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#Grand Rounds

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

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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

METHODS:

  • 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

RESULTS:

  • 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

CONCLUSION:

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

Learn More – Primary Sources:

Evaluating ureteral patency in the post-indigo carmine era: a randomized controlled trial

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