Cystoscopy at the time of benign hysterectomy: a decision analysis

Published:January 24, 2019DOI:


      Gynecologists debate the optimal use for intraoperative cystoscopy at the time of benign hysterectomy. Although adding cystoscopy leads to additional up-front cost, it may also enable intraoperative detection of a urinary tract injury that may otherwise go unnoticed. Prompt injury detection and intraoperative repair decreases morbidity and is less costly than postoperative diagnosis and treatment. Because urinary tract injury is rare and not easily studied in a prospective fashion, decision analysis provides a method for evaluating the cost associated with varying strategies for use of cystoscopy.


      The objective of the study was to quantify costs of routine cystoscopy, selective cystoscopy, or no cystoscopy with benign hysterectomy.

      Study Design

      We created a decision analysis model using TreeAge Pro. Separate models evaluated cystoscopy following abdominal, laparoscopic/robotic, and vaginal hysterectomy from the perspective of a third-party payer. We modeled bladder and ureteral injuries detected intraoperatively and postoperatively. Ureteral injury detection included false-positive and false-negative results. Potential costs included diagnostics (imaging, repeat cystoscopy) and treatment (office/emergency room visits, readmission, ureteral stenting, cystotomy closure, ureteral reimplantation). Our model included costs of peritonitis, urinoma, and vesicovaginal/ureterovaginal fistula. Complication rates were determined from published literature. Costs were gathered from Medicare reimbursement as well as published literature when procedure codes could not accurately capture additional length of stay or work-up related to complications.


      From prior studies, bladder injury incidence was 1.75%, 0.93%, and 2.91% for abdominal, laparoscopic/robotic, and vaginal hysterectomy, respectively. Ureteral injury incidence was 1.61%, 0.46%, and 0.46%, respectively. Hysterectomy costs without cystoscopy varied from $884.89 to $1121.91. Selective cystoscopy added $13.20–26.13 compared with no cystoscopy. Routine cystoscopy added $51.39–57.86 compared with selective cystoscopy. With the increasing risk of injury, selective cystoscopy becomes cost saving. When bladder injury exceeds 4.48–11.44% (based on surgical route) or ureteral injury exceeds 3.96–8.95%, selective cystoscopy costs less than no cystoscopy. Therefore, if surgeons estimate the risk of injury has exceeded these thresholds, cystoscopy may be cost saving. However, for routine cystoscopy to be cost saving, the risk of bladder injury would need to exceed 20.59–47.24% and ureteral injury 27.22–37.72%. Model robustness was checked with multiple 1-way sensitivity analyses, and no relevant thresholds for model variables other than injury rates were identified.


      While routine cystoscopy increased the cost $64.59–83.99, selective cystoscopy had lower increases ($13.20–26.13). These costs are reduced/eliminated with increasing risk of injury. Even a modest increase in suspicion for injury should prompt selective cystoscopy with benign hysterectomy.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Aarts J.W.
        • Nieboer T.E.
        • Johnson N.
        • et al.
        Surgical approach to hysterectomy for benign gynaecological disease.
        Cochrane Database Syst Rev. 2015; : CD003677
        • Ibeanu O.A.
        • Chesson R.R.
        • Echols K.T.
        • Nieves M.
        • Busangu F.
        • Nolan T.E.
        Urinary tract injury during hysterectomy based on universal cystoscopy.
        Obstet Gynecol. 2009; 113: 6-10
        • Visco A.G.
        • Taber K.H.
        • Weidner A.C.
        • Barber M.D.
        • Myers E.R.
        Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy.
        Obstet Gynecol. 2001; 97: 685-692
        • Morgan D.M.
        • Kamdar N.S.
        • Swenson C.W.
        • Kobernik E.K.
        • Sammarco A.G.
        • Nallamothu B.
        Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women.
        Am J Obstet Gynecol. 2018; 218: 425.e1-425.e18
        • Chung D.
        • Briggs J.
        • Turney B.W.
        • Tapping C.R.
        Management of iatrogenic ureteric injury with retrograde ureteric stenting: an analysis of factors affecting technical success and long-term outcome.
        Acta Radiol. 2017; 58: 170-175
        • Cohen A.J.
        • Packiam V.T.
        • Nottingham C.U.
        • Pariser J.J.
        • Faris S.F.
        • Bales G.T.
        Iatrogenic bladder injury: national analysis of 30-day outcomes.
        Urology. 2016; 97: 250-256
        • Anand M.
        • Casiano E.R.
        • Heisler C.A.
        • et al.
        Utility of intraoperative cystoscopy in detecting ureteral injury during vaginal hysterectomy.
        Female Pelvic Med Reconstr Surg. 2015; 21: 70-76
        • Tan-Kim J.
        • Menefee S.A.
        • Reinsch C.S.
        • et al.
        Laparoscopic hysterectomy and urinary tract injury: experience in a health maintenance organization.
        J Minim Invasive Gynecol. 2015; 22: 1278-1286
        • Chi A.M.
        • Curran D.S.
        • Morgan D.M.
        • Fenner D.E.
        • Swenson C.W.
        Universal cystoscopy after benign hysterectomy: examining the effects of an institutional policy.
        Obstet Gynecol. 2016; 127: 369-375
        • Cadish L.A.
        • Shepherd J.P.
        • Barber E.L.
        • Ridgeway B.
        Risks and benefits of opportunistic salpingectomy during vaginal hysterectomy: a decision analysis.
        Am J Obstet Gynecol. 2017; 217: 603.e1-603.e6
        • Teeluckdharry B.
        • Gilmour D.
        • Flowerdew G.
        Urinary tract injury at benign gynecologic surgery and the role of cystoscopy: a systematic review and meta-analysis.
        Obstet Gynecol. 2015; 126: 1161-1169
        • Adelman M.R.
        • Bardsley T.R.
        • Sharp H.T.
        Urinary tract injuries in laparoscopic hysterectomy: a systematic review.
        J Minim Invasive Gynecol. 2014; 21: 558-566
        • Jelovsek J.E.
        • Chiung C.
        • Chen G.
        • Roberts S.L.
        • Paraiso M.F.
        • Falcone T.
        Incidence of lower urinary tract injury at the time of total laparoscopic hysterectomy.
        JSLS. 2007; 11: 422-427
        • Kiran A.
        • Hilton P.
        • Cromwell D.A.
        The risk of ureteric injury associated with hysterectomy: a 10-year retrospective cohort study.
        BJOG. 2016; 123: 1184-1191
        • Mamik M.M.
        • Antosh D.
        • White D.E.
        • et al.
        Risk factors for lower urinary tract injury at the time of hysterectomy for benign reasons.
        Int Urogynecol J. 2014; 25: 1031-1036
        • Wallis C.J.
        • Cheung D.C.
        • Garbens A.
        • et al.
        Occurrence of and risk factors for urological intervention during benign hysterectomy: analysis of the National Surgical Quality Improvement Program Database.
        Urology. 2016; 97: 66-72
        • Patil S.B.
        • Guru N.
        • Kundargi V.S.
        • Patil B.S.
        • Patil N.
        • Ranka K.
        Posthysterectomy ureteric injuries: presentation and outcome of management.
        Urol Ann. 2017; 9: 4-8

      Linked Article

      • Cystoscopy at the time of benign hysterectomy: a decision analysis
        American Journal of Obstetrics & GynecologyVol. 221Issue 3
        • Preview
          We were excited to read your timely and important publication “Cystoscopy at the time of benign hysterectomy: a decision analysis”1 because safety in and quality of gynecologic surgery is a major focus. We wish to express several concerns regarding the methods of this study and possible implications for its interpretation and conclusions.
        • Full-Text
        • PDF
      • Reply
        American Journal of Obstetrics & GynecologyVol. 221Issue 3
        • Preview
          We agree that delayed ureteral injury causes significant morbidity after hysterectomy. We intentionally modeled hysterectomy modalities separately, accounting for increased thermal injury with laparoscopic or robotic approaches. Blackwell et al1 published their study of delayed ureteral injury sequelae after our analysis was complete, but even so, delayed injury rarely is diagnosed beyond the 90-day postoperative period, even when time to definitive management extends beyond >90 days. Our model included any injury diagnosed within 90 days, even if treatment extended further.
        • Full-Text
        • PDF