Indocyanine green for intraoperative localization of ureter.

Intraurethral injection of indocyanine green (ICG; Akorn, Lake Forest, IL) and visualization under near-infrared (NIR) light allows for real-time delineation of the ureter. This technology can be helpful to prevent iatrogenic ureteral injury during pelvic surgery. Patients were scheduled to undergo robot-assisted laparoscopic sacrocolpopexy. Before the robotic surgery started, the tip of a 6-F ureteral catheter was inserted into the ureteral orifice. Twenty-five milligrams of ICG was dissolved in 10-mL of sterile water and injected through the open catheter. The same procedure was repeated on the opposite side. The ICG reversibly stained the inside lining of the ureter by binding to proteins on urothelial layer. During the course of robotic surgery, the NIR laser on the da Vinci Si surgical robot (Intuitive Surgical, Inc, Sunnyvale, CA) was used to excite ICG molecules, and infrared emission was captured by the da Vinci filtered lens system and electronically converted to green color. Thus, the ureter fluoresced green, which allowed its definitive identification throughout the entire case. In all cases of >10 patients, we were able to visualize bilateral ureters with this technology, even though there was some variation in brightness that depended on the depth of the ureter from the peritoneal surface. For example, in a morbidly obese patient, the ureters were not as bright green. There were no intraoperative or postoperative adverse effects attributable to ICG administration for up to 2 months of observation. In our experience, this novel method of intraurethral ICG injection was helpful to identify the entire course of ureter and allowed a safe approach to tissues that were adjacent to the urinary tract. The advantage of our technique is that it requires the insertion of just the tip of ureteral catheter. Despite our limited cohort of patients, our findings are consistent with previous reports of the excellent safety profile of intravenous and intrabiliary ICG. Intraurethral injection of ICG and visualization under NIR light allows for real-time delineation of the ureter. This technology can be helpful to prevent iatrogenic ureteral injury during pelvic surgery.

The Location and Distribution of Transurethral Bulking Agent: 3-Dimensional Ultrasound Study.

OBJECTIVES: To use 3-dimensional endovaginal ultrasound to describe the location and distribution of bulking agent after an uncomplicated transurethral injection. METHODS: Endovaginal ultrasound was performed in 24 treatment-naive patients immediately after bulking agent was injected. The distance between the center of the hyperechoic density of bulking agent and the urethrovesical junction (UVJ) was measured in the sagittal and axial views. This was calculated in percentile length of urethra. Also, the pattern of tracking of bulking agent was assessed if it is presented. RESULTS: After the 2 subjects were excluded because of the poor quality of images, 22 patients were included in this study. Eighteen (82%) subjects showed 2 sites of bulking agents, and mostly, they were located around 3- and 9-o'clock positions. The average distance of bulking agent from left UVJ was at 16.9% of the length of the urethra (6.2 mm; range, 0.5-17 mm) and at 25.5% of the length of the urethra (8.9 mm; range, 0-24.8 mm) in the right side. The average length of urethra was 36.7 mm. Eleven of the 22 subjects (50%) had both sides within upper one third of urethra. The difference in distance between the 2 sides was less than 10 mm in 12 of 22 patients (54%). Nine of the 22 patients (41%) had a significant spread of bulking agent mostly either into the bladder neck or toward the distal urethra. CONCLUSIONS: Although the bulking agent is most often found at 3- and 9-o'clock positions as intended, the distance from the UVJ is highly variable after an uncomplicated office-based transurethral injection. The bulking material does not form the characteristic spheres in 41% of cases and tracks toward the bladder neck or the distal urethra.

Unsuccessful foley catheterization had an unexpected explanation.

BACKGROUND: Foley catheterization is a simple procedure routinely performed during many obstetric and gynecologic procedures. Failure to adequately drain the bladder with catheter insertion should prompt further investigation to minimize morbidity to the patient. CASE: After repeated attempts to place a Foley catheter during a cesarean section, the urinary bladder did not drain. Postoperatively, it was found that the catheter was positioned inside the left ureter, and cystoscopy confirmed an ectopic ureter inserting into the proximal urethra. CONCLUSIONS: This case presents an unusual cause of oliguria in an operative patient requiring Foley catheterization. An ectopic ureteral orifice should be considered in the differential diagnosis of a patient presenting with unexplained oliguria or anuria and failure to decompress the bladder with catheter placement.

Perceptions and practice patterns of general gynecologists regarding urogynecology and pelvic reconstructive surgery.

OBJECTIVES: The purpose of this study was to describe the current practice patterns of general gynecologists regarding management of various urogynecologic conditions. METHODS: A 15-item Web-based survey was sent to obstetrician and gynecologists in 2011. Subjects who chose to participate answered questions about their comfort level with management of various urogynecologic conditions, their perceptions of the need for a pelvic reconstructive surgeon in their community, and when they feel it is appropriate to refer to a specialist. RESULTS: Two hundred ninety-four obstetrics/gynecology generalists responded to the survey with overall 33% response rate. There was a wide range of comfort level depending on the complexity of the condition. Most of the subjects felt comfortable in the management of stress and urge incontinence, cystocele, rectocele, and uterine prolapse. On the other hand, most of the subjects were uncomfortable with management of intrinsic sphincter deficiency, fecal incontinence, recurrent incontinence after failed surgery, and complications of vaginal mesh surgery. In addition, there was wide variation in types of surgical options offered by different practitioners. When we compared the results by age, younger gynecologists have a smaller repertoire of procedures they offer for treatment of urogynecologic conditions. Burch colposuspension, uterosacral ligament suspension, and colpocleisis were performed more often by older surgeons than younger surgeons. On the other hand, cystoscopy was performed more commonly by the younger group. CONCLUSIONS: Among general gynecologists, there is a wide range in both comfort level for management of different urogynecologic conditions and types of urogynecologic services performed.