CHAPTER 111 Diagnostic Cystourethroscopy
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
Contraindications
Equipment
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.
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