Grand Rounds

Best Method of Evaluating the Ureters When Indigo Carmine is Not Available?

BACKGROUND AND PURPOSE:

Indigo carmine has been limited or unavailable, requiring other approaches to assess ureteral patency
Grimes et al. (AJOG, 2017) sought to determine surgeon satisfaction with 4 alternative methods of evaluating ureteral patency during cystoscopy

Unblinded randomized controlled trial (RCT)
4 treatment groups:
- 200 mg oral phenazopyridine
- 25 mg IV sodium fluorescein
- mannitol bladder distention
- normal saline bladder distention
Primary outcome was surgeon satisfaction with the method, assessed via a 100-mm visual analog scale
Secondary outcomes included comparing visual analog scale responses about ease of each method and visualization of ureteral jets, bladder mucosa and urethra, and operative information, including time to surgeon confidence in the ureteral jets

130 subjects were randomized
Mannitol was the method that physicians found most satisfactory (P<.001)
- easiest method to use, with the best visualization of the ureteral jets, bladder mucosa, and urethra
The median (range) scores for physicians assessing ureteral patency were
- 48 (0-83) for phenazopyridine
- 20 (0-82) for 25 mg sodium fluorescein
- 0 (0-44) for mannitol bladder distention
- 23 (3-96) for normal saline bladder distention
No differences were identified between groups for the following
- Surgery length, cystoscopy length
- Adverse events, including UTIs, within 23 hours, and at 2 to 6-week postoperatively
- Visualization of ureteral jets

The use of mannitol gave surgeons the most overall satisfaction, ease of use, and superior visualization without affecting surgery or cystoscopy times

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