CYSTOSCOPY
Cystoscopy refers to the direct visualization of the anterior and posterior urethra, bladder neck, and bladder mucosa using an endoscope. This procedure is performed both to evaluate the lower urinary tract and to establish access to the upper urinary tract (see Plate 10-33). Common indications include microscopic or gross hematuria, obstructive voiding symptoms, surveillance of a known urinary tract malignancy, inability to urinate following surgery for incontinence, and removal of a foreign body.
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| Plate 10-37 CYSTOSCOPE DESIGN |
CYSTOSCOPE
DESIGN
Cystoscopes are available in a variety of sizes and may be either rigid or flexible in design. The size (outer diameter) of a cystoscope is given in the French scale. Rigid Cystoscopes. A rigid cystoscope has a long metal sheath, bridge, and rod-lens system. The sheath is the outer cover through which the rod-lens system is inserted. It remains within the bladder when the rod-lens system must be removed or exchanged. It also contains the port for infusion of irrigant fluid, which helps maintain continuous visualization. The sheath is inserted into the bladder with an obturator in its lumen, which has an atraumatic tip to ensure safe passage through the urethra. “Visual” obturators contain a lumen for the lens, which permits direct visualization of the insertion process, whereas “nonvisual” obturators lack such a lumen.
The sheath
attaches to a bridge, which contains an opening for the rod-lens system and
also contains the working channel through which instruments such as biopsy
forceps, hand-held graspers, wires, catheters, and cautery probes may be
inserted.
The rod-lens
system contains an objective lens at its tip that transmits an image to the
eyepiece. Lenses are designed at different angles (0, 12, 30, and 70 degrees)
so that different aspects of the urinary tract can be visualized. When a
different lens is required, the rodlens system is withdrawn from the sheath and
exchanged for another one. In the past, the urologist would look directly
through the eyepiece, but in contemporary practice a camera is attached so the
image can be trans- mitted to a monitor.
Advantages
of rigid cystoscopes over flexible cystoscopes include a larger sheath diameter
for better irrigation, as well as a
larger working channel. Because of these features, it is easier to perform
procedures such as retrograde pyeloureterography and bladder biopsy. Rigid
cystoscopes, however, are uncomfortable for patients and thus require regional
or general anesthesia. In addition, the patient must be in lithotomy position.
Flexible
Cystoscopes. Flexible cystoscopes have small, soft, flexible shafts; a working
channel; and an irrigation port. The optics consist of either fiberoptic bundles or, more recently,
a distal sensor (either a complimentary metal oxide sensor or charge coupled device). Flexible cystoscopes have
deflective capabilities of up to 220 degrees, controlled by a thumb-operated
lever. Unlike a rigid cystoscope, a flexible cystoscope is a single unit and
does not come in multiple pieces. Flexible cystoscopes are more comfortable
than rigid cystoscopes, and in some cases they can be deployed without anesthesia. In addition, the deflection capabilities improve
visualization of the bladder mucosa and allow the cystoscope to be deployed
with the patient supine.
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| Plate 10-38 CYSTOSCOPIC VIEWS |
PREOPERATIVE
ASSESSMENT AND TECHNIQUE
Before
undergoing cystoscopy, the patient should have a recent negative urinalysis and
urine culture, so as to reduce the risk of urosepsis. If even bacteriuria is
present, the patient should be treated with culture-directed oral antibiotics,
and the cystoscopy should be rescheduled.
Rigid
cystoscopy is performed in an operating room under regional or general anesthesia.
Flexible cystoscopy, in contrast, is often performed in the office, with local
intraurethral anesthetic (lidocaine/HCl 2% jelly) provided several minutes
before the procedure.
The
patient’s genital area is sterilized and draped. If the urethral meatus is
stenotic, a urethral dilator can be deployed first. Either saline or sterile
water can be used for irrigation; however, if electrocautery is planned, either
water or another nonconductive irrigant should be used.
When placing
a rigid sheath in a female, a nonvisual obturator may be used. In contrast,
when placing a rigid sheath in a male, a visual obturator should be used with a
30-degree lens to examine the urethra. The penis should be placed on gentle
stretch to straighten the urethra and facilitate cystoscope passage. Some men
with large prostates or an elevated bladder neck may require gentle
manipulation of the cystoscope to access the urinary bladder.
Once the
cystoscope is in the bladder, the trigone and ureteral orifices are visualized.
Next, the entire mucosal surface is examined. If a rigid cystoscope is being
used, a 30-degree lens permits visualization of the trigone and posterior wall,
whereas a 70-degree lens offers visualization of the lateral walls, anterior
wall, and dome of the bladder. If a flexible cystoscope is being used, active
deflection of the tip can be performed to visualize all of these areas. All
urologists should have a thorough routine to ensure no areas of mucosa are missed. During this process,
care should be taken not to overfill the bladder with irrigation fluid, as this
can increase the risk of postoperative urinary retention.
Following
inspection of the mucosal surface, various procedures may be performed by
inserting instruments into the working channel. After these procedures are
completed, the cystoscope is removed, and the bladder is drained through either
the rigid sheath or a Foley catheter.
COMPLICATIONS
Complications
of flexible and rigid cystoscopy include urinary tract infection, postprocedural
hematuria and dysuria, and transient urethral pain. The creation of a false
passage and urethral trauma may also occur, but these complications are more
common with rigid cystoscopes. In addition, a rigid cystoscope is more
traumatic in men with enlarged prostates, who may experience postprocedural
hematuria even with gentle passage of the cystoscope under direct vision.
