N Tang

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.

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.

Integration of Didactics and Simulation to Teach Proper Laparoscopic Positioning [104]

INTRODUCTION: Proper patient positioning is paramount to both patient safety and surgical efficacy. In laparoscopic surgery, the patient is subjected to steep Trendelenburg positioning and prolonged surgical times. These are significant risk factors in positioning-related nerve injuries. We developed a workshop integrating a classic didactic curriculum with a simulation component for residents to experience first hand the importance of proper laparoscopic positioning. METHODS: A 10-question preintervention assessment on “Laparoscopic positioning and nerve injury” based on a comprehensive review in the Journal of Minimally Invasive Gynecology was administered to 20 obstetrics and gynecology residents. The residents then participated in an interactive peer-led didactic course reviewing upper and lower extremity nerve injuries common in laparoscopic surgery. The residents were individually assessed on their technique by an attending physician and their peers. At completion of the workshop, the same 10-question quiz was administered to assess retention of the material. RESULTS: The average pretest score was 67.9% with the highest average score in the postgraduate year 4 level (73.3%) and lowest average score in the postgraduate year 1 level (36.7%). The average posttest score was 90.6% with the highest average score in the postgraduate year 3 level (92.5%) and lowest average score in the postgraduate year 1 level (88.3%). CONCLUSION: This study demonstrates a benefit in implementing an integrated didactic and simulation workshop in laparoscopic positioning during residency training. This illustrates the benefits of peer-to-peer instruction in didactic education and the use of a patient-centered simulation model to enhance resident education.

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.