The Effect of Patient Positioning on Ureteral Efflux During Intraoperative Cystoscopy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To identify the relationship between patient position during surgery and time to confirmation of ureteral patency on cystoscopy. DESIGN: Randomized controlled trial. SETTING: Academic tertiary care medical center. PATIENTS OR PARTICIPANTS: A total of 91 adult women undergoing laparoscopic (either conventional or robotic) hysterectomy between February 2021 and February 2022 were randomized to intervention (n = 45) or control (n = 46). Exclusion criteria included known kidney disease or urinary tract anomaly, current ureteral stent, pregnancy, malignancy, and recognized intraoperative urinary tract injury. INTERVENTIONS: Subjects in the control group were placed in a 0° supine position during cystoscopy. Subjects in the intervention group were placed in a 20° angle in reverse Trendelenburg (RT) position during cystoscopy. MEASUREMENTS AND MAIN RESULTS: The primary outcome, time to confirmation of bilateral ureteral patency, was measured at the time the second ureteral jet was viewed during intraoperative cystoscopy. There was no significant difference in mean time to confirmation (66.5 seconds in supine vs 67 seconds in RT, p = .2) nor in total cystoscopy time (111 seconds in supine vs 104.5 seconds in RT, p = .39). There were no significant differences in need for alternative modalities to aid in ureteral efflux visualization, delayed diagnosis of ureteric injury, and operative time. RT position seemed to have reduced the time to confirmation for the small group of patients with longer confirmation time (>120 seconds). CONCLUSION: RT position does not change time to confirmation of bilateral ureteral patency compared with supine position. However, there may be a benefit in position change if time to confirmation is >120 seconds.

Combined robotic and cystoscopic surgery for rectal cancer invading urinary bladder.

Although the application of laparoscopic rectal surgery has been widely accepted by accumulated evidence, it remains technically difficult in some cases of obesity, narrow male pelvis, bulky tumors, or involvement of adjacent organs. After robotic rectal surgery has been covered by the health insurance system in Japan since April 2018, we have employed robotic rectal surgery for an increasing number of cases by taking advantages of its 3D vision and wrist function. When a colorectal cancer involves the urinary bladder, the surgical treatment of choice is an anterior resection with en bloc (partial or total) bladder resection, depending on the site and extent of bladder involvement. In the attached video, robotic surgery was conducted with the aid of intraoperative cystoscopy, which resulted in curative resection with negative margin. Given that the robotic system provides excellent stability and dexterity for bladder reconstruction, the robotic approach can be technically suitable for locally advanced T4 colorectal cancer with urinary involvement.

Potency and Sterility of 10% Sodium Fluorescein Injection, USP Stored in Sterile Polypropylene Syringes for Use During Cystoscopy.

Background: A shortage of indigotindisulfonate sodium has led to a search for an alternative visualizing agent. Objective: The primary objective of this study was to evaluate the potency and sterility of 10% sodium fluorescein, USP solutions stored in sterile polypropylene syringes and refrigerated. Methods: Four samples of 10% fluorescein injection, USP were aseptically drawn up in 3 mL polypropylene syringes and stored in a refrigerator at an average temperature of 3.9°C for 7 days. After 7 days, the samples were cultured for microbial growth. Four other samples were assayed by UV/VIS spectroscopy. Concentration measurements were made at day 0 and at day 7. The pH was also measured at day 0 and day 7. Results: There was no statistical difference between the mean sodium fluorescein concentration at day 0 and at day 7 (α = 0.05, p = .622). There was no statistical difference in the pH of the samples at day 0 and at day 7 (α = 0.05, p = .0689). There was no evidence of microbial growth in any of the samples for the duration of the study period. Conclusions: The findings of this study demonstrate that a sterile solution of 10% sodium fluorescein, USP retained its potency and showed no signs of microbial growth for a period of 7 days when refrigerated and stored in sterile polypropylene syringes.

Options to Evaluate Ureter Patency at Cystoscopy in a World Without Indigo Carmine.

Intraoperative cystoscopy has been studied as a means to identify ureteral injuries at the time of gynecologic surgery. The majority of published studies investigating intraoperative cystoscopy have used indigo carmine to dye the urine to allow visualization of ureteral jets; unfortunately, however, this dye is currently not available in North America. The unavailability of indigo carmine may be a permanent reality that forces gynecologists to examine alternatives for the evaluation of ureteral integrity. Various alternative methods have been suggested, ranging from cystoscopy without dye to other commercially available products that dye the urine. Alternatives to cystoscopy for assessing ureteral integrity exist as well. This review provides an evidence-based review of the various methods available for evaluating ureteral patency, with specific information on dosing, adverse effects, and contraindications. This review will equip practicing gynecologists to choose an alternative method for assessing ureteral integrity that is tailored to their specific needs.

Ureteral injury in laparoscopic gynecologic surgery.

The introduction of laparoscopy to gynecologic surgery has allowed for both innovative advancements and new challenges in the field. As the complexity of laparoscopically approached gynecologic cases continues to increase, it is imperative for surgeons to be aware of the risk of ureteral injury. Although rare, ureteral complications with gynecologic surgery may be quite morbid; therefore, knowledge about their prevention, diagnosis, and management is of the utmost importance.