Diagnostic Cystourethroscopy

CHAPTER 111 Diagnostic Cystourethroscopy



Grant C. Fowler


The construction of the cystoscope has progressed from the original tube-and-candle, first described in the early 1800s, to the flexible fiberoptic cystoscope available today. The standard rigid cystourethroscope is composed of three components: the telescope, the sheath, and the bridge. (Rigid urethroscopes are also available, designed exclusively for evaluation of the urethra, and are a modification of the cystoscope.) Once the sheath is in place, the telescope can be removed and changed as needed for different lenses to view different aspects of the bladder. Various instruments useful for procedures (e.g., biopsy, cautery, injection), both rigid and flexible, can also be inserted.


Unlike the rigid cystoscope, the flexible cystoscope combines the optical systems and irrigation/working channel into a single unit. The flexible cystoscope also has a smaller diameter and a tip that can be deflected as much as 290 degrees in a single plane; it can be used without a working sheath, and is generally more comfortable for the patient. The patient can be in the recumbent position as opposed to the dorsal lithotomy position. This makes it ideal for use in the office or outpatient setting. However, the image from a flexible cystoscope is not as clear as that obtained with a rigid cystoscope, and because the diameter of the flexible cystoscope is smaller, operative and diagnostic procedures are limited by the decreased capacities of the irrigating and working channels. Because there is no sheath, the flexible cystoscope has to be removed completely to change the lens, and reinserted to assess residual urine and to reevacuate the irrigant. Therefore, the flexible cystoscope is used more commonly in the office setting for routine diagnostic viewing of the bladder and urethra (hematuria or tumor surveillance, double-J stent retrieval) as opposed to operative procedures. That said, either type of cystoscope, rigid or flexible, can be useful in the diagnosis of various conditions ranging from urinary incontinence to pain syndromes.


EDITOR’S NOTE: It might be helpful to review Chapter 110, Bladder Catheterization (and Urethral Dilation), along with this chapter.



Indications



• Urethral stricture or diverticulum on radiograph (for diagnostic or therapeutic purposes; e.g., using the rigid cystourethroscope or urethroscope, a cold knife incision of a limited stricture can be performed or a catheter placed into a diverticulum for localization during open surgical repair)

• Suspected urethral calculi (rare), foreign body, or condylomata (for diagnosis or removal)

• Urinary incontinence
• Intrinsic sphincter deficiency (cystourethroscopy confirms the diagnosis and allows treatment with periurethral bulking agents)

• Obstructive or irritative voiding symptoms (e.g., urgency, frequency, urge incontinence) unresponsive to conservative measures

• Suspected or known bladder diverticulum or fistula, or ectopic ureter (e.g., seen on radiograph)

• Gross or microscopic hematuria

• Known or suspected urogynecologic malignancy
• Staging or surveillance for bladder, cervical, or endometrial cancer

• Recurrent urinary tract infections

• Pelvic pain symptoms
• Dyspareunia

• Suspected interstitial cystitis, urethritis, or trigonitis (see also Chapter 12, Office Testing and Treatment Options for Interstitial Cystitis [Painful Bladder Syndrome])

• Endometriosis of the bladder

• Traumatic injury to the lower genital tract

• Intraoperative assessment of the bladder or urethra
• Exclusion of inadvertent intraluminal suture placement or bladder trauma after incontinence or prolapse correction procedures

• Assessment of coaptation of the urethra after suburethral sling procedures

• Evaluation of ureteral patency with intravenous indigo carmine dye


Contraindications



• Acute cystitis, prostatitis, or pyelonephritis should be treated before cystourethroscopy is performed because sepsis has been reported after cystoscopy in an infected patient.

• Anticoagulated patient or patient with coagulopathy (either the anticoagulation/coagulopathy should be reversed or urology consulted).


Equipment



• Rigid cystoscope and sheath (Fig. 111-1).
• Sterile rigid telescopes with 0-, 30-, 70-, and 120-degree lenses.

• The 0-degree lens (forward looking) is useful for intraurethral work, the 30-degree lens (forward oblique) is useful for evaluation of the urethra and bladder, the 70-degree lens (lateral) is useful for inspecting the interior of the bladder, and the 120-degree lens (retrograde) is useful for retrograde viewing of the bladder neck.

• Sterile sheath of 17- to 26-Fr diameter with inflow and outflow ports.

• Sterile scope-to-sheath bridge. This bridge may have one or two operative ports that admit the passage of biopsy instruments or urethral catheters.

• A light cable and light source compatible with the telescope.

• Urethral dilators, including a range from 14 to 32 Fr.

• Flexible cystoscope and light source.

• Irrigation tubing.

• Distension medium in 500-mL to 3-L bags. Saline or Ringer’s lactate may be used if electrocautery is not anticipated. If electrocautery is anticipated, then a nonconductive medium such as sterile water, mannitol, sorbitol, or glycine should be used, with water having the advantages of increased visibility and, because it is hypotonic, lysing tumor cells.

• Cotton balls moistened with an antiseptic solution (e.g., povidone–iodine).

• Sterile gloves.

• Sterile cotton-tipped applicators.

• 1% or 2% lidocaine (Xylocaine) gel.

• Blue towel for tray top.

• Basin to capture irrigation runoff.

image

Figure 111-1 Cystoscope components, including (from top to bottom) operative sheath, telescopes (two), sheath and bridge, and obturator.


Although optional and expensive, video equipment, such as a camera, high-resolution monitor, video recorder, and printer, has its advantages. Video equipment provides a magnified, binocular view, allows the clinician the ability to maintain a more comfortable position when performing the procedure, is helpful for teaching or when an assistant is available, and provides the clinician greater eye protection from body fluids.



Preprocedure Patient Preparation


Indications for, alternatives to, and risks of cystourethroscopy should be explained to the patient, and informed consent obtained before the procedure. The patient should be informed of the possibility of discomfort during and after the procedure, as well as the potential for postprocedure urinary tract infection.


If a urinary tract infection is suspected or the patient has a history of mitral valve prolapse, valvular heart disease or replacement, or a recent prosthesis such as a total knee or joint, a urine culture and sensitivity should be obtained and the patient placed on a broad-spectrum antibiotic for at least 3 days. If the patient is not allergic to fluoroquinolones, ciprofloxacin or levofloxacin is an appropriate choice (see Chapter 221, Antibiotic Prophylaxis).



Technique


Before routinely performing cystoscopy, clinicians should familiarize themselves with the equipment and feel comfortable recognizing abnormalities or pathology on visualization of the urethra or bladder. Universal blood and body fluid precautions should be followed throughout the procedure.



Preparation



1 After the patient has emptied the bladder, cleanse the urethral meatus with an antiseptic solution.

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Diagnostic Cystourethroscopy

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