Administering indigo carmine dye intravenously 5 minutes before cystoscopy aides in the assessment of ureteral patency. Quick efﬂux of stained urine should be seen bilaterally. Sluggish efﬂux should prompt further investigation. However, preexisting ureteral obstruction may be responsible for lack of ﬂow. In 157 women who underwent complex urogynecologic procedures, 5 cases (3.2%) of unsuspected ureteral obstruction were identified with intraoperative cystoscopy (139). One was caused by ureteral ligation, and the remaining four represented chronic ureteral obstruction resulting from pelvic organ prolapse (two cases), ureteropelvic junction obstruction (one case), and ureterovesical junction stenosis after prior transurethral resection of bladder cancer (one case).
Figure 26.14 Repair of apical vesicovaginal fistula. A: The fistula at the vaginal apex is exposed with adequate retraction. A pediatric foley can be placed into the fistula tract to aid in traction and dissection. B: The vaginal epithelium is dissected from the fistula to mobilize the tissue to allow for tension-free closure. In the classic Latzko procedure, the vaginal epithelium 2 cm around the opening of the fistula is removed. C: The fistula tract may either be completely excised, or in the Latzko procedure, the fistula edge may freshened up slightly but is not excised. D: Interrupted absorbable sutures are placed in an extramucosal location in an interrupted fashion. An additional layer of interrupted sutures is often placed to invert the initial suture line. The vaginal epithelium is then closed over the repair. In the classic Latzko procedure, the initial layer involves closure of the vagina over the fistula tract, then two additional layers with the vaginal epithelium result in an apical colpocleisis. (Redrawn from original by Jasmine Tan.)
Figure 26.15 Cystoscopic view of normal-appearing trigone with left ureteral orifice visible.
Voiding Dysfunction Women are afﬂicted less commonly than men with voiding difficulties, but these disorders do occur in women and can be defined as emptying dysfunction resulting from relaxation of the pelvic ﬂoor musculature or failure of the detrusor muscle to contract appropriately. True outﬂow obstruction (defined as a detrusor pressure of more than 50 cm H2O in association with a urine ﬂow rate of less than 15 mL/sec) is rare in women and, when seen, is usually found in those who underwent obstructive bladder neck surgery for stress incontinence (140,141). For normal voiding to occur, the pelvic ﬂoor and urethral sphincter must relax, which should happen in conjunction with a coordinated contraction of the detrusor muscle that leads to complete bladder emptying. The bladder may be emptied by other mechanisms, such as by abdominal straining in the absence of a detrusor contraction or simply by relaxation of the pelvic ﬂoor. Complete bladder emptying is not the same as normal voiding. Some women may empty their bladders completely but only by expending great effort over several minutes. In such cases, voiding is clearly abnormal, even though the bladder is empty when voiding ceases. In the worst cases, voiding is both difficult and incomplete.
Causes Neurologic diseases, such as multiple sclerosis, may cause voiding difficulty as a result of detrusor-sphincter dyssynergia, in which the urethral sphincter contracts at the same time as the detrusor (143). Great effort is required to overcome urethral resistance; the patient voids with an interrupted stop-and-start stream and usually has a significant amount of residual urine.