Fluorescein Administration for Hysterectomy
For intraoperative assessment of ureteral patency during hysterectomy, administer 25 mg of 10% intravenous sodium fluorescein after vaginal cuff closure, which produces brilliant yellow ureteral jets visible on cystoscopy within 3-9 minutes. 1, 2
Administration Protocol
Dosing and Timing
- Administer 0.25-1.0 mL of 10% sodium fluorescein (25-100 mg total dose) intravenously after completing the hysterectomy and vaginal cuff closure 1, 2
- The standard effective dose is 25 mg (0.25 mL of 10% solution), which provides excellent visualization without excessive side effects 1, 3
- Visualization occurs rapidly: average time to bilateral ureteral jet coloration is 1 minute, with a range of 3-9 minutes 1, 4
Injection Technique
- Inject slowly over 5-10 seconds into the antecubital vein, taking precautions to avoid extravasation 5
- Use a syringe with transparent tubing and 23-gauge butterfly needle for optimal control 5
- Draw patient's blood to the hub of the syringe first to create a small air bubble separating blood from fluorescein, allowing detection of extravasation before dye injection 5
- If extravasation occurs, the blood will bulge the skin—stop injection immediately 5
Clinical Performance
Efficacy
- 93% of patients demonstrate bilateral ureteral jet coloration, with 90% of surgeons reporting high satisfaction with this method 1
- Sodium fluorescein provides significantly improved visibility and surgeon satisfaction compared to saline control (p<0.001) 3
- Excretion time is dramatically faster than oral phenazopyridine (5.1 minutes vs 81.9 minutes, p=0.0057) 4
Advantages Over Alternatives
- No urological procedure required (unlike intraureteral ICG which requires cystoscopy, ureteral stenting, and direct injection) 6
- Rapid results without prolonging operative time—cystoscopy duration averages 4-5 minutes total 3
- Superior to methylene blue for ureteral assessment as fluorescein is specifically FDA-approved for ophthalmic angiography and has extensive safety data 5
Safety Considerations
Common Side Effects
- Yellow discoloration of urine occurs in 50% of patients and is expected, lasting several hours 1
- Transient hypotension may occur in approximately 10% of patients (3 of 30 in one series) 1
- Temporary yellowing of sclera and palms has been reported but resolves spontaneously 2
Contraindications and Precautions
- Avoid in patients with known fluorescein allergy 5
- Use caution in pregnancy (Category C) and nursing mothers, as fluorescein is excreted in breast milk 5
- Do not mix or dilute with other solutions or drugs 5
- Inspect solution for particulate matter before administration 5
Clinical Context and Limitations
Off-Label Use
Important caveat: While sodium fluorescein is FDA-approved for ophthalmic angiography, its use for ureteral identification constitutes off-label use, similar to ICG and methylene blue for urinary tract evaluation 6
When to Consider Fluorescein
This technique is particularly valuable in:
- Complex hysterectomies with anticipated difficult anatomy (obesity, prior pelvic surgery, endometriosis, large uteri 76-885g) 1
- Cases where rapid confirmation of bilateral ureteral patency is needed without the time and expertise required for ureteral stenting 6
- Settings where indigo carmine is unavailable due to ongoing national shortages 2
Alternative Approaches
While fluorescein is effective, intraureteral ICG with near-infrared fluorescence provides direct ureteral visualization and may be preferred in extremely high-risk cases, though it requires cystoscopy, stenting, and specialized equipment 7, 8. For routine cases, 10% dextrose bladder distention provides comparable satisfaction without systemic drug administration 9, 3.