title: Assessing ureteral patency using 10% dextrose cystoscopy fluid: evaluation of urinary tract infection rates.
abstract: BACKGROUND
  Intravenous indigo carmine has routinely been used to confirm ureteral patency after urogynecologic surgery. Recent discontinuation of the dye has altered clinical practice. In the absence of indigo carmine, we have used 10% dextrose in sterile water (D10) as cystoscopic fluid to evaluate ureteral patency. Glucosuria has been associated with urinary tract infection (UTI) in vivo and significantly enhanced bacterial growth in vitro. The concern is that the use of D10 would mimic a state of glucosuria albeit transient and increase the risk of postoperative UTI.
  
  
  OBJECTIVE
  The objectives of this study were to compare the rates of postoperative UTI and lower urinary tract (LUT) injuries between patients who underwent instillation of D10 vs normal saline at the time of intraoperative cystoscopy after urogynecological surgery.
  
  
  METHODS
  This was a retrospective cohort study of all women who underwent cystoscopic evaluation of ureteral patency at the time of urogynecological surgery from May through December 2014 at a tertiary care referral center. We compared patients who received D10 cystoscopy fluid vs those who used normal saline. Outcomes included UTI and diagnosis of ureteral or LUT injuries. UTI was diagnosed according to Centers for Disease Control and Prevention guidelines by symptoms alone, urine dipstick, urinalysis, or urine culture. Descriptive statistics compared the rates of UTI between the 2 groups, and a multivariable model was fit to the data to control for potential confounders and significant baseline differences between the groups.
  
  
  RESULTS
  A total of 303 women were included. D10 was used in 113 cases and normal saline (NS) was used in 190. The rate of UTI was higher in the D10 group than the NS group: 47.8% (95% confidence interval [CI], 38.3-57.4) vs 25.9% (95% CI, 19.8-32.8, P < .001). After adjusting for age, pelvic organ prolapse stage, use of perioperative estrogen, days of postoperative catheterization, menopausal status, diabetes mellitus, and history of recurrent UTI, the UTI rate remained significantly higher with the use of D10 (adjusted odds ratio, 3.4 [95% CI, 1.6-7.5], P = .002) compared with NS. Overall, 3 cases of transient ureteral kinking (1.0%) and one cystotomy (0.3%) were identified intraoperatively. However, ureteral and LUT injuries were not different between groups. No unidentified injuries presented postoperatively.
  
  
  CONCLUSIONS
  Although the use of D10 cystoscopy fluid has been successful in identifying ureteral patency in the absence of indigo carmine, it is associated with an increased rate of postoperative UTI compared with NS.
authors.affiliation: Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH. Electronic address: siffl@ccf.org.
authors.forename: Lauren N
authors.initials: LN
authors.lastname: Siff
authors.affiliation: Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Cecile A
authors.initials: CA
authors.lastname: Unger
authors.affiliation: Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: J Eric
authors.initials: JE
authors.lastname: Jelovsek
authors.affiliation: Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Marie Fidela R
authors.initials: MF
authors.lastname: Paraiso
authors.affiliation: Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Beri M
authors.initials: BM
authors.lastname: Ridgeway
authors.affiliation: Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Barber
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003558:Cystoscopy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005950:Glucose Solution, Hypertonic / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D008875:Middle Aged; D012189:Retrospective Studies; D012462:Saline Solution, Hypertonic / Q000008:administration & dosage / Q000009:adverse effects; D014513:Ureter / Q000000981:diagnostic imaging* / Q000293:injuries; D014515:Ureteral Diseases / Q000000981:diagnostic imaging*; D014552:Urinary Tract Infections / Q000209:etiology* / Q000382:microbiology; D055815:Young Adult
chemical_list: D005950:Glucose Solution, Hypertonic; D012462:Saline Solution, Hypertonic
keywords: cystoscopy; dextrose; ureteral patency; urinary tract infection