Is routine cystoscopy an essential intraoperative test at hysterectomy?

G surgeons dread urinary tract complications. Surgeons in training are taught to identify and avoid these injuries. Regrettably, despite prevention efforts, a persistently low level of injuries occurs at the time of hysterectomy, regardless of the route. It is well-known that the intraoperative detection of otherwise silent injuries clearly enhances patient safety and outcomes after hysterectomy, especially in the setting of hysterectomy with concomitant pelvic organ prolapse (POP) or urinary incontinence (UI) surgery. The report by Ibeanu et al1 (see p. 6) confirms previous reports that routine cystoscopy for detection of lower urinary tract injuries is an essential tool for reconstructive pelvic surgeons. Their data also raise the question of whether routine cystoscopy should be included at the time of hysterectomy for indications other than POP or UI. Surgeons and patients have benefited from significant advances in surgical practices that enhance the conduct and safety of surgery. These include techniques such as “time outs” before initiation of the procedure to verify consistency between the surgical plan and the reality—team documentation that the patient is correct, that the planned procedure is correct, and that, in the case of laterality, the side of the procedure is correct (ie, removal of the right ovary only). Many routine safety tasks have significantly reduced surgical sequelae, such as a retained instruments or sponges or burn injuries. Although perfect safety is desirable, it is likely an unattainable goal. Surgery, after all, has inherent risks and complications despite optimal technical performance. Most likely, the best we can do is to institute pragmatic, effective safety techniques. Thus, the authors suggest that routine cystoscopy at the time of hysterectomy, for indications other than POP or UI, is one such safety technique. Ibeanu’s data demonstrate that all but a single injury (which presented weeks after surgery) were detected intraoperatively. Based on this report, each practicing surgeon must decide whether the accumulating data are compelling enough to add routine cystoscopy to their hysterectomy cases. The options for each surgeon are essentially “selective” compared with “routine” use. These two choices have not been compared in a randomized trial of non-POP or UI hysterectomies. Selective use of cystoscopy is typically associated with a “more difficult” case, or a suspicion of lower urinary tract injury. However, because of the low rate of injury, the cystoscopy is likely to be performed infrequently. This translates to a longer time to gather and use appropriate equipment and may translate to more difficult interpretation of the cystoscopic findings. Undoubtedly, selective use will miss otherwise “silent” injuries, because most injuries are associated with “uncomplicated” cases. In Ibeanu’s report,1 approximately 75% of injuries were otherwise unsuspected. Thus, surgeons who use cystoscopy selectively must accept the fact that some low percentage of patients will leave the operating room with an untreated lower urinary tract injury. See related article on page 6.