Cheruba Prabakar

Use of 50% Dextrose as the Distension Medium During Cystoscopy for Visualization of Ureteric Jets.

BACKGROUND: Indigotindisulfonate sodium has been used to color the urine and thereby improve the visualization of ureteric jets during intraoperative cystoscopy. After indigotindisulfonate sodium became unavailable, there has been an ongoing search for an alternate agent to improve visualization of the jets. METHOD: We used 50% dextrose, which is more viscous than urine, as the distension medium during cystoscopy so that the ureteric efflux is seen as a jet of contrasting viscosity. We instilled 100 mL of 50% dextrose into the bladder through an indwelling catheter, which is then removed and cystoscopy is performed as usual. EXPERIENCE: We observed jets of contrasting viscosity in every patient in whom 50% dextrose was used as compared with coloring agents in which the jet is not always colored at the time of cystoscopy. Visualization of the other structures in the bladder and the bladder wall itself is not altered by 50% dextrose, although the volume of 50% dextrose that we typically use may not provide adequate distension for a complete assessment of the bladder. If additional distension is necessary, normal saline may be used in addition to the 50% dextrose once the ureteric jets have been assessed. CONCLUSION: Fifty percent dextrose is an effective alternative to indigotindisulfonate sodium for visualization of ureteric jets during cystoscopy.

50% dextrose versus normal saline as distension media during cystoscopy for assessment of ureteric patency

OBJECTIVE To compare the visualization of ureteric jets when using 50% dextrose (D50) as opposed to normal saline (NS) as distension media during cystoscopy. STUDY DESIGN Cross sectional study. METHODS Two patients each had two cystoscopy videos recorded at the time of a ureteric jet; one using NS and the other using D50 resulting in two sets of paired videos (four videos). A fifth cystoscopy video was recorded, as a control, at a time when there was no ureteric-jet. Fifty participants including attending physicians, residents and medical students were recruited at an academic-affiliated community hospital. Participants were blinded to the medium used and viewed each of the five videos. Participants assessed each video for presence of a ureteric-jet, ease of interpretation, and compared the paired D50 and NS videos for clarity of ureteric-jets. MAIN OUTCOME MEASURES Participants assessment of clarity of the ureteric jets when D50 was used as compared to when NS was used in the paired videos. RESULTS All 100 observations of the two D50 videos with jets identified the presence of a jet; for the NS videos, 96/100 observations identified a jet, 2/100 did not identify a jet and 2/100 were unsure. 48/50 observations of the video with no jet were correct, while 2/50 were unsure. Participants rated the ureteric-jets to be clearer in videos with D50 (86% vs 14%, P<0.001); and had difficulty interpreting cystoscopy videos with NS (62% vs 2%, OR: 80, 95% CI: 10.2-627.6). CONCLUSION Participants preferred the clarity of the ureteric-jet when 50% dextrose was used as the distension medium during cystoscopy as compared to normal saline.

Patient Perceptions of Open, Laparoscopic, and Robotic Gynecological Surgeries

Objective. To investigate patient knowledge and attitudes toward surgical approaches in gynecology. Design. An anonymous Institutional Review Board (IRB) approved questionnaire survey. Patients/Setting. A total of 219 women seeking obstetrical and gynecological care in two offices affiliated with an academic medical center. Results. Thirty-four percent of the participants did not understand the difference between open and laparoscopic surgeries. 56% of the participants knew that laparoscopy is a better surgical approach for patients than open abdominal surgeries, while 37% thought that laparoscopy requires the surgeon to have a higher technical skill. 46% of the participants do not understand the difference between laparoscopic and robotic procedures. 67.5% of the participants did not know that the surgeon moves the robots arms to perform the surgery. Higher educational level and/or history of previous abdominal surgeries were associated with the highest rates of answering all the questions correctly (p < 0.05), after controlling for age and race. Conclusions. A substantial percentage of patients do not understand the difference between various surgical approaches. Health care providers should not assume that their patients have an adequate understanding of their surgical options and accordingly should educate them about those options so they can make truly informed decisions.

Use of 50% Dextrose as the Distension Medium During Cystoscopy for Visualization of Ureteric Jets

The lower urinary tract is at risk of injury during pelvic surgery. Intraoperative cystoscopy can identify most ureteric injuries. Traditionally, indigotindisulfonate sodium has been administered intravenously to color the urine and improve the visualization of ureteric jets during intraoperative cystoscopy. In June 2104, the US Food and Drug Administration announced a shortage of indigotindisulfonate sodium. Because this coloring agent is no longer available, there has been an ongoing search Health, Inc. All rights reserved. 220 Obstetrical and Gynecological Survey for a safe and cost-effective alternative agent to improve visualization of the jets. Distension media have been investigated as an alternative to coloring agents to facilitate visualization of ureteric jets. The aim of this study was to evaluate use of 50% dextrose as the distension medium during cystoscopy. A solution of 50% dextrose is more viscous than urine and allows clear visualization of the jet at the time of ureteric efflux as a result of their contrasting viscosities. An indwelling catheter was used to instill 100 mL of 50% dextrose into the bladder. After the catheter was removed, cystoscopy was performed as usual. The study reports on experience in 43 patients at a single institution. In every patient in whom 50% dextrose was used, jets of contrasting viscosity were observed. With coloring agents, the ureteral jet is not always colored at the time of cystoscopy. Visualization of the other structures in the bladder is not altered by 50% dextrose; however, the volume of 50% dextrose typically used may not provide adequate distension for a complete bladder assessment. When additional distension is needed, normal saline can be used in addition to the 50% dextrose once the ureteric jets have been assessed to facilitate full bladder assessment. These findings demonstrate that 50% dextrose may be an effective alternative to indigotindisulfonate sodium for visualization of ureteric jets during cystoscopy.

What Your Patient Does Not Know: A Survey of Patient Knowledge About Surgical Approaches in Gynecology [385]

OBJECTIVE: To investigate patient knowledge and attitudes about surgical approaches in gynecology. METHODS: At an outpatient obstetrics and gynecology triage and clinic of an academic medical center in New York, a questionnaire was administered to 154 patients who were in triage or clinic to receive routine obstetrics and gynecology care. Each participant anonymously completed the institutional review board–approved questionnaire. MEASUREMENTS AND MAIN RESULTS: Ninety percent of respondents were younger than 39 years of age. Forty-one percent had some high school and 32% had some college education. Racial groups surveyed were equally represented. Thirteen percent had previous surgeries with only 4.5% of those being minimally invasive abdominal surgeries. We found that 41% participants did not understand the difference between an open and laparoscopic approach to surgery, although 48% thought a laparoscopic approach was more beneficial to patients. Only 30% of respondents thought laparoscopy needed a higher level of skill compared with open surgery. Fifty-one percent did not know the difference between conventional and robotic laparoscopy, and 64% did not know whether it was the surgeon or the robot that operated during robotic surgeries. Sixty percent believed that conventional and robotic laparoscopy required the same amount of operator skill. Forty percent of participants would have no preference as to surgical approach if they had to undergo a procedure. When seeking information about a surgical approach, 60% said they would consult their doctor first compared with the Internet or a friend. More educated participants were shown to have a better understanding of the differences between open and laparoscopic approaches (r=0.20, P=.03), whereas age did not play a significant role. Neither age nor education influenced how well participants understood the difference between laparoscopic and robotic surgery. CONCLUSION: A substantial percentage of the patients we studied who were seeking obstetric and gynecologic care did not understand the differences between various surgical approaches. Health care providers should educate and empower patients to understand the surgical options available to them.

A Randomized Clinical Trial Comparing Two Different Methods of Trocar Placement in Gynecologic Laparoscopy [127]

OBJECTIVE: To determine whether the “look” method or the “feel” method of trocar insertion results in placement that is closest to a 90° angle to the patients anterior abdominal wall. METHODS: This is a prospective, randomized crossover study with patients serving as their own control group. A total of 27 patients aged 24–75 years undergoing gynecologic surgery with either conventional or robotic laparoscopy in an academic hospital setting in New York were included. INTERVENTION: Trocars were placed in the patients right and left lower quadrants by the same resident using either the “look” or the “feel” method. In the “look” method, the surgeon looked at the video monitor throughout trocar placement. In the “feel” method, the surgeon looked directly at the patient until the fascia was entered, after which the surgeon looked up at the monitor for the rest of the placement. Method and site of placement were randomized within each patient. Once the trocar was inserted to a predetermined mark, the length of the trocar beneath the peritoneum was calculated and used as a surrogate measure for the angle of trocar placement. Local anesthesia was not used. RESULTS: The principal outcome variable was the length of the trocar beneath the peritoneum. Covariates included patients age and body mass index (BMI, calculated as weight (kg)/[height (m)]2) and the postgraduate year level of the resident who placed both trocars. The mean difference in length of the trocar beneath the peritoneum was 0.18 cm (P=.26) by paired t test. By analysis of covariance, the absolute difference in trocar length between methods was not affected by age, BMI, or postgraduate year level of the resident. The analysis of covariance did show that for both methods, trocar placement was closer to 90° with increasing age above the median age of 45 years (r=−27, P=.02). CONCLUSION: Both “look” and “feel” methods yield similar results in trocar placement; no statistically significant difference was identified.

The Utility of the Transverse Abdominus Plane (TAP) Block in Minimally Invasive Gynecologic Surgery: A Randomized Double Blinded Clinical Trial

Study Objective: To estimate the effect of trainee involvement on morbidity following vaginal, laparoscopic and abdominal hysterectomy for benign disease. Design: Retrospective cohort study. Setting: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP). Patients: Patients undergoing laparoscopic, vaginal, or abdominal hysterectomy for benign disease from 2005-2012. Intervention: Patients with and without trainee involvement were compared with regard to 30-day postoperative complications. Complications were defined as per the Clavien-Dindo classification with grade 3-5 complications defined as major and grade 2 complications defined as minor. Measurements and Main Results: We identified 22,499 patients with 42.1% trainee participation. Surgical approaches were vaginal (22.7%), abdominal (47.1%) and laparoscopic (30.2%). The rate of major complication was 3.2% and minor complication was 7.2%. In bivariate analysis, trainee involvement was associated with major complication in vaginal hysterectomy (p=0.026), but not laparoscopic or abdominal hysterectomy. Trainee involvement was also associated with minor complication in vaginal (p=0.007), laparoscopic (p\0.0001), and abdominal hysterectomy (p\0.0001). In multivariate analysis controlling for age, race, BMI, medical comorbidity, ASA score, and surgical complexity, the association between trainee involvement in vaginal hysterectomy and major complication persisted (OR 1.49, 95%CI 1.052.12, p=0.026). In the same model, trainee involvement was also associated with minor complication among patients undergoing vaginal (OR 1.27, 95%CI 1.002-1.61, p=0.048), laparoscopic (OR 1.30, 95%CI 1.08-1.57, p=0.006), and abdominal hysterectomy (OR 1.47, 95%CI 1.241.73, p\0.0001). When operative time was added to the model, there was no longer a relationship between trainee involvement and major complication. Conclusion: Surgical approach influences the relationship between trainee involvement and postoperative complication. Trainee involvement is associated with major complication in vaginal hysterectomy, but not abdominal or laparoscopic hysterectomy. Operative time is a key mediator of the relationship between trainee involvement and complication, and may be a modifiable risk factor.

Use of D50 as Distension Medium in Diagnostic Cystoscopy

An elongated utero-ovarian ligament is associated with an increased risk for ovarian torsion. Our review of literature revealed no published studies on absent utero-ovarian ligament and its management. To present a unique case of congenital absence of the utero-ovarian ligament and the clinical dilemma associated with it. A 37-year-old G6P1 female presented to us with recurrent pregnant loss. She had regular periods with dysmenorrhea and no dyspareunia. The patient underwent diagnostic laparoscopy, which revealed congenital absence of the left utero-ovarian ligament. The left ovarian was adhered to the right utero-sacral ligament secondary to endometriosis. It was a clinical dilemma as to whether we should free the ovary from its current position and reattach it to the posterior surface of the uterus near the normal insertion of the utero-ovarian ligament. We decided to leave the ovary.