Factors Associated With Cystoscopy Performed at the Time of Hysterectomy

INTRODUCTION: Undetected lower urinary tract injury at the time of hysterectomy can lead to increased patient morbidity. OBJECTIVE: To determine factors associated with cystoscopy performed at the time of hysterectomy. METHODS: A retrospective cohort study was performed at a single tertiary care center of women undergoing hysterectomy with or without concomitant cystoscopy between November 2020 and November 2023 within the Department of Obstetrics and Gynecology. All indications for hysterectomy were included. Patient demographics, clinical characteristics, and perioperative outcomes through 30 days postoperatively were abstracted from the medical chart. Additionally, a survey was distributed to all surgeons within the Department of Obstetrics and Gynecology to assess opinions and barriers to performing universal cystoscopy at the time of hysterectomy. The primary objective was to identify factors associated with cystoscopy at the time of hysterectomy. Standard group comparisons were performed. Backward logistic regression was performed to determine factors independently associated with cystoscopy performed at the time of hysterectomy after controlling for potential confounding variables. Variables with p<0.10 on bivariate analysis were included. RESULTS: 1,152 women underwent hysterectomy: 726 (63.0%) had a cystoscopy performed at the time of hysterectomy, while 426 (37.0%) did not. The cystoscopy cohort was more likely to be younger (p<0.001), Black (p<0.001), have a higher BMI (p<0.001), and American Society of Anesthesiology (ASA) class 2 physical status (p<0.001) (Table 1). Obstetrician–gynecologists (OBG), minimally invasive gynecologic surgeons (MIGS), and urogynecology and reconstructive pelvic surgeons (URPS) were more likely to perform cystoscopy at the time of hysterectomy (p<0.001), while gynecologic oncologists (GYNONC) were less likely to perform cystoscopy. Cystoscopy was more common in cases for pelvic floor disorders and benign indications (p<0.001). Indications for gynecologic malignancy were less likely to have a cystoscopy performed. Cystoscopy was also more commonly performed during laparoscopic, robotic, and vaginal hysterectomies (p<0.001) compared to open abdominal hysterectomy, and in cases with specimen morcellation (p<0.001) and the addition of modifier 22 (p<0.001). On backward logistic regression, Black race (aOR 1.02), ASA class 2 (aOR 6.36), ASA class 3 (aOR 4.45), and robotic approach (aOR 1.58) were associated with increased odds of cystoscopy performed at the time of hysterectomy (Table 2). GYNONC (aOR 0.25) service, laparotomy approach (aOR 0.13), and vaginal approach (aOR 0.40) were associated with decreased odds. Out of 84 surgeons, 30 (36%) completed the faculty survey (Table 3). Majority (70%) performed routine cystoscopy at the time of hysterectomy. 8 (26.7%) stated their decision was dependent on route of hysterectomy, and total laparoscopy (36.7%) was the most identified type of hysterectomy that would necessitate a cystoscopy. Reasons for not performing routine cystoscopy included concern about health care costs and operating time (13.3%), low suspicion for injury (10.0%), and adequate visualization of the ureter during surgery (10.0%). CONCLUSIONS: Routine cystoscopy at the time of hysterectomy varied with the surgeon’s specialty and route of hysterectomy. Given the significant morbidity of undetected lower urinary tract injuries at the time of hysterectomy, implementation of strategies to avoid these complications, such as universal cystoscopy, should first focus on barriers to performance of cystoscopy.