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Comment and Controversy

Cystoscopy is a skill, not a requirement

May 2009 · Vol. 21, No. 05
This week's quiz:
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Yes, cystoscopy is valuable—not just at hysterectomy but also at oophorectomy and cases involving stress urinary incontinence and pelvic relaxation. However, the data quoted by Dr. Iglesia seem suspect. I would estimate that 90% of hysterectomies performed today are laparoscopic or vaginal and 10% are abdominal—at least in my hands and those of my colleagues. In contrast, in the study discussed by Dr. Iglesia, approximately 65% of hysterectomies were performed abdominally, 27% vaginally, and 7% vaginally with laparoscopic assistance.

Moreover, when I added up the numbers, I got a total of 832 hysterectomies—not 839 as listed. The reason the numbers do not add up is that, in the original article, seven cases were missing the primary surgery label.

These do not seem like real-world numbers to me!

It is unrealistic to conclude, on the basis of this report, that every case should include cystoscopy. I do believe that every gynecologist should have cystoscopy privileges and know how to find the ureteral orifices and identify problems—and know when to call in a urologist. But the declaration that every case requires cystoscopy provides yet another opportunity for lawyers to sue us. Why not require intravenous pyelography before every surgery, too?

I believe medical judgment is the critical ingredient for every case.

Robert Frischer, MD
Wichita Falls, Tex

Dr. Iglesia responds: In expert hands, cystoscopy may not always be necessary

I concur. Medical judgment is the critical factor when deciding when and how to perform hysterectomy. Dr. Frischer’s perception about the most common route of hysterectomy performed in the United States is incorrect, however. In 2006, according to the National Center for Health Statistics (, 569,000 hysterectomies were performed—65% of them abdominally, and approximately 35% laparoscopically or vaginally.

Dr. Frischer’s surgical experience in minimally invasive gynecologic surgery is clearly above the national average. Therefore, the recommendation for cystoscopy at the time of hysterectomy may not be applicable for him and his colleagues, especially if their rate of injury to the lower urinary tract is known to be less than 1.5%.

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Vaginal hysterectomy 
with basic instrumentation