The value of intravenous urography prior to abdominal hysterectomy for gynecologic disease

Indocyanine green for intraoperative localization of ureter

Intraurethral injection of indocyanine green (ICG; Akorn, Lake Forest, IL) and visualization under near-infrared (NIR) light allows for real-time delineation of the ureter. This technology can be helpful to prevent iatrogenic ureteral injury during pelvic surgery. Patients were scheduled to undergo robot-assisted laparoscopic sacrocolpopexy. Before the robotic surgery started, the tip of a 6-F ureteral catheter was inserted into the ureteral orifice. Twenty-five milligrams of ICG was dissolved in 10-mL of sterile water and injected through the open catheter. The same procedure was repeated on the opposite side. The ICG reversibly stained the inside lining of the ureter by binding to proteins on urothelial layer. During the course of robotic surgery, the NIR laser on the da Vinci Si surgical robot (Intuitive Surgical, Inc, Sunnyvale, CA) was used to excite ICG molecules, and infrared emission was captured by the da Vinci filtered lens system and electronically converted to green color. Thus, the ureter fluoresced green, which allowed its definitive identification throughout the entire case. In all cases of >10 patients, we were able to visualize bilateral ureters with this technology, even though there was some variation in brightness that depended on the depth of the ureter from the peritoneal surface. For example, in a morbidly obese patient, the ureters were not as bright green. There were no intraoperative or postoperative adverse effects attributable to ICG administration for up to 2 months of observation. In our experience, this novel method of intraurethral ICG injection was helpful to identify the entire course of ureter and allowed a safe approach to tissues that were adjacent to the urinary tract. The advantage of our technique is that it requires the insertion of just the tip of ureteral catheter. Despite our limited cohort of patients, our findings are consistent with previous reports of the excellent safety profile of intravenous and intrabiliary ICG. Intraurethral injection of ICG and visualization under NIR light allows for real-time delineation of the ureter. This technology can be helpful to prevent iatrogenic ureteral injury during pelvic surgery.

Urinary tract injury during hysterectomy based on universal cystoscopy

OBJECTIVE

To estimate the incidence and location of injury to the urinary tract during hysterectomy for benign gynecologic disease.

METHODS

This was a prospective clinical study in an academic environment performed at three sites. Diagnostic cystourethroscopy was performed on all patients after hysterectomy for benign disease.

RESULTS

Eight hundred thirty-nine patients were enrolled. The incidence of urinary tract injury associated with hysterectomy for benign disease was 4.3% (39 of 839 cases). The rate of bladder injury was 2.9% (24 of 839 cases), and rate of ureteral injury was 1.8% (15 of 839 cases). There were three cases of simultaneous bladder and ureteral injuries, resulting in a cumulative injury rate of 4.3%. The injury detection rate using intraoperative diagnostic cystoscopy was 97.4% (817 of 839 cases). The most common site of injury to the ureter was at the junction of the ureter and the uterine artery in 80% (12 of 15 cases) of ureteral injuries. Transection and kinking injuries were the most frequent type of injury. There were 21 cases of subnormal dye efflux from the ureteral orifices, with no subsequent injury detected on further evaluation.

CONCLUSION

Ureteral injury occurred most commonly at the level of the uterine artery, and transection and kinking injuries were most frequent. Diminished dye efflux from ureteral orifices was not associated with injury.

LEVEL OF EVIDENCE

III.

Preoperative investigations for suspected pelvic masses

Ultrasound examination was performed on 307 patients admitted to Herlev Hospital, Copenhagen, for suspicion of a pelvic tumor. Of these, 194 were operated on, 38 (19.6%) having a malignant tumor and 156 with benign conditions. A solid tumor was suspected in 72 patients on whom intravenous pyelography, barium enema, cystoscopy and rectoscopy were performed, although 11 did not undergo an intravenous pyelography and 12 did not undergo a barium enema. Intravenous pyelography, barium enema, rectoscopy and cystoscopy very seldom gave unsuspected information and never changed the indications for operation. Ultrasound examination of the kidneys, urinary tract, bowel system, liver and retroperitoneum as a complementary investigation to the gynecologic examination of the pelvic tumor gave the same information as did the barium enema, intravenous pyelography, rectoscopy and cystoscopy. Therefore, we conclude that these investigations should be carried out only in patients with symptoms from the urinary tract or the bowel system. Instead, we suggest that ultrasound examination of a pelvic mass also include an examination of the kidneys, urinary tract, bowel system, liver and retroperitoneum.

Can ultrasound replace the intravenous urogram in preliminary investigation of renal tract disease? A prospective study

The intravenous urogram has long been the mainstay of urinary tract imaging in adult practice. It has been shown recently that in many clinical situations the routine use of intravenous urography is no longer justified and in some situations avoidance of adverse contrast reactions, reduced examination time and significant cost reduction. In order to assess the clinical and financial aspects of a change in practice in our department, a prospective study was undertaken over a total of 10 weeks when 328 patients who were referred for intravenous urography were also examined independently by ultrasound combined with the plain abdominal radiograph. The results were compared and in 81.4% of cases the two techniques yielded identical information. Ultrasound plus a plain abdominal radiograph provided more diagnostic information in a further 12.5% of cases, whilst intravenous urography was more informative in only 6.1%. The findings of the study are discussed by considering the main clinical groups and comparing the relative yields of ultrasound and urography. A scheme of routine urinary tract investigations using ultrasound and the plain abdominal radiograph is proposed. We estimate a 58% reduction in number of urographic examinations while retaining diagnostic accuracy. The financial and planning implications for our department are discussed.

Routine intravenous pyelograms before hysterectomy in cases of benign disease: possibly effective, definitely expensive

Intraoperative ureteral injuries are potentially serious iatrogenic complications. Routine preoperative intravenous pyelograms might decrease the risk of such injuries during hysterectomy in cases of nonmalignant disease, but no prospective studies have been conducted to determine their effectiveness. Since gynecologists must frequently decide whether to obtain pyelograms, we used decision analysis to determine how costly routine pyelograms would be and under what circumstance pyelograms might be especially justifiable. Our cost-effectiveness study was based on decision analysis techniques, with the best available estimates from the literature, and on expert opinion. These estimates were varied over a broad range during a sensitivity analysis so as not to bias the results. At a baseline ureteral incidence injury rate of 0.5%, the marginal cost-effectiveness ratio indicates 833 pyelograms would be obtained to prevent a single injury and approximately $3.33 million would be spent to prevent a single death. As the probability of an injury increases, the marginal cost-effectiveness ratio is less dependent on the test efficacy and is more modest. Since abnormal ureteral anatomy probably predicts ureteral injury, we suggest selectively obtaining preoperative pyelograms only when the probability of an abnormality is high.

Urologic imaging and correlation with serum laboratory determinations in staging gynecologic malignancies

The records of 526 patients with gynecologic malignancies were reviewed to determine the correlation of urologic imaging modalities with serum renal function studies in detecting ureteral obstruction at the time of initial staging. Three hundred and forty-three of these patients had excretory urograms and 305 patients had concurrent serum urea nitrogen and creatinine determinations and 261 patients had concurrent radionuclide bone scans. Twenty-six patients had concurrent sonograms. Hydronephrosis (either unilateral or bilateral) was demonstrated at urography in 11% of patients with carcinoma of the cervix and ovary, but in only two percent of patients with carcinoma of the endometrium (the latter probably due to anatomic differences and an earlier stage of disease at the time of presentation). Serum urea nitrogen and creatinine determinations were abnormal in only 30% of the patients with urinary obstruction. Although only a small proportion of patients with hydronephrosis had bone scans and sonography, these appeared to be sensitive methods of detecting obstructions, but were more expensive than urography.

Sonographic identification of collecting system duplications

Sonography can replace urography in the search for a duplication anomaly of the collecting system. As a screening procedure, sonography is more cost effective and does not require ionizing radiation or an intravascular injection.

Modified excretory urography in prehysterectomy patients

A retrospective (520 patients) and prospective study (100 patients) of prehysterectomy patients was done to determine the role of preoperative excretory urography. Potentially useful information was provided by the urogram in only a small number of patients (7.4%). It is arguable whether or not preoperative intravenous urography should be done in these patients. However, since most of these patients routinely undergo this study, we suggest that a curtailed urogram consisting of a KUB film, a postinjection 15-minute prone film, and a supine film of the contrast-filled urinary bladder is adequate for preoperative screening, thereby minimizing cost and radiation to the patient.