Sodium fluorescein and 10% dextrose provide clear visibility of ureteral jets in cystoscopy
Espaillat-Rijo L, Siff L, Alas AN, et al. Intraoperative cystoscopic evaluation of ureteral patency: a randomized controlled trial. Obstet Gynecol. 2016;128(6):1378–1383.
In a multicenter randomized controlled trial, Espaillat-Rijo and colleagues compared various methods for visualizing ureteral efflux in participants who underwent gynecologic or urogynecologic procedures in which cystoscopy was performed.
Study compared 4 media
The investigators enrolled 176 participants (174 completed the trial) and randomly assigned them to receive 1 of 4 modalities: 1) normal saline as a bladder distention medium (control), 2) 10% dextrose as a bladder distention medium, 3) 200 mg oral phenazopyridine given 30 minutes prior to cystoscopy, or 4) 50 mg IV sodium fluorescein at the start of cystoscopy. Indigo carmine was not included in this study because it has not been routinely available since 2014.
Surgeons were asked to categorize the ureteral jets as “clearly visible,” “somewhat visible,” or “not visible.”
The primary outcome was subjective visibility of the ureteral jet with each modality during cystoscopy. Secondary outcomes included surgeon satisfaction, adverse reactions to the modality used, postoperative urinary tract infection, postoperative urinary retention, and delayed diagnosis of ureteral injury.
Visibility assessment results. Overall, ureteral jets were “clearly visible” in 125 cases (71%) compared with “somewhat visible” in 45 (25.6%) and “not visible” in 4 (2.3%) cases. There was a statistically significant difference between the 4 groups. Use of sodium fluorescein and 10% dextrose resulted in significantly better visualization of ureteral jets (P < .001 and P = .004, respectively) compared with the control group. Visibility with phenazopyridine was not significantly different from that in the control group or in the 10% dextrose group (FIGURE).
Surgeon satisfaction was highest with 10% dextrose and sodium fluorescein. In 6 cases, the surgeon was not satisfied with visualization of the ureteral jets and relied on fluorescein (5 times) or 10% dextrose (1 time) to ultimately see efflux. No significant adverse events occurred; the rate of urinary tract infection was 24.1% and did not differ between groups.
Results are widely generalizable
This was a well-designed randomized multicenter trial that included both benign gynecologic and urogynecologic procedures, thus strengthening the generalizability of the study. The study was timely since proven methods for visualization of ureteral patency became limited with the withdrawal of commercially available indigo carmine, the previous gold standard.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Intravenous sodium fluorescein and 10% dextrose as bladder distention media can both safely be used to visualize ureteral efflux and result in high surgeon satisfaction. Although 10% dextrose has been associated with higher rates of postoperative urinary tract infection,11 this was not found to be the case in this study. Preoperative administration of oral phenazopyridine was no different from the control modality with regard to visibility and surgeon satisfaction.
Intravenous sodium fluorescein and 10% dextrose as bladder distention media can both safely be used to visualize ureteral efflux and result in high surgeon satisfaction. Although 10% dextrose has been associated with higher rates of postoperative urinary tract infection,11 this was not found to be the case in this study. Preoperative administration of oral phenazopyridine was no different from the control modality with regard to visibility and surgeon satisfaction.
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