Discussion
Intra-operative cystoscopy for detecting surgical trauma in the bladder
or the ureter is a useful gynecologist procedure. Rates of Urinary tract injuries during
gynecologic procedures have varied by type of surgery and type of
injury. Therefore, hysterectomy has a risk of ureteric injury from 1,7%
for a benign indication to 4 % for malignancies (8). Bladder injury is
prevalent in terms of perforation or trauma when Tension-free vaginal
tapes are inserted (4,4%-71%) (9). The routine use of cystoscopy in
gynecologic operations may induce intra-operative urinary trauma
detection rate. Vakilli et al. have shown that universal cystoscopy
after hysterectomy may detect up to 96% of urinary tract injuries
intra-operatively. Before cystoscopy, only 12,5% of ureteral injuries
and 35,3% of bladder injuries were detected (10). Moreover, in a
systematic review, Teeluckdharry et al. tried to determine the urinary
tract injury rates with and without the routine use of cystoscopy for
patients who underwent any hysterectomy and concluded that routine
cystoscopy clearly increases the intra-operative detection rate of urinary tract injuries(11).
We tried to develop an easy to use, a low-cost, portable endoscopic
system to make cystoscopy friendly to the gynecologist. The whole
system, including the light source, has no cables and may be contained
in the same carrying case as the cystoscope for transportation. The
system’s portability (total weight <1000gr) allows for easy
transfer among the operating room, outpatient office, or emergency room,
contrasting with the standard cumbersome endoscopic tower. The system’s
cost is another major advantage as the modified camera, light source,
and tablet cost $2,047 in sum, considerably lower than $50,000, which
is the average cost of a standard tower.
Surgeons may use the wireless setup to perform cystoscopy simultaneously
with laparoscopic surgery, without occupying the endoscopic tower
(Figure 2). There is no need to stop the ongoing operation from
performing cystoscopy and either stand by an endoscopic tower for the
same reason in vaginal or abdominal hysterectomy cases. This may induce
the producibility of a health care facility and allow for more
conservative use of the valuable and costly standard endoscopic
equipment.
The new system may have multiple applications as cystoscopy may even be
performed at facilities that do not possess endoscopic equipment other
than a rigid cystoscope. Therefore, in vaginal surgery (vaginal
hysterectomy with suspension, urethral sling placement), abdominal
hysterectomy, laparoscopic hysterectomy, or deep endometriosis surgery,
the new setup may contribute to cost reduction of intra-operative
cystoscopy markedly. Moreover, it may be utilized for pigtail catheter
replacement, which is an often procedure, especially in gynecologic
oncology departments, mainly for patients with advanced cervical cancer.
Finally, the new setup is useful beyond gynecology limits as it may be
used for urologic indications.
We now have a new cost-effective and easily reproducible cystoscopic
setup that combines all the benefits already analyzed. The reduction in
cystoscopy cost could result in a more wide implementation, eliminating
patient risk for undiagnosed urinary tract injuries.
Figure 1, Wireless Cystoscope set-up
Figure 2, Intra-operative wireless cystoscopy