Intraoperative cystoscopy for urinary tract complications during robotic gynecological hysterectomy surgery

The effectiveness of cystoscopy in reducing urinary tract complications during robotic gynecologic surgery is poorly documented. Since the introduction of robotic surgery at our institution, cystoscopy has been consistently employed as a standard practice, and its usefulness was investigated. This retrospective study evaluated the utility of routine cystoscopy in patients who underwent robotic surgery between February 2017 and April 2024. The outcome was the detection rate of bladder and ureteral complications. Indigo carmine was injected intravenously while suturing the post-hysterectomy vaginal stump. Light permeation of the bladder wall was visually assessed intra-abdominally. Any leakage of the indigo carmine into the peritoneum or outflow from the external ureteral opening were noted. Eleven of 403 patients were suspected of having urinary tract complications. Among the 11 patients, two exhibited damage to the serous and muscular layers of the bladder, while nine had no outflow from the external ureteral opening. Among these nine cases, one patient was found to have right ureteral obstruction, which was attributed to vaginal stump suturing. The sensitivity and specificity for ureteral obstruction detection were 100% and 98.0%, respectively. In the remaining eight patients, no urinary complications could be identified postoperatively. Overall, the rate of bladder injury was 4/403 (0.9%), all of which were repaired intraoperatively, including two cases found by cystoscopy. Ureteral obstruction was identified in 1/403 (0.2%), and the case was due to intraoperative cystoscopy. Postoperatively, ureteral stenosis was observed in 1/403 (0.2%), and urinary tract infection (cystitis: Grade 2 or less) was noted in 6/403 (1.5%). This technique is an effective diagnostic tool with minimal patient burden and is likely to accurately identify ureteral obstruction or bladder injury during surgery.