Cystoscopy imperative during female incontinence surgery

US researchers say that cystoscopy for lower urinary tract (LUT) injury should be performed in all women undergoing urinary incontinence surgery, after finding that abnormalities are detected in one in 20 patients.

“Given the safety and efficiency of intra-operative cystoscopy, it is prudent to provide this safeguard to all patients,” comments the team, led by Halina Zyczynski (University of Pittsburgh, Pennsylvania, USA).

They studied data on 1830 women who underwent cystoscopy during surgical treatment for stress urinary incontinence (SUI) as part of three clinical trials.

Overall, 95 (5.2%) women had abnormal findings in the bladder or urethra, 75.8% of which were due to iatrogenic injury. LUT injury was most common during Burch retropubic urethropexy and retropubic midurethral slings, at 6.4%, and least common for transobturator midurethral slings, at 0.4%.

Compared with uninjured women, those with abnormal cystoscopy due to injury undergoing Burch retropubic urethropexy were significantly more likely to be older (mean 56.9 vs 51.9 years), to have experienced a greater number of vaginal deliveries (mean 3.1 vs 2.6), and to have had greater intraoperative blood loss (mean 393 vs 218 mL).

Meanwhile, among women undergoing an autologous pubovaginal sling procedure, older age (mean 62.9 vs 51.4 years) and former smoking (83.3 vs 32.8%) were associated with LUT injury.

Additionally, the team reports that when iatrogenic bladder injury with a trocar was immediately identified with intraoperative cystoscopy, there was no difference in surgical outcome.

“Clinicians and patients can be reassured that a bladder perforation by trocar is not likely to influence continence outcomes, or increase the risk for de novo or worsening urgency symptoms, voiding dysfunction or postoperative recurrent [urinary tract infections] despite repeated intraoperative cystoscopy or the subsequent management with longer catheterization,” they write.

Reporting in the American Journal of Obstetrics and Gynecology, they estimate that cystoscopy will detect abnormalities in one in 20 women overall, and non-iatrogenic abnormalities in one in 100.

“It seems prudent to survey the bladder at the time of SUI surgery since these lesions may cause urgency and/or urgency incontinence which could be attributed to the surgical intervention,” the authors write.

“When these non-iatrogenic findings are combined with the iatrogenic abnormalities (4%), there is a strong rationale for routine cystoscopy as a safety measure,” they conclude.

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