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.
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 When a different lens is required, the rodlens system is withdrawn from the sheath and exchanged for another one.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.
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 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.