Routine Preoperative Cystourethroscopy in Urogynecology: An Unwarranted Practice

Objectives: Preoperative cystourethroscopy is associated with increased costs, higher risk of infection, and patient discomfort. Therefore, the role of preoperative cystourethroscopy is justified if findings of the procedure lead to significant changes in surgical plan. Since cystourethroscopy is not routinely used for evaluation of preoperative patients, cystoscopic findings in asymptomatic patients are not well described. The objective of this study is to determine whether findings on preoperative office cystourethroscopy alters the surgical plan, leads to additional testing or consultation, or causes surgical delay in patients undergoing surgery for urinary incontinence (UI) and/or pelvic organ prolapse (POP). It also describes cystoscopic findings in women undergoing preoperative in-office cystourethroscopy.

Methods: This is a retrospective chart review of 285 women aged 18 years and older who underwent routine preoperative cystourethroscopy prior to surgical management for UI and POP in an outpatient Urogynecology office setting from December 2018 to December 2020. Patients were excluded if they had an indication for cystourethroscopy per current guidelines or if the preoperative cystoscopy was not completed. Patient demographics, surgical history, and preoperative cystoscopy findings were collected. Statistical analyses were performed as appropriate using independent-samples t-test for continuous variables and χ2 or Fisher’s exact test for categorical variables.

Results: 1053 women underwent office cystourethroscopy and 285 met inclusion criteria. The most common reason for exclusion was that the office cystourethroscopy was not performed for preoperative purposes. The mean age was 60.2 ± 12.7 years and mean BMI was 29.0 ± 6.10. Ninety-two patients (32.6%) had prior hysterectomy and 36 patients (12.8%) had prior anti-incontinence procedure. Sixty-one (21.6%) identified as Hispanic or Latina. 64 (22.5%) had abnormal findings: 40 (62.5%) had trabeculations, 6 (9.4%) had bladder diverticula, 4 (6.3%) had absent ureteric flow, 3 (4.7%) had cystitis cystica, and 2 (3.1%) had bladder calculi. 17 (26.6%) had other findings. The women with abnormal findings were significantly older (66.0 ± 11.3 vs 58.5 ± 12.6 years; p < 0.001) and were more likely to have a history of a hysterectomy (48.4% vs 27.6%; p = 0.002) [see Table 1]. Seven patients (2.5%) required additional testing or consultation as a direct result of the preoperative cystourethroscopy. Three patients (1.1%) had their planned surgeries canceled and 4 patients (1.4%) had their surgeries delayed as a direct result of preoperative cystourethroscopy. [See Table 2].

Conclusions: Based on our findings, routine preoperative cystourethroscopy in asymptomatic patients undergoing surgery for UI and POP is not indicated, may lead to additional cost, and may cause surgical delay and/or cancellation. Women undergoing preoperative cystourethroscopy have mostly normal findings, and in those with abnormalities, bladder trabeculations are most common. Older women and women with history of hysterectomy are significantly more likely to have abnormal findings.