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PFD Week 2016
Life After Indigo Carmine: A Look at What is Avail ...
Life After Indigo Carmine: A Look at What is Available
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Video Transcription
Cystoscopic evaluation is a common and important assessment performed during certain gynecologic procedures to evaluate for bladder integrity and ureteral patency. Ureteral patency is presumed when a strong ureteral jet is clearly observed during cystoscopy. As seen here, cystoscopic evaluation with saline alone may not allow for conclusive visceralization of the ureteral jets, raising concern for possible injury. Traditionally, indigo carmine was used to aid in the visceralization of ureteral jets and so provide evidence of ureteral patency. Given its properties, it is quickly and reliably excreted in the urine within 5-10 minutes after IV administration. Recently one manufacturer has stopped production because of raw material shortage and the other has experienced manufacturing delays. Neither company can estimate a resupply or product return date so an alternative is needed. This video aims to demonstrate alternatives to indigo carmine. As demonstrated here, dextrose solution may be useful in allowing better visceralization of the ureteral jets, both in its 50% and 10% concentration, as the turbulence of the interactions between the ureteral urine jet and instilled dextrose solution, as well as the difference in viscosity of the two fluids, easily permits the visceralization of the urine stream exiting the ureteral orifice. When the 50% concentration is used, only 50 mL is necessary to partially distend the bladder and allow for better visceralization of the urine jet. Alternatively, a pre-mixed liter of 10% dextrose may be used with similar results. This technique is limited by the scarce literature available describing its use and complications when used for this indication. There is at least a theoretical potential for higher incidence of urinary tract infections and hyperglycemia, but further studies are needed to evaluate this. Phenazopyridine, usually used to relieve symptoms caused by irritation of the urinary tract, would also help the surgeon better visualize the ureteral urine jet. Oral administration will result in colorization of the urine within 30 minutes and will persist for approximately 4 hours. This use may be limited because it must be administered at least 30 minutes before the time of evaluation. It may also mask bloody urine coming from the ureter, potentially masking a non-obstructive injury. Methylene blue, used in emergency treatment of methemoglobinemia, ifosfamide-induced encephalopathy, or cyanide poisoning, has also been used for its colorization properties. Even when administered at the described dosages of 50mg over 5 minutes with an adjunct diuretic and after multiple attempts, the desired colorization of the urine jet proved to be unreliable. Great caution is needed in patients with G6PD deficiency or other hemolytic anemias, patient taking serotonergic drugs, as it may precipitate serotonin syndrome. More recently, sodium fluorescein has been proposed as an alternative to indigocarmine. This dye has been more commonly used for its colorization properties in retinal angiographies. However, given its excretion profile, it may be useful for this indication. When a cystoscopy is performed, a bright yellow urine jet is easily observed. At times, cystoscopy proved difficult with this agent, as it restricted thorough evaluation of the bladder walls, requiring extensive irrigation. At our institution, surgeons have adopted the use of dextrose solution, vanazopyridine, or sodium fluorescein to aid in the visualization of the ureteral jet when indicated.
Video Summary
The video discusses the importance of cystoscopic evaluation in gynecologic procedures to assess bladder integrity and ureteral patency. Traditionally, indigo carmine was used to visualize ureteral jets, but due to production issues, alternatives are needed. The video demonstrates the use of dextrose solution, both in 50% and 10% concentrations, to allow better visibility of ureteral jets. Phenazopyridine can be used to colorize urine, and methylene blue can be used for its colorization properties, although reliability is limited. Sodium fluorescein, commonly used in retinal angiographies, may be a suitable alternative. Various options are used at the institution based on individual needs. No credits are mentioned.
Asset Subtitle
Luis Espaillat-Rijo, MD
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Keywords
cystoscopic evaluation
gynecologic procedures
bladder integrity
ureteral patency
alternative options
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