M.D. Truong

Evaluating ureteral patency in the post-indigo carmine era: a randomized controlled trial

BACKGROUND: Many gynecologic, urologic, and pelvic reconstructive surgeries require accurate intraoperative evaluation of ureteral patency. OBJECTIVE: We performed a randomized controlled trial to compare surgeon satisfaction with 4 methods of evaluating ureteral patency during cystoscopy at the time of benign gynecologic or pelvic reconstructive surgery: oral phenazopyridine, intravenous sodium fluorescein, mannitol bladder distention, and normal saline bladder distention. STUDY DESIGN: We conducted an unblinded randomized controlled trial of the method used to evaluate ureteral patency during cystoscopy at time of benign gynecologic or pelvic reconstructive surgery. Subjects were randomized to receive 200 mg oral phenazopyridine, 25 mg intravenous sodium fluorescein, mannitol bladder distention, or normal saline bladder distention during cystoscopy. The primary outcome was surgeon satisfaction with the method, assessed via a 100‐mm visual analog scale with 0 indicating strong agreement and 100 indicating strong disagreement with the statement. Secondary outcomes included comparing visual analog scale responses about ease of each method and visualization of ureteral jets, bladder mucosa and urethra, and operative information, including time to surgeon confidence in the ureteral jets. Adverse events were evaluated for at least 6 weeks after the surgical procedure, and through the end of the study. All statistical analyses were based on the intent‐to‐treat principle, and comparisons were 2‐tailed. RESULTS: In all, 130 subjects were randomized to phenazopyridine (n = 33), sodium fluorescein (n = 32), mannitol (n = 32), or normal saline (n = 33). At randomization, patient characteristics were similar across groups. With regard to the primary outcome, mannitol was the method that physicians found most satisfactory on a visual analog scale. The median (range) scores for physicians assessing ureteral patency were 48 (0‐83), 20 (0‐82), 0 (0‐44), and 23 (3‐96) mm for phenazopyridine, sodium fluorescein, mannitol, and normal saline, respectively (P < .001). Surgery length, cystoscopy length, and time to surgeon confidence in visualization of ureteral jets were not different across the 4 randomized groups. During the 189‐day follow‐up, no differences in adverse events were seen among the groups, including urinary tract infections. CONCLUSION: The use of mannitol during cystoscopy to assess ureteral patency provided surgeons with the most overall satisfaction, ease of use, and superior visualization without affecting surgery or cystoscopy times. There were no differences in adverse events, including incidence of urinary tract infections.

Unsuspected Uterine Sarcoma in an Urban Hospital: Does Surgical Approach Matter?

Abstract Study Objective To compare the incidence of unsuspected uterine sarcoma based on surgical approach, open versus minimally invasive, for myomectomy and hysterectomy. Design Retrospective chart review of demographic data, preoperative characteristics, operative details, and pathology results from the electronic medical record (Canadian Task Force classification II-3). Setting A large, urban, academic medical center. Patients All women undergoing myomectomy or hysterectomy performed for a benign indication via a benign gynecologic surgical procedure between 2010 and 2014. Measurements and Main Results A total of 1959 myomectomies and hysterectomies were performed, among which 4 unsuspected uterine sarcomas were identified, for an incidence of 2.0 per 1000 cases. The incidence of sarcoma was similar in patients undergoing open abdominal surgery and those undergoing minimally invasive surgery (MIS) (3 in 743 [0.40%] vs. 1 in 1216 [0.08%]; p = .16). The mean age, body mass index, and specimen weights were also similar in the 2 groups. Although more than one-quarter of all cases involved morcellation, the majority via power morcellation, no specimens with sarcoma were morcellated. Conclusion The incidence of unsuspected uterine sarcoma during myomectomy or hysterectomy for benign indications is low at our institution, and is similar for open and MIS cases. Patients should be counseled on the risks and benefits of both open surgery and MIS approaches.