Abstract
Objective:
To compare the rate of delayed 30-day lower genitourinary tract injury in women who underwent cystoscopy at the time of benign hysterectomy to those who did not.
Methods:
This was a retrospective cohort study of patients who underwent hysterectomy without a concomitant procedure for prolapse or incontinence for benign pathology with a general obstetrician–gynecologist recorded in the National Surgical Quality Improvement Program (NSQIP) targeted hysterectomy file between 2015 and 2017 were identified. The primary outcome was a delayed lower genitourinary tract injury in the 30 days after hysterectomy. Secondary outcomes included urinary tract infection and operative time. The exposure of interest was cystoscopy at the time of hysterectomy. Stratified analysis was performed by route of surgery. Bivariable tests were used to examine associations.
Results:
We identified 39,529 women who underwent benign hysterectomy with a general obstetrician–gynecologist. Surgical approach was open (26%), laparoscopic or robotic assisted laparoscopic (46%) and vaginal or vaginally assisted (28%). Overall, 25% of women underwent cystoscopy at the time of hysterectomy, cystoscopy was more commonly performed in laparoscopic or robotic (32%) and vaginal hysterectomy (25%) as compared to open hysterectomy (11%) (p<0.001). There was no difference in delayed lower genitourinary tract injury between patients who underwent cystoscopy at time of hysterectomy compared to those who did not undergo cystoscopy (0.27% versus 0.24%, p=0.64). Patients who underwent cystoscopy were more likely to be diagnosed with a urinary tract infection (2.6% versus 2.0%, RR 1.27 95%CI 1.09–1.47). Median operative time was increased by 17 minutes in cases where cystoscopy was performed (132 versus 115 minutes, p<0.001).
Conclusions:
Cystoscopy at the time of benign hysterectomy does not result in a lower rate of 30-day delayed lower genitourinary tract injury compared to no cystoscopy.
PRECIS:
Cystoscopy at the time of benign hysterectomy is not associated with a lower rate of 30-day delayed lower genitourinary tract injury compared to no cystoscopy.
INTRODUCTION
Iatrogenic injury to the genitourinary tract is a rare, but significant cause of morbidity in patients undergoing benign gynecologic surgery.1–3 In 2012, AAGL Elevating Gynecologic Surgery recommended that routine cystoscopy be performed after all laparoscopic hysterectomies, while the American College of Obstetrician Gynecologists (ACOG) limited the endorsement to prolapse and incontinence procedures.4,5 Currently, no definitive guidelines regarding the role of cystoscopy at the time of benign hysterectomy in the absence of prolapse and incontinence procedures currently exist.
Universal cystoscopy, where all women undergoing hysterectomy undergo cystoscopy, has been advocated given that as many of 75% of genitourinary injuries occur in women without identifiable risk factors. At the University of Michigan, implementation of a universal cystoscopy policy at the time of benign hysterectomy performed by benign gynecologists was associated with a significant decrease in delayed postoperative urologic complications (7 injuries, 0.7% 95% CI 0.3–1.2% pre-implementation vs 2 injuries, 0.1% 95% CI 0.0–0.3% post-implementation).6 The authors concluded that a universal cystoscopy policy at the time of hysterectomy is a low-cost intervention that poses minimal risk to patients. Larger studies, however, have not corroborated this finding. A systematic review and meta-analysis that included 79 studies with 41,482 hysterectomies found that universal cystoscopy did not decrease the incidence of delayed genitourinary injuries.7 Risks of cystoscopy include increased rates of urinary tract infection, bladder and urethral trauma, allergic reaction to contrast agents, cost and increased operating room time. Given the conflicting reports in the literature regarding the benefits of cystoscopy in decreasing the incidence of delayed genitourinary injuries, further research into the best application of cystoscopy to benign hysterectomy is needed to inform quality and practice guidelines.8
Routine post-procedure cystoscopy is intended to recognize a genitourinary injury intra-operatively, allowing for immediate repair. If cystoscopy is a sufficiently sensitive screening tool, women who undergo cystoscopy should have a lower risk of a subsequent delayed genitourinary tract injury9–11 The objective of this study was to estimate the association between cystoscopy at the time of benign hysterectomy and the subsequent occurrence of a delayed genitourinary tract injury. Secondary objectives were to estimate the association between cystoscopy and urinary tract infection as well as operative time.
METHODS
A retrospective cohort study of women who underwent hysterectomy for benign indications recorded in the National Surgical Quality Improvement Program (NSQIP) was performed. The National Surgical Quality Improvement Program is a national quality database that collects preoperative, intraoperative and postoperative variables related to surgical procedures. Hospitals voluntarily participate in the database, and in exchange for participation, are given data regarding their own procedures to drive quality improvement.12 Data are abstracted by trained clinical reviewers and are audited regularly. For an institution’s data to be used in the nationally available file, the interobserver agreement during the audit must be greater than 95% and averages 98% for included sites.13 Within NSQIP, there is a targeted hysterectomy file that includes patient history, intraoperative, and postoperative variables specific to hysterectomy.14 This study was reviewed by the Institutional Review Board at Northwestern University and was deemed exempt from formal review given the deidentified nature of the data.
Our cohort included all women recorded in both the hysterectomy-specific file and the general NSQIP file from 2015–2017, which were linked. Patients who underwent benign hysterectomy were identified by excluding patients who underwent hysterectomy for cancer using the cancer case variable. Patients who underwent surgery with gynecologic oncologists, maternal fetal medicine specialists, reproductive endocrinologists, urogynecologists and physicians categorized as ‘other’ were excluded given the differences in patient populations and guidelines regarding cystoscopy for the various subspecialties.4,15 Hysterectomy with additional procedures performed to treat prolapse and urinary incontinence, as defined by CPT code (Table 1) were also excluded, again given the clear guidelines for cystoscopy in this population due to the higher rate of urinary tract injury. Hysterectomies with additional procedures performed that were not directed at prolapse or incontinence were included. Data regarding surgical volume or center volume was not available in this data source.
Table 1.
Current Procedural Terminology Codes Used to Define Patient Groups
| CPT codes defining cystoscopy | 52000, 52001, 52005, 52204, 52260, 52332 |
| CPT codes for reoperation for delayed GU injury | 50760, 50780, 50947, 50949, 51785, 51800, 51860, 51865, 51880, 51900, 51999, 52282, 52332, 52334, 52341, 52351, 57320 |
| CPT codes for laparoscopic hysterectomy | 58541, 58542, 58543, 58544, 58548, 58570, 58571, 58572, 58573 |
| CPT codes for open hysterectomy | 58150, 58152, 58180, 58200, 58210 |
| CPT codes for vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy | 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58550, 58552, 58553, 58554 |
| CPT codes for additional procedures directed at incontinence and prolapse | 57288, 57287, 51992, 57425, 57280, 57282. 57283 |
CPT, current procedural terminology
The primary outcome was delayed lower genitourinary tract injury. This was a composite outcome defined as an occurrence of a National Surgical Quality Improvement Program defined lower genitourinary tract injury as well as reoperation for a repair of the genitourinary tract. The National Surgical Quality Improvement Program collects three genitourinary complications from the medical record: ureteral obstruction, bladder fistula and ureteral fistula. As these complications are collected from direct medical record review, non-surgical treatment, such as percutaneous nephrostomy tube placement or catheter placement to treat a genitourinary tract injury, are included. The postoperative day on which the complication is recognized is also recorded. Women who experienced a lower genitourinary tract injury on postoperative days 1–30 were defined as having a delayed lower genitourinary tract injury, while women who had the injury diagnosed on postoperative day 0 were not. Furthermore, women who experienced a reoperation for repair of the genitourinary tract were also defined as experiencing a delayed lower genitourinary tract injury. Current procedural terminology (CPT) codes that defined a reoperation for a delayed lower genitourinary tract injury are listed in Table 2. Our exposure of interest was the occurrence of cystoscopy during hysterectomy which was defined by CPT code (Table 1) listed in addition to the hysterectomy CPT code.
Table 2:
Association between population characteristics and use of cystoscopy
| Overall N = 39,529 |
No cystoscopy N = 29,752 |
Cystoscopy N = 9,777 |
p-value | |
|---|---|---|---|---|
| Age (years) | <0.001 | |||
| 18–29 | 939 (2) | 716 (2) | 223 (2) | |
| 30–39 | 8301 (21) | 6129 (21) | 2172 (21) | |
| 40–49 | 20128 (51) | 15152 (51) | 4978 (51) | |
| 50–59 | 7363 (19) | 5527(19) | 1836 (19) | |
| ≥60 | 2796 (7) | 2228 (8) | 568 (6) | |
| BMI (kg/m2) | ||||
| <18.5 | 183 (0.5) | 136 (0.5) | 47 (0.5) | 0.65 |
| 18.5–24.9 | 7158 (18) | 5397 (18) | 1761 (18) | |
| 25–29.9 | 10910 (28) | 8233 (28) | 2677 (27) | |
| 30–34.9 | 9049 (23) | 6824 (23) | 2225 (23) | |
| 35–39.9 | 5935 (15) | 4433 (15) | 1502 (15) | |
| 40–49.9 | 4521 (11) | 3425 (12) | 1096 (11) | |
| ≥50 | 929 (2) | 680 (2) | 249 (3) | |
| Unknown | 844 (2) | 624 (2) | 220 (2) | |
| Race | ||||
| White | 23887 (60) | 17757 (60) | 6130 (63) | <0.001 |
| Black | 8290 (21) | 6467 (22) | 1823 (19) | |
| Asian | 1930 (5) | 1243 (4) | 687 (7) | |
| Unknown | 5422 (14) | 4285 (14) | 1137 (12) | |
| Hypertension | 9270 (23) | 7134 (24) | 2136 (22) | <0.001 |
| Smoking | 6488 (16) | 4935 (17) | 1553 (16) | 0.10 |
| Diabetes | 2736 (7) | 2071 (7) | 665 (7) | 0.59 |
| ASA score | ||||
| 1 | 4605 (12) | 3516 (12) | 1089 (11) | <0.001 |
| 2 | 27378 (69) | 20445 (69) | 6933 (71) | |
| 3 | 7368 (19) | 5642 (19) | 1726 (18) | |
| 4+ | 159 (0.4) | 133 (0.4) | 26 (0.3) | |
| None assigned | 19 (0.05) | 16 (0.05) | 3 (0.04) | |
| Prior abdominal surgery | 10239 (26) | 7615 (26) | 2624 (27) | 0.02 |
| Prior pelvic surgery | 23350 (59) | 17413 (59) | 5937 (61) | <0.001 |
| Median uterine weight (g) | 157 (100–314) | 158 (99–327) | 155 (101–286) | 0.01 |
| Parity | ||||
| 0 | 8069 (20) | 6292 (21) | 1777 (18) | <0.001 |
| 1 | 6487 (16) | 4874 (16) | 1613 (16) | |
| 2 | 12981 (33) | 9677 (33) | 3304 (34) | |
| 3+ | 11992 (30) | 8909 (30) | 3083 (32) | |
| Year of operation | ||||
| 2015 | 10667 (27) | 8418 (28) | 2249 (23) | <0.001 |
| 2016 | 13929 (35) | 10500 (35) | 3429 (35) | |
| 2017 | 14933 (38) | 10834 (36) | 4099 (42) |
Data presented as n (%) or median (IQR).
The exposure of interest, cystoscopy at the time of hysterectomy, was also compared to additional secondary outcomes of urinary tract infection and operative time. Urinary tract infection was defined by the NSQIP participant user file. Operative time was also defined as in NSQIP, however, because NSQIP contains up to 20 additional procedural codes for multiple procedures performed at the time of surgery, this analysis was performed in a subset of patients. To isolate the operative time attributable to cystoscopy alone, patients with only a hysterectomy CPT code (Table 1) and a diagnostic cystoscopy code (CPT 52000) were compared to patients with only a hysterectomy code to eliminate operative time that could be explained by the time required to perform additional procedures.
Associations between cystoscopy and primary and secondary outcomes were estimated using chi square test, fishers exact test, Wilcoxon rank sum test, and modified poisson regression as appropriate. Given the low number of genitourinary injuries, there were insufficient outcomes to perform a multivariable analysis. A stratified analysis was performed by route of hysterectomy which was defined based on CPT code as open, laparoscopic or robotic assisted laparoscopic, and vaginal or vaginally assisted (Table 1). All p-values were two sided with p<0.05 considered significant. STATA version 14.0 (College Station, TX) was used for all analyses.
Sensitivity analyses were performed to ensure that our results remained unchanged in subgroups. Specifically, a comparison was made between each of the different delayed genitourinary complications to ensure that there were not differences in specific injuries with and without cystoscopy that would be masked by a composite outcome. Furthermore, the association between cystoscopy and the outcomes of delayed lower genitourinary tract injury and urinary tract infection were also performed in the subgroup of women who had only one hysterectomy CPT code recorded compared to those who had one hysterectomy code and a diagnostic cystoscopy CPT code (as described above).
RESULTS
We identified 39,529 women who underwent benign hysterectomy with an obstetrician gynecologist. Patient characteristics are described in Table 2. Patients who underwent cystoscopy were more likely to be of white and Asian race and less likely to be of black race compared to patients who did not undergo cystoscopy. Patients who underwent cystoscopy were also 1–2% more likely to have a history of abdominal or pelvic surgery and had higher parity. Additionally, the use of cystoscopy increased through the study period from 21.1% in 2015 to 27.4% in 2017 (p<0.001). There were few differences between patients who experienced a delayed lower genitourinary tract injury and those who did not (Table 3). Patients who experienced a delayed injury had larger uteri by approximately 30 grams compared to those who did not.
Table 3:
Association between population characteristics and delayed lower genitourinary tract injury
| No delayed lower genitourinary tract injury N = 39,432 |
Delayed lower genitourinary tract injury N = 97 |
p-value | |
|---|---|---|---|
| Age (years) | |||
| 18–29 | 939 (2) | 0 (0) | 0.09 |
| 30–39 | 8284 (21) | 17 (18) | |
| 40–49 | 20067 (51) | 61 (63) | |
| 50–59 | 7347(19) | 16 (16) | |
| >60 | 2793 (7) | 3 (3) | |
| BMI (kg/m2) | |||
| <18.5 | 181 (0.5) | 1 (1) | 0.26 |
| 18.5–24.9 | 7135 (18) | 23 (24) | |
| 25–29.9 | 10887 (28) | 23 (24) | |
| 30–34.9 | 9030 (23) | 19 (20) | |
| 35–39.9 | 5917 (15) | 18 (19) | |
| 40–49.9 | 4508 (11) | 13 (13) | |
| ≥50 | 929 (2) | 0 (0) | |
| Missing | 844 (2) | 0 (0) | |
| Race | |||
| White | 23838 (61) | 49 (51) | 0.07 |
| Black | 8264 (21) | 26 (27) | |
| Asian | 1921 (5) | 9 (9) | |
| Unknown | 5409 (14) | 13 (13) | |
| Hypertension | 9249 (23) | 21 (22) | 0.68 |
| Current smoking | 6472 (16) | 16 (16) | 0.98 |
| Diabetes | 2728 (7) | 8 (8) | 0.61 |
| ASA score | 0.07 | ||
| 1 | 4592 (12) | 13 (14) | |
| 2 | 27312 (69) | 66 (66) | |
| 3 | 7352 (19) | 16 (18) | |
| 4+ | 157 (0.4) | 2 (2) | |
| None assigned | 19 (0.05) | 0 (0.0) | |
| Prior abdominal surgery | 10239 (26) | 24 (25) | 0.79 |
| Prior pelvic surgery | 23296 (59) | 54 (55) | 0.50 |
| Median Uterine weight (g) | 157 (100–313) | 185.5 (111–529) | 0.03 |
| Parity | 0.25 | ||
| 0 | 8042 (20) | 27 (28) | |
| 1 | 6472 (16) | 15 (15) | |
| 2 | 12949 (33) | 32 (33) | |
| 3+ | 11969 (31) | 23 (24) | |
| Year of operation | |||
| 2015 | 10643 (27) | 24 (25) | 0.88 |
| 2016 | 13894 (35) | 35 (36) | |
| 2017 | 14895 (38) | 38 (39) |
Data presented as n (%) or median (IQR).
For the primary outcome, there was no difference between patients who underwent cystoscopy and those who did not and the rate of 30-day delayed lower genitourinary tract injury (Table 4). Patients who did not undergo cystoscopy had a 0.24% rate of 30-day injury while patients who did undergo cystoscopy had a 0.27% injury rate, this difference was neither clinically nor statistically significant. Subsets of the composite outcome were examined to ensure that there was not an association between cystoscopy and delayed lower genitourinary tract injury in certain types of injury. Rates of ureteral obstruction, bladder fistula, ureteral fistula and any reoperation for a lower genitourinary tract injury were all similar with no significant clinical or statistical difference between women who underwent cystoscopy and those who did not. Additionally, the median postoperative day the injury was diagnosed was not statistically different between patients who underwent cystoscopy and those who did not (Table 4).
Table 4:
Association between cystoscopy and delayed genitourinary tract injury
| No cystoscopy N = 29,752 |
95% CI | Cystoscopy N = 9,777 |
95% CI | p-value | |
|---|---|---|---|---|---|
| Any delayed lower genitourinary tract injury | 71 (0.24) | 0.19–0.30 | 26 (0.27) | 0.17–0.39 | 0.64 |
| Postoperative day of delayed lower genitourinary tract injury | 7 (3–21) | 10 (3–16) | 0.71 | ||
| Ureteral obstruction* | 27 (0.09) | 0.06–0.13 | 11 (0.11) | 0.06–0.20 | 0.55 |
| Bladder fistula* | 16 (0.05) | 0.03–0.09 | 8 (0.08) | 0.04–0.16 | 0.33 |
| Ureteral fistula* | 19 (0.06) | 0.04–0.10 | 5 (0.05) | 0.02–0.12 | 0.66 |
| Reoperation for a GU injury* | 29 (0.10) | 0.07–0.14 | 7 (0.07) | 0.03–0.15 | 0.46 |
Summation of individual injuries are larger than the total as patient may have experienced more than one injury or be represented in multiple categories.
GU – genitourinary.
Data presented as n (%) or median (IQR).
A stratified analysis was also performed by route of surgery to investigate if there were differences in the relationship between cystoscopy and delayed lower genitourinary tract injury by route of surgery (Table 5). Surgical approach was open (26%), laparoscopic or robotic (46%), and vaginal or vaginally assisted (28%). The rates of cystoscopy differed by surgical approach with laparoscopic, robotic and vaginal approaches having an approximately 25–32% prevalence of cystoscopy while patients undergoing open surgery had a lower prevalence of cystoscopy (11%, p<0.001). For laparoscopic, robotic and vaginal approaches there was no association between cystoscopy and subsequent delayed lower genitourinary tract injury; for both groups the rate of delayed lower genitourinary tract injury was approximately 0.18–0.25%. However, for open surgery the rate of delayed lower genitourinary tract injury was higher in the patients who had cystoscopy performed. These patients had a 0.78% delayed GU injury rate compared to 0.30% for patients who did not undergo cystoscopy (p=0.01).
Table 5:
Association between cystoscopy and delayed genitourinary tract injury stratified by surgical approach
| Proportion undergoing cystoscopy | Delayed GU injury among those without cystoscopy | Delayed GU injury with cystoscopy | p-value | |
|---|---|---|---|---|
| Open N = 10,150 |
1,161 (11) | 27 (0.30) | 9 (0.78) | 0.01 |
| Laparoscopic or Robotic-Assisted Laparoscopic N = 18,321 |
5,877 (32) | 23 (0.18) | 12 (0.20) | 0.78 |
| Vaginal or Laparoscopic-Assisted Vaginal N = 11,058 |
2,739 (25) | 21 (0.25) | 5 (0.18) | 0.51 |
GU – genitourinary.
Data are presented as n (%).
Patients undergoing cystoscopy had a 2.6% rate of subsequent urinary tract infection while women who did not had a 2.0% rate (RR 1.27 95%CI 1.09–1.47). Patients undergoing cystoscopy also had a longer median operative time. In a subgroup analysis of patients with only two CPT codes recorded (n=6,072), one hysterectomy code and one diagnostic cystoscopy code, compared to patients with only a hysterectomy code recorded (n=25,837), patients who underwent cystoscopy had a median operative time of 132 minutes (IQR 100–172) while patients who did not had a median operative time of 115 minutes (IQR 86–157) (Table 6). This was a difference of 17 minutes and was statistically significant (p<0.001). Additional sensitivity analyses were carried out in this population for both primary and secondary outcomes of delayed lower genitourinary tract injury and urinary tract infection which are reported in Table 6 and confirmed our primary analysis.
Table 6:
Association between cystoscopy and outcomes in patients with no additional procedures performed
| No cystoscopy N=25,293 |
Cystoscopy N=6,559 |
p-value | |
|---|---|---|---|
| Delayed Lower genitourinary tract injury | 61 (0.24) | 16 (0.24) | 0.96 |
| Urinary tract infection | 485 (1.9) | 164 (2.5) | 0.003 |
| Operative time | 115 (86–157) | 132 (100–172) | <0.001 |
Data are presented as n (%) or median (IQR).
DISCUSSION
Cystoscopy after benign hysterectomy was not associated with a decrease in delayed 30-day genitourinary injuries compared to no cystoscopy in this study. The rate of delayed lower genitourinary tract injury was 0.27% and 0.24% with and without cystoscopy, respectively, and the results are neither statistically or clinically significant (p=.64). This is consistent with the results of a prior systematic review and meta-analysis that found universal cystoscopy was not associated with a decrease in the rate of delayed lower genitourinary tract injury.7 The incidence of delayed lower genitourinary tract injury in that meta-analysis was 0.07–0.16% which is similar although less frequent than our findings.
Our data also confirms that the sensitivity of cystoscopy as a screening tool for detection and prevention of a delayed lower genitourinary tract injury is not 100%, as the rate of delayed injury remained 0.27% even after cystoscopy. Specifically, intraoperative cystoscopy is likely to be normal in the case of thermal injuries. In the era of increased use of minimally invasive surgery, thermal injuries may become a more prevalent mechanism of injury. The rate of delayed lower genitourinary tract injury in women undergoing laparoscopic or robotic hysterectomy was not different and was without a suggestion of clinical benefit (0.18% versus 0.20%) potentially because these injuries are more likely to be thermal in nature. Interestingly, the one statistically significant finding in this paper was the association between cystoscopy and subsequent delayed lower genitourinary tract injury in women undergoing open surgery. This likely represents a selection bias given the low prevalence of cystoscopy (11%) in the open group. Surgeons likely performed cystoscopy because of an intraoperative concern of lower genitourinary tract injury. However, it is interesting that even after presumably identifying cases at higher risk, cystoscopy did not ultimately prevent these women from experiencing a delayed lower genitourinary tract injury or developing a fistula. Consideration for an intraoperative consultation or prophylactic stent placement may be warranted if there is a suspicion of genitourinary tract injury, even if cystoscopy is normal, as it cannot definitively rule out these conditions. Although cystoscopy is a powerful tool to assess the genitourinary tract, ultimately, the best approach to prevent injury is meticulous retroperitoneal dissection and awareness of the ureter and bladder through the entire procedure.
The policies and surgical practice patterns regarding cystoscopy for these institutions and surgeons are unknown and thus the debate regarding universal versus selective cystoscopy cannot be resolved with these data. However, approximately 70% of the women in this study did not undergo cystoscopy and had delayed urologic injury rates that were not different from the women who underwent cystoscopy, suggesting that surgeons were able to identify a large population of women in whom delayed urinary tract injury rates were not increased with the omission of cystoscopy. Therefore, these data could be interpreted in favor of selective over universal cystoscopy.
Ultimately, the decision to use cystoscopy in a given hysterectomy is a risk/benefit determination by the surgeon. Although the risks to cystoscopy are minimal, in this study, we did find a statistically significant 27% increase in the risk of urinary tract infections in women who underwent cystoscopy. Urinary tract infections are the fourth most common health-care associated infection and urinary tract infection is included in the Medicare list of eight hospital acquired infections for which penalties or non-payment can be levied against institutions.16,17 Additionally, cystoscopy was associated with a median increase in operative time of 17 minutes. Increases in operative time and cost are the most commonly cited concerns regarding cystoscopy with recent estimates of operating room time, not including surgeon and anesthesiologist fees, at $37 per minute,18 cystoscopy results in an additional $629 per hysterectomy in operating room time alone. The only published cost-effectiveness analysis on this topic suggests that urinary tract injury rates would have to be between 1.5–2.0% for universal cystoscopy to be considered cost-effective.19 Although this analysis has been criticized and cystoscopy may be cost effective at lower thresholds of injury; the most recent systematic review and meta-analysis found a contemporary lower genitourinary tract injury rate of 0.3%20 and cost-effectiveness analyses performed using these lower genitourinary tract injury rates are of great interest. Other risks of cystoscopy include a false sense of reassurance for the surgeon and potentially changes in surgeon behavior or technique as a result of knowing cystoscopy will be performed.
This study has the strengths of a large sample size from a large repository of surgical quality data with robust information about postoperative complications including three variables specific for complications related to the urinary tract. Additionally, the data set contains a large amount of information regarding the surgical procedure itself and any reoperations which were particularly important in defining our exposure and our outcome. Finally, our results were unchanged in various sub-populations and sensitivity analyses. Limitations of this study include that NSQIP is a hospital-based registry and thus is not nationally representative. Additionally, complications in NSQIP are only recorded for 30 days postoperatively, and thus any complications beyond this are unknown. However, genitourinary injuries recognized at greater than 30 days after hysterectomy may be more likely to have a normal cystoscopy given the amount of time required for the injury to manifest. Finally, although we had a large sample size, delayed genitourinary injuries were rare and thus the ability to adjust for confounders or to have sufficient power to detect a small benefit to cystoscopy (smaller than magnitude 0.16% or 0.18% for the sensitivity analysis) was limited, however, as can be seen in Tables 2 and 3, clinical differences to suggest confounding were rare. Although injuries were rare, the 97 injuries among over 39,000 women reported in this paper are similar in size to the single systematic review and meta-analysis on this topic and significantly larger than the majority of papers commonly cited. However, even with these limitations, in this contemporary series, the rate of delayed lower genitourinary tract injury after benign hysterectomy was approximately 0.25% in both women who underwent cystoscopy and those who did not. Our data highlight the limitations of cystoscopy in prevention of delayed lower genitourinary tract injury and encourages the use of other strategies, beyond cystoscopy, to improve surgical quality and decrease the rate of delayed urinary tract injury in women undergoing benign hysterectomy.
Supplementary Material
Acknowledgments
FINANCIAL SUPPORT: Dr. Barber is supported by NIH K12 HD050121–12.
Footnotes
Financial Disclosure
Matthew Siedhoff received money paid to him from Olympus, Caldera Medical, Applied Medical, and Cooper Surgical. The other authors did not report any potential conflicts of interest.
Each author has confirmed compliance with the journal’s requirements for authorship.
The data used in the study are derived from a deidentified National Surgical Quality Improvement file. The American College of Surgeons have not verified and are not responsible for the analytic or statistical methodology used, or the conclusions drawn from these data by the investigators.
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