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