Examining the Evidence
Should cystoscopy be routine at the time of hysterectomy?
The overall rate of ureteral injury at the time of hysterectomy and other gynecologic procedures for benign disease has been estimated at 8.8 injuries for every 1,000 procedures, with the highest rate (17.3/1,000) occurring during laparoscopic hysterectomy with bilateral salpingo-oophorectomy (BSO). The rate of bladder injury is estimated at 16.3 for every 1,000 gynecologic procedures and 29.2 for every 1,000 laparoscopic hysterectomies with BSO. 1
Cystoscopy is a low-risk procedure that may be beneficial in surgeries associated with a high rate (1% to 2%) of lower urinary tract injury. 2 Early detection of bladder or ureteral injury is preferable to avoid postoperative complications such as fistula formation, loss of renal function, and other complications requiring additional surgery and prolonged hospitalization. Early detection also reduces medicolegal risk.
Ibeanu and associates point out that many gynecologic surgeons do not perform cystoscopy routinely, because of either a lack of training or difficulty obtaining privileges to perform this urologic procedure. They also note that the benefits of cystoscopy clearly outweigh the risks.
Only 25.6% of injuries were detected by visual inspection
Roughly one in four injuries to the bladder and ureter were detected without the aid of cystoscopy; the rest were identified using cystoscopy.
Twenty-four cases of bladder injury (2.9%) and 15 cases of ureteral injury (1.8%) were identified at the time of rigid diagnostic cystoscopy after hysterectomy. The majority (544) of the hysterectomies were abdominal, followed by vaginal hysterectomy (227) and laparoscopically assisted vaginal hysterectomy (61) ( TABLE ).
Most ureteral injuries (80%) occurred at the level of the uterine artery. The ureter is difficult to visualize or palpate once it goes under the uterine artery and courses along the anterior vagina before entry into the urinary bladder.
Ureteral injury also was common at the level of the infundibulopelvic ligament. One patient developed vesicovaginal fistula postoperatively that was missed on initial cystoscopy.
Injury rate, by hysterectomy procedure
Type of procedure
Total abdominal hysterectomy
Total vaginal hysterectomy (alone)
Total vaginal hysterectomy (with prolapse procedures)
Laparoscopically assisted vaginal hysterectomy
Cystoscopy is imperfect, but effective, and its cost is justifiable
Cystoscopy should be performed routinely after any gynecologic procedure associated with a high risk of injury, such as difficult bladder or ureteral dissection. Findings that justify cystoscopy include de novo hematuria and air in the Foley bag during laparoscopy.
Although cystoscopy may not identify all injuries, its benefits likely outweigh any additional cost associated with the procedure when a high rate of injury is likely (greater than, say, 1.5%). 3
This study was conducted over 8 years at three academic practices, so it may not be possible to generalize its findings broadly across practitioners.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Perform cystoscopy to verify integrity of the lower urinary tract at the time of hysterectomy for benign disease. Appropriate training to detect and repair injury is required to optimize surgical outcomes.—CHERYL IGLESIA, MD
1. Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol. 2006;107:1366-1372.
2. American College of Obstetricians and Gynecologists. ACOG Committee Opinion. Number 372. July 2007. The role of cystourethroscopy in the generalist obstetrician-gynecologist practice. Obstet Gynecol. 2007;110:221–224.
3. Visco AG, Taber KH, Weidner AC, Barber MD, Myers ER. Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy. Obstet Gynecol. 2001;97:685-692.