indigo-carmine and Urinary-Incontinence

Many gynecologic, urologic, and pelvic reconstructive surgeries require accurate intraoperative evaluation of ureteral patency.. We performed a randomized controlled trial to compare surgeon satisfaction with 4 methods of evaluating ureteral patency during cystoscopy at the time of benign gynecologic or pelvic reconstructive surgery: oral phenazopyridine, intravenous sodium fluorescein, mannitol bladder distention, and normal saline bladder distention.. We conducted an unblinded randomized controlled trial of the method used to evaluate ureteral patency during cystoscopy at time of benign gynecologic or pelvic reconstructive surgery. Subjects were randomized to receive 200 mg oral phenazopyridine, 25 mg intravenous sodium fluorescein, mannitol bladder distention, or normal saline bladder distention during cystoscopy. The primary outcome was surgeon satisfaction with the method, assessed via a 100-mm visual analog scale with 0 indicating strong agreement and 100 indicating strong disagreement with the statement. Secondary outcomes included comparing visual analog scale responses about ease of each method and visualization of ureteral jets, bladder mucosa and urethra, and operative information, including time to surgeon confidence in the ureteral jets. Adverse events were evaluated for at least 6 weeks after the surgical procedure, and through the end of the study. All statistical analyses were based on the intent-to-treat principle, and comparisons were 2-tailed.. In all, 130 subjects were randomized to phenazopyridine (n = 33), sodium fluorescein (n = 32), mannitol (n = 32), or normal saline (n = 33). At randomization, patient characteristics were similar across groups. With regard to the primary outcome, mannitol was the method that physicians found most satisfactory on a visual analog scale. The median (range) scores for physicians assessing ureteral patency were 48 (0-83), 20 (0-82), 0 (0-44), and 23 (3-96) mm for phenazopyridine, sodium fluorescein, mannitol, and normal saline, respectively (P < .001). Surgery length, cystoscopy length, and time to surgeon confidence in visualization of ureteral jets were not different across the 4 randomized groups. During the 189-day follow-up, no differences in adverse events were seen among the groups, including urinary tract infections.. The use of mannitol during cystoscopy to assess ureteral patency provided surgeons with the most overall satisfaction, ease of use, and superior visualization without affecting surgery or cystoscopy times. There were no differences in adverse events, including incidence of urinary tract infections.

Topics: Administration, Intravenous; Administration, Oral; Adult; Coloring Agents; Contrast Media; Cystoscopy; Female; Fluorescein; Gynecologic Surgical Procedures; Humans; Hysterectomy; Indigo Carmine; Leiomyoma; Mannitol; Middle Aged; Phenazopyridine; Plastic Surgery Procedures; Postoperative Complications; Sodium Chloride; Ureter; Urinary Incontinence; Urologic Surgical Procedures; Uterine Hemorrhage; Uterine Neoplasms; Uterine Prolapse

Our purpose was to examine the frequency of significant intraoperative cystoscopic findings during major vaginal reconstructive and urogynecologic surgeries.. The records of 526 consecutive women who underwent routine cystoscopy with intravenous injection of indigo carmine at the time of their urogynecologic and major vaginal reconstructive procedures between January 1, 1997, and April 20, 2001, were reviewed. We determined the incidence of significant cystoscopic findings and their effect on intraoperative management. Two-tailed t tests and logistic regression analyses were used to compare characteristics between the groups with and without significant cystoscopic findings.. During the 526 operations, 26 significant findings (4.9%) were unsuspected before cystoscopy and 15 (2.9%) of these findings were operative injuries that required intervention. Seventy-nine subjects (15.0%) had no anti-incontinence operation performed. Of these patients, there was one partial ureteral obstruction from an anterior colporrhaphy (1.3%). Seven of 184 Burch procedures (3.8%) resulted in injuries to the lower urinary tract, of which 3 (1.6%) required intervention that were unrecognized before cystoscopy. Seven of the 15 cases resulting in changes in intraoperative management were caused by anterior colporrhaphy sutures (2.0% of all anterior colporrhaphies). There were no unrecognized injuries that caused morbidity after surgery. There were no significant differences between patients with abnormal and normal cystoscopic findings in regard to mean age, weight, parity, estimated blood loss, previous surgery, or previous incontinence surgeries. No complications or morbidity occurred as a direct result of intraoperative cystoscopy.. Intraoperative cystoscopy with intravenous indigo carmine is a safe and effective way to detect injury of the lower urinary tract. Cystoscopy detected unsuspected operative injuries in 2.9%. In cases that did not involve anti-incontinence procedures, the rate of injury was 1.3%. With a significant rate of detection, cystoscopy allows for immediate recognition and easier repair of lower urinary tract injury, lowering the patient's risk for morbidity. Anterior colporrhaphy was the most common cause of unrecognized ureteral compromise.

Topics: Coloring Agents; Cystoscopy; Female; Gynecologic Surgical Procedures; Humans; Indigo Carmine; Intraoperative Complications; Logistic Models; Urinary Incontinence; Urinary Tract; Urologic Diseases; Urologic Surgical Procedures; Vagina

Unrecognized ureteral and bladder injury are a known source of morbidity and mortality in gynecologic surgery. The objective of this study was to determine the frequency that intraoperative cystoscopy during prolapse and incontinence procedures produced a change in intraoperative management to prevent ureteric and bladder injury.. This study reviewed the charts and operative reports of 235 cases of routine intraoperative cystoscopy during prolapse and incontinence surgery during a 2-year period in a tertiary care urogynecology unit. Demographic data and potential risk factors for intraoperative urinary tract injury were recorded. Cases that involved a change in management brought about by intraoperative cystoscopy with intravenous indigo carmine were compared with cases in which intraoperative cystoscopy was normal. Variables were compared with use of the Student t test and the chi(2) test.. Of 235 cases, 11 were excluded. Of the 224 remaining cases, 12 (5.3%) underwent changes in intraoperative management as a result of cystoscopic findings. Eight cases involved ureteric blockage. Patients with abnormal cystoscopies did not differ from patients with normal intraoperative findings with regard to age, weight, parity, maximum grade of prolapse, estimated blood loss, or previous surgery. In 58% of patients with abnormal cystoscopies, there was no suspicion of technical difficulty on the basis of previous surgical history. Preoperative renal imaging did not predict cases with abnormal cystoscopy. There were no cases of complications caused by the intraoperative cystoscopy.. Intraoperative cystoscopy with intravenous injection of indigo carmine is a safe technique that can detect otherwise undetected intraoperative compromise of the urinary tract during prolapse and incontinence surgery. It is recommended that cystoscopy be used liberally to reduced the frequency of serious sequelae from urinary tract injury.

Topics: Adult; Aged; Coloring Agents; Cystoscopy; Female; Humans; Indigo Carmine; Intraoperative Period; Middle Aged; Urinary Incontinence; Urologic Diseases; Uterine Prolapse