Clinical Review

2018 Update on pelvic floor dysfunction

OBG Manag. 2018 October;30(10):25-26, 28-30, 32-33

References

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ACOG Committee on Practice Bulletins–Gynecology and the American Urogynecologic Society. Urinary incontinence in women. Female Pelvic Med Reconstr Surg. 2015;21(6):304–314.
Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson HB. Hysterectomy in the United States, 1988–1990. Obstet Gynecol. 1994;83(4):549–555.
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Mäkinen J, Johansson J, Tomás C, et al. Morbidity of 10,110 hysterectomies by type of approach. Hum Reprod. 2001;16(7):1473–1478.
Gilmour DT, Dwyer PL, Carey MP. Lower urinary tract injury during gynecologic surgery and its detection by intraoperative cystoscopy. Obstet Gynecol. 1999;94(5 pt 2):883–889.
Barber MD, Brubaker L, Burgio KL, et al; Eunice Kennedy Schriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA. 2014;311(10):1023–1034.
Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int. 2004;94(3):277–289.
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Siff LN, Unger CA, Jelovsek JE, Paraiso MF, Ridgeway BM Barber MD. Assessing ureteral patency using 10% dextrose cystoscopy fluid: evaluation of urinary tract infection rates. Am J Obstet Gynecol. 2016;215(1):74.e1–74.e6.
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Universal cystoscopy policy proves protective, surgeon adherence is high

Chi AM, Curran DS, Morgan DM, Fenner DE, Swenson CW. Universal cystoscopy after benign hysterectomy: examining the effects of an institutional policy. Obstet Gynecol. 2016;127(2):369–375.

In a retrospective cohort study, Chi and colleagues evaluated urinary tract injuries at the time of hysterectomy before and after the institution of a universal cystoscopy policy. At the time of policy implementation at the University of Michigan, all faculty who performed hysterectomies attended a cystoscopy workshop. Attending physicians without prior cystoscopy training also were proctored in the operating room for 3 sessions and were required to demonstrate competency with bladder survey, visualizing ureteral efflux, and urethral assessment. Indigo carmine was used to visualize ureteral efflux.

Detection of urologic injury almost doubled with cystoscopy

A total of 2,822 hysterectomies were included in the study, with 973 in the pre–universal cystoscopy group and 1,849 in the post–universal cystoscopy group. The study period was 7 years, and data on complications were abstracted for 1 year after the completion of the study period.

The primary outcome had 3 components:

the rate of urologic injury before and after the policy
the cystoscopy detection rate of urologic injury
the adherence rate to the policy.

The overall rate of bladder and ureteral injury was 2.1%; the rate of injury during pre–universal screening was 2.6%, and during post–universal screening was 1.8%. The intraoperative detection rate of injury nearly doubled, from 24% to 47%, when intraoperative cystoscopy was utilized. In addition, the percentage of delayed urologic complications decreased from 28% to 5.9% (P = .03) following implementation of the universal cystoscopy policy. With regard to surgeon adherence, cystoscopy was documented in 86.1% of the hysterectomy cases after the policy was implemented compared with 35.7% of cases before the policy.

The investigators performed a cost analysis and found that hospital costs were nearly twice as much if a delayed urologic injury was diagnosed.

Study had many strengths

This study evaluated aspects of implementing quality initiatives after proper training and proctoring of a procedure. The authors compared very large cohorts from a busy academic medical center in which surgeon adherence with routine cystoscopy was high. The majority of patient outcomes were tracked for an extended period following surgery, thereby minimizing the risk of missing delayed urologic injuries. Notably, however, there was shorter follow-up time for the post–universal cystoscopy group, which could result in underestimating the rate of delayed urologic injuries in this cohort.

WHAT THIS EVIDENCE MEANS FOR PRACTICE

Instituting a universal cystoscopy policy for hysterectomy was associated with a significant decrease in delayed postoperative urinary tract complications and an increase in the intraoperative detection rate of urologic injuries. Intraoperative detection and repair of a urinary tract injury is cost-effective compared with a delayed diagnosis.

Continue to: Cystoscopy reveals ureteral obstruction...

2018 Update on pelvic floor dysfunction

References

Universal cystoscopy policy proves protective, surgeon adherence is high

Detection of urologic injury almost doubled with cystoscopy

Study had many strengths

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