title: Utility of intraoperative cystoscopy in detecting ureteral injury during vaginal hysterectomy.
abstract: OBJECTIVE
  The aim of this study was to determine the utility of intraoperative cystoscopy in detecting and managing ureteral injury among women undergoing vaginal hysterectomy.
  
  
  METHODS
  We performed a secondary analysis of a retrospective cohort study of 593 patients who underwent vaginal hysterectomy for benign indications, with or without additional pelvic floor reconstructive surgery, from January 2, 2004, through December 30, 2005. A logistic regression model determining the propensity to undergo intraoperative cystoscopy was constructed. Comparisons of ureteral injury and cost between patients with and without cystoscopy were adjusted for the cystoscopy propensity score. We further explored the feasibility of using perioperative change in creatinine level to detect ureteral injury.
  
  
  RESULTS
  In total, 230 (38.8%) of 593 patients underwent cystoscopy. Six patients (2.6%) in the cystoscopy group and 5 (1.4%) in the no-cystoscopy group had ureteral injuries (odds ratio, 1.92; 95% confidence interval [CI], 0.58-6.36). This association was further attenuated after adjusting for the propensity to undergo cystoscopy (odds ratio, 1.31; 95% CI, 0.19-9.09). Four injuries detected cystoscopically were managed intraoperatively. Adjusted mean-predicted costs for patients undergoing cystoscopy were $10,686 (95% CI, $7500-$13,872) versus $10,217 (95% CI, $6894-$13,540). In the no-cystoscopy group, patients with ureteral injury had a median increase in creatinine level of 0.2 mg/dL, whereas patients without injury had a median decrease of 0.1 mg/dL (P < 0.001).
  
  
  CONCLUSIONS
  The level of selection for cystoscopy did not significantly increase the mean predicted costs for patients. Reliance on postoperative creatinine level to detect ureteral injury, while highly sensitive, is limited by a low positive predictive value and variable range.
authors.affiliation: From the *Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN; †Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX; ‡Department of Obstetrics and Gynecology, Spectrum Health Medical Group, Grand Rapids, MI; §Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN; and ║Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN.
authors.forename: Mallika
authors.initials: M
authors.lastname: Anand
authors.forename: Elizabeth R
authors.initials: ER
authors.lastname: Casiano
authors.forename: Christine A
authors.initials: CA
authors.lastname: Heisler
authors.forename: Amy L
authors.initials: AL
authors.lastname: Weaver
authors.forename: Bijan J
authors.initials: BJ
authors.lastname: Borah
authors.forename: Amy E
authors.initials: AE
authors.lastname: Wagie
authors.forename: James P
authors.initials: JP
authors.lastname: Moriarty
authors.forename: John B
authors.initials: JB
authors.lastname: Gebhart
mesh_terms: D000328:Adult; D003558:Cystoscopy / Q000191:economics / Q000379:methods*; D005260:Female; D006801:Humans; D007045:Hysterectomy, Vaginal / Q000009:adverse effects*; D007430:Intraoperative Care; D016015:Logistic Models; D008875:Middle Aged; D012189:Retrospective Studies; D014513:Ureter / Q000293:injuries*; D001743:Urinary Bladder / Q000293:injuries*; D014947:Wounds and Injuries / Q000175:diagnosis* / Q000209:etiology