is now a mandated expectation of resident training and has very low complication rates.
“The proponents against universal cystoscopy would say that you are going to give them UTIs, bladder and ureteral trauma, and they’re going to react to our contrast agent, but I will tell you that after the five major studies that I’ve pulled that represent 5,283 patients, there was one complication,” she said. “The one complication was one you wouldn’t even think to occur. That institution had bought a new warming unit and they put their fluid in there, and it was too hot and they scalded the bladder.”
Dr. Rogers acknowledged that as an urogynecologist, she does perform cystoscopy so she can “sleep at night.”
“I worry that I have an undetected injury if I don’t do a cystoscopy, but I am almost universally doing prolapse and incontinence procedures where cystoscopy is indicated,” she said.
To support the case against universal cystoscopy, she shared complication concerns.
“Literature shows that cystoscopy may increase urinary tract infections,” Dr. Rogers said. “And we know how unhappy patients are with that postoperatively. Since the specificity, meaning the ability of cystoscopy to detect all injuries is not 100 percent, sometimes we think there is an injury when there is not an injury.”
Dr. Rogers also shared a systematic review that looked at 79 studies and 41,000 hysterectomies. With routine cystoscopy there was a five-fold increase in injury detection but no reduction in the number of postoperatively detected injuries.
“Ureteral injuries didn’t change, bladder injuries didn’t change, and, in fact, most of these studies support that bladder injuries are detected more commonly than ureteral injuries interoperatively,” she said.
Both doctors agreed that more research and cost analysis is needed in order to determine the value of universal cystoscopy.
“We still need more research and cost analysis,” Dr. Peacock said. “The cost analysis we’ve been working on is 16 years old. It had significant limitations that could have impacted the threshold rate and it may actually be lower. We need better prospective studies to really determine our injury rates. We need to look at how we can reduce costs. This could be an effective way to detect injury at a cost price point where it’s not egregious.”
Brewer Lecture Streaming Colloquia Video