Barriers to Universal Cystoscopy After Hysterectomy

Introduction

Hysterectomy is one of the most common surgical procedures performed, with an estimated 400,000 to 600,000 women having undergone the procedure annually from 2000 to 2010. ¹ Urinary-tract injuries during hysterectomy were reported to be as high as 4%. ² Routine use of cystoscopy after hysterectomy has been shown to increase the intraoperative detection rate of urinary-tract injuries and potentially decrease delayed postoperative complications, and has been advocated as a fundamental skill for gynecologic surgeons for more a decade.^3,4 Yet, no professional organization in the United States advocates the routine use of cystoscopy following hysterectomy. ⁵

Even with the known benefits of cystoscopy after hysterectomy, many gynecologic surgeons have not adopted universal cystoscopy after this operation. Citing an increased risk of urinary-tract infection, ⁶ an unclear cost–benefit, ⁷ added surgical time, and little ability to detect postoperative urinary-tract injury ³ many surgeons prefer to perform the procedure selectively or not at all.

Acknowledging that there is likely more research to be done to answer definitively the question of whether universal cystoscopy is warranted after hysterectomy, this research was conducted to determine, if gynecologic surgeons did adopt this practice, what they would perceive as deterrents to it. A focus on gynecologic teaching surgeons with high-volume hysterectomy numbers was chosen. The goal of the study was to evaluate logistical reasons that preclude the adoption of universal cystoscopy after hysterectomy among practicing gynecologic surgeons at an academic teaching institution.

Materials and Methods

This was a mixed-methods study, utilizing a cross-sectional approach and focus groups of gynecologic surgeons in Baylor College of Medicine's (Houston, TX), Department of Obstetrics and Gynecology to assess attitudes about universal cystoscopy after hysterectomy. The institutional review board of Baylor College of Medicine approved the study (10/17/2016, # H-39922).

An online questionnaire was developed based on a review of the literature regarding the perceived barriers to the use of cystoscopy following hysterectomy.^2,3,6–11 The questionnaire consisted of 2 parts. The first part addressed demographic characteristics, including age, gender, primary role (specialist or subspecialist), and years in practice. The second part was used to assess the volume of hysterectomies performed annually, the most common route of hysterectomy, prior cystoscopy training, and barriers to routine performance of cystoscopy after hysterectomy. This questionnaire was used in December of 2016. This study was approved by the institutional review board at the Baylor College of Medicine (H-39922).

All 18 physicians who performed more than 12 major gynecologic procedures per year (“high-volume surgeons” ¹² ) at the Ben Taub and Texas Children's Pavilion for Women Hospitals, Houston, Tx were identified by a review of surgical case logs for 2016. The survey was distributed via e-mail, utilizing Survey Monkey. After the initial e-mail, a reminder e-mail was sent 2 weeks later and the responses were collected. Based on the survey results 1 questionnaire item was used to guide focus-group sessions (Box 1).

All the surgeons who were asked to complete the survey were invited to participate in an hour-long focus group. The focus group was started by communicating to participants to consider what would happen if, moving forward, they had decided to perform universal cystoscopy after hysterectomy. Therefore, the subject of the focus groups was current logistical barriers to performing universal cystoscopy after hysterectomy rather than the perceived necessity of the procedure. Focus groups with a moderator, observer, and participants were conducted over 2 months. Two focus group sessions (1 at each clinical site) were conducted. Focus Group 1 consisted of 7 practitioners from the private-hospital setting, while Focus Group 2 consisted of 5 practitioners from a safety-net hospital.

With verbal participants' consent at the onset, the sessions were recorded and an outside transcription service provided the sessions' contents verbatim with identifying material removed. Immediately after the sessions, the observer and moderator led a debriefing session to document verbal and nonverbal impressions. The transcriptions of the focus-group sessions were reviewed, and deductive and inductive analyses ¹³ were applied to solidify themes. Then, qualitative-analysis software (NVivo; QSR International Pty Ltd., version 10, 2012) was used to assist with data extraction and theme-frequency documentation. A third-party faculty member applied deductive and inductive analysis to create direct and indirect themes from the transcribed data. Then, comparisons were made of the results obtained from the debriefing and transcription review, the third-party faculty review, and the qualitative-analysis software results for final theme development. In this fashion, a consensus was established regarding the major themes uncovered.

Results

Of the 18 high-volume surgeons e-mailed the questionnaire, 12 (66.7%) responded. Of the questionnaire participants, two-thirds were female (8/12), averaging 56 years of age, with 18 years of practice since residency graduation, and with the majority (83%) interested in additional cystoscopy training. The respondents reported performing an average of 3–4 hysterectomies per month, with the route divided in thirds among abdominal, laparoscopic or robotic, and vaginal. Concerning prior cystoscopic training, 58.3% of the respondents received training in residency (none utilizing simulations), 33% learned the skill after residency, 83.3% had hospital privileges to perform cystoscopy, and 25% performed cystoscopy routinely after hysterectomy. Most respondents felt that an increase in operative time (75%) and cost (58.3%) were barriers to performing universal cystoscopy after hysterectomy, and some respondents (41.7%) did not feel cystoscopy was needed after hysterectomy. Only a small percentage of respondents reported that they were unfamiliar with cystoscopy setup (16.6%) or performance (8.3%), or were not comfortable teaching the skill to learners (8.3%).

From the private and safety net-focus-group sessions' analyses, the three themes developed were similar among the observer, the moderator, and the third-party faculty-member reviewer: (1) cost; (2) training; and (3) resident teaching. While both focus groups agreed that cost was a concern, the private group focused on patients' costs, concerned that patients would be charged additionally for the procedure. The safety-net group's concerns were directed toward facility costs. If the training facility used universal cystoscopy, it would require a requisite number of cystoscopy sets available for use. The respondents were concerned about whether or not they would have reliable access to the cystoscopy equipment, as well as proper ancillary staff training and equipment maintenance.

Most focus-group participants communicated that they were in residency training prior to common cystoscopy use and performance, and that they did not receive much training. Both groups reported having average skill in performing cystoscopy and a lack of confidence in the ability to troubleshoot cystoscopy problems (mainly assembly issues). One skill item was the type of cystoscope lens utilized, and the respondents' comments reflected a lack of understanding of the different telescope options. One surgeon communicated feeling more comfortable scanning a patient's bladder and visualizing ureteral jets with a 0° or 12° lens, and a quote about lens selection was: “I think it is important to let everyone know that we use 70° scopes. That is one of the things that I think can be hard, because, if you don't do cysto routinely, you don't appreciate that difference and, if you use a 30° [lens], it looks totally different than what you anticipate.”

Respondents felt more comfortable once the cystoscopy equipment was assembled and they just had to focus on scanning a patient's bladder and locating the ureteral orifices. One of the quotes about an inability to troubleshoot issues and general cystoscopy knowledge was that “the other problem is when they give you the cystoscopy tray, and there are like 7 different options and you don't really know which part goes with which.”

Inadequate training of the operating-room (OR) ancillary staff was also mentioned. Participants were concerned about a lack of expertise by ancillary staff to have the equipment ready and working correctly. A direct quote that was representative of surgeons who do not universally perform cystoscopy after hysterectomy was that, “if I have a scrub tech that does not know how to put the equipment together, that can sometimes add 30 minutes on to the length of the case while they go find the right person.”

The last theme was a concern for providing quality resident teaching. Most focus-group participants stated they were uneasy teaching a skill to residents that the participants themselves had not yet mastered. Hesitancy to provide teaching was magnified when there were variances from the norm that they were unable to explain in real time to residents in training. There was a consensus that these respondents knew the general “how-to” of cystoscopy but were uncomfortable when they ran into infrequent occurrences. “I pretty much know what to do. So, it's not that I need to learn the steps. I need to know the nuances. … ,” was a representative viewpoint. In general, the group felt uncomfortable facing novel situations in which the surgeons were expected to teach and provide guidance to residents. The use of selective cystoscopy and increased OR time were also mentioned but were not major themes. A word cloud created from NVivo software of the private-hospital focus-group session is shown in Figure 1. The word cloud created for the safety-net hospital was similar (data not shown).

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FIG. 1.

Word cloud created from private hospital focus group session.

Discussion

New procedures continue to be introduced into gynecologic surgery, so it is important to understand why gynecologic surgeons do not incorporate new procedures into their clinical practices when doing so can improve patient care. The data from the current study suggest that the rationale for not incorporating this procedure is an increased perception of costs, and a need for adequate training that would facilitate resident instruction.

Similar to current literature, the current study results identified cost of universal cystoscopy after hysterectomy as a deterrent to utilization. These current results differ slightly regarding cost although, pointing to patient procedure and facility capital costs rather than the potential cost savings from decreasing ureteral injuries. ⁷ Selective cystoscopy and increased surgical time was mentioned in the focus groups, as occurred in other studies, but neither factor emerged as a major theme.^3,9,14 There are few data surrounding logistical reasons why universal cystoscopy after hysterectomy has not been incorporated into general practice at a teaching institution. An Ovid-PubMed search from 1946 to July 2018, using the search terms universal cystoscopy and hysterectomy, was performed, and 7 studies concerning this topic were retrieved.^{2,5,7,8,11,15,16} The articles had mixed recommendations concerning universal cystoscopy performance after hysterectomy, utilizing opinion, retrospective, case series, or decision analyses data. In a survey of program directors, case difficulty and surgeon preference governed surgeon performance of cystoscopy after hysterectomy, ¹⁴ although this is a poor predictor of lower urinary-tract injury. ⁹

The current study is unique in that it identified logistical barriers to the adoption of universal cystoscopy after hysterectomy by practicing gynecologic surgeons. This study also adds to the body of literature on barriers to implementing evidence-based practices. ¹⁷ The use of a questionnaire with subsequent focus groups allowed the current authors to truly understand participants' thinking and opinions about universal cystoscopy after hysterectomy. The focus groups were successful because a safe environment was created by acknowledging and removing the individual's “immunity to change.” ¹⁸ To begin the focus group, it was introduced with the concept that that the participants had decided to incorporate universal cystoscopy, so the goal of the session was to determine logistical reasons that would hinder this adoption. In other words, many of the barriers posited in theories that described a resistance or immunity to change were addressed and removed. These barriers can be rooted in individual, social, or organizational contexts. ¹⁷

It was interesting that, in the initial questionnaire, only 8%–16% cited either unfamiliarity with cystoscopy use and performance or being uncomfortable teaching the skill, while the focus groups uncovered inadequate cystoscopy training leading to hesitancy in performing and teaching the skill to residents. Practitioners, in general, are not good self-assessors. ¹⁹ The questionnaire items listed (Box 1) provided other plausible reasons why a surgeon would not choose universal cystoscopy after hysterectomy. Unlike the focus groups, in which each item was discussed in more detail, the questionnaire did not require the participants to focus specifically on the skill of performing cystoscopy. The focus groups uncovered that, indeed, the participants were unfamiliar with setup and performance of cystoscopy and, therefore, were uncomfortable teaching the skill. The current authors also speculated that, by removing the decision of whether to perform the skill at the outset of the focus group, they might have removed any unconscious biases the participants had.

Several limitations of this study should be noted. First, although there were content experts to review and take the questionnaire results to provide feedback, the instrument was not piloted and was not formally validated. Second, the questionnaire mainly consisted of closed-ended questions with the information limited to what was asked, but there was space for participants to comment when queried on perceived barriers to universal cystoscopy after hysterectomy. The current study's findings were based on a small sample size within one institution, and the response rate of the initial questionnaire represented only two-thirds of the surgeons who were queried. However, the current authors did not feel that the nonresponder rate lessened their ability to pinpoint reasons for not adopting universal cystoscopy after hysterectomy. Further studies at other institutions could be helpful to corroborate these findings.

The current authors believe that their “ground up” approach, using gynecologic surgeons to examine barriers to universal cystoscopy after hysterectomy, will lead to adoption of the practice within the current authors' institution and likely others. Rather than a mandate, or a “top down” method, the approach of actively involving the current authors' own surgeons in reflecting on why the practice has not been adopted will support an intrinsic motivation to adopt universal cystoscopy after hysterectomy. ²⁰ The performance of diagnostic cystoscopy is not challenging, compared to other tasks gynecologic surgeons perform, but, as with the current study, it is the familiarity one develops with the setup and the knowledge that one gains in problem-solving issues that arise during performance that allows one to incorporate this skill successfully into practice.

Conclusions

General gynecologic surgeons at U.S. teaching hospitals currently do not use universal cystoscopy after hysterectomy because of cost concerns and a lack of training necessary to troubleshoot issues, and, therefore, are not comfortable teaching cystoscopy assembly and use to junior learners. Urogynecologists and other surgeons who are adept in the skill of diagnostic cystoscopy have a real opportunity to assist and strengthen the performance and teaching of surgeons who utilize cystoscopy selectively. Diagnosing individual, social, and even organizational immunity to change is an important first step to ensuring that necessary technical skills are developed and that best practices are implemented to improve patient care.