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 Table of Contents     
Year : 2019  |  Volume : 15  |  Issue : 2  |  Page : 177-178

Easy and effective way to evaluate the urological complication during laparoscopic gynaecologic surgery

1 Department of Obstetrics and Gynecology, Faculty of Medicine, Srinakharinwirot University, Nakhonnayok, Thailand
2 Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Kweishan, Taoyuan, Taiwan

Date of Submission04-Dec-2017
Date of Acceptance11-Feb-2018
Date of Web Publication12-Mar-2019

Correspondence Address:
Dr. Kuan-Gen Huang
Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, No. 5, Fu-Hsin Street, Kweishan, Taoyuan 333
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_242_17

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How to cite this article:
Tantitamit T, Huang KG. Easy and effective way to evaluate the urological complication during laparoscopic gynaecologic surgery. J Min Access Surg 2019;15:177-8

How to cite this URL:
Tantitamit T, Huang KG. Easy and effective way to evaluate the urological complication during laparoscopic gynaecologic surgery. J Min Access Surg [serial online] 2019 [cited 2022 Jul 1];15:177-8. Available from:

According to the American Association of Gynecologic Laparoscopists (AAGL) 2012, the routine cystoscopy at the time of laparoscopic hysterectomy could be detected almost all bladder injuries and 80%–90% of ureteral injuries.

The preferred is visualising ureteral ejection after the intravenous (IV) indigo carmine injection through the cystoscopy.[1] Since there was a shortage of indigo carmine, various alternative methods have been suggested: methylene blue, sodium fluorescein, phenazopyridine, Vitamin B or using other distensions.

Two randomised control trials compared the surgeon's satisfaction with different strategies including phenazopyridine. The most satisfaction and superior visualisation from these two studies are sodium fluorescein and mannitol.[2],[3]

We cannot draw a conclusion about the most effective method based on the limited data. To select the optimal method, the surgeon should consider all aspects, not only satisfaction but also the feasibility, cost and safety. There are alternative approaches to assess the intraoperative ureteric integrity such as ureteral catheterisation, intraureteral Indocyanine green (ICG), fluoroscopy with urography, light ureteral stent and on-table IV pyelogram. However, these alternatives approached require additional or special equipment and skilled surgeon.

We would like to share our long experience with a simple method using phenazopyridine and also support the AAGL recommendation to encourage the gynaecologic surgeons making cystoscopy an integral component of laparoscopic hysterectomy. The Division of Minimal Invasive Surgery of the Department of Obstetrics and Gynecology at the Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine has utilised the routine cystoscopy after laparoscopic hysterectomy in every case. We used the pyridium (phenazopyridine) as a dying agent more than 10 years. The patient received a single dose of phenazopyridine (200 mg) with a sip of water the night before surgery. The safety profile of this drug showed no complications with use in a single course. It is contraindicated in patients with hepatic and renal impairment; therefore, the physicians should avoid used with caution in geriatric patients.[4] Cystoscopy is performed immediately after the operation by the gynaecologic surgeon. The bilateral ureteric jet was clearly and rapidly seen. There has not been any severe adverse effect occurred from this agent. However, a well-designed study is needed to provide additional support for phenazopyridine as a good agent for intraoperative cystoscopy.

Some barriers to routine performance of cystoscopy after laparoscopic hysterectomy have been reported.[1] First, cystoscopy may increase the operative time. In our daily practice, the total processing time is <10 min, depends on the time to see the ureteric jet clearly which takes approximately 2–3 min. This does not have much effect on the length of surgery. Second, it requires a specialised operating room team and often requires consultants. In our hospital, we train the resident and allow them to practice this procedure under supervision. Most of them can perform correctly and smoothly within 1–2 months. Urologist consultation may be required only if it shows the abnormal result. Finally, there is unclear evidence of cost-effective data. Visco et al. reported that if the rate of urinary tract injury exceeds 2% for laparoscopic-assisted vaginal hysterectomy, routine cystoscopy is cost-effective. In this study, the estimated cystoscopy cost included the cost of indigo carmine [5] which is much more expensive than phenazopyridine (29 USD vs. 0.22 USD). Therefore, using pre-operative oral phenazopyridine might make routine cystoscopy after laparoscopic hysterectomy more cost-effective even the injury rate is low. The study of cost-effective analysis is required.

From our perspective, using phenazopyridine to evaluate the bladder and ureteric patency is an easy, inexpensive, safe and effective method. We recommend this agent with intraoperative cystoscopy and strongly support AAGL practice guideline to implement routine cystoscopy immediately after laparoscopic total hysterectomy if available.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: Practice guidelines for intraoperative cystoscopy in laparoscopic hysterectomy. J Minim Invasive Gynecol 2012;19:407-11.  Back to cited text no. 1
Grimes CL, Patankar S, Ryntz T, Philip N, Simpson K, Truong M, et al. Evaluating ureteral patency in the post-indigo carmine era: A randomized controlled trial. Am J Obstet Gynecol 2017;217:601.e1-000000000.  Back to cited text no. 2
Espaillat-Rijo L, Siff L, Alas AN, Chadi SA, Zimberg S, Vaish S, et al. Intraoperative cystoscopic evaluation of ureteral patency: A randomized controlled trial. Obstet Gynecol 2016;128:1378-83.  Back to cited text no. 3
Pergialiotis V, Arnos P, Mavros MN, Pitsouni E, Athanasiou S, Falagas ME, et al. Urinary tract analgesics for the treatment of patients with acute cystitis: Where is the clinical evidence? Expert Rev Anti Infect Ther 2012;10:875-9.  Back to cited text no. 4
Visco AG, Taber KH, Weidner AC, Barber MD, Myers ER. Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy. Obstet Gynecol 2001;97:685-92.  Back to cited text no. 5


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2004 Journal of Minimal Access Surgery
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Online since 15th August '04