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Cystoscopy Periprocedural Care

  • Author: Gamal Mostafa Ghoniem, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Jan 05, 2016
 

Equipment

The materials required for cystoscopy (see the image below) include a cystoscope, a video system, and an irrigating medium.

Cystoscopy supplies. Image courtesy of Michel Rivl Cystoscopy supplies. Image courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.

Cystoscope

A rigid cystoscope (see the image below) is composed of 3 parts: telescope, bridge, and sheath. The telescope transmits the light into the urinary bladder and the image to the examiner. The telescopes have different viewing angles (eg, 0°, 12°, 25°, 30°, 70°, or 120°), each with its own viewing capabilities and indications. The 0° and 12° devices angle downward. This helps to visualize the whole bladder.

Rigid cystoscope with connections to irrigation an Rigid cystoscope with connections to irrigation and light source.

Of particular importance is retrograde visualization of the bladder neck area, which could not be achieved with the rigid cystoscope. The flexible cystoscope (see the image below) is less painful to the patient,[7] permits inspection of the entire bladder with a single optical instrument, and is invaluable when the patient cannot be placed in the lithotomy position, as in cases of frozen pelvis, limb deformities, or joint diseases.

Flexible cystoscope. Flexible cystoscope.

The major disadvantage of the flexible cystoscope is the limited irrigation flow port, which impairs the visualization process. The use of working instruments through the same port results in further impairment of visualization, as well as limits the deflection mechanism.

Assembly of a cystoscope is depicted in the videos below.

Cystoscope assembly, part 1. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
Cystoscope assembly, part 2. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.

Video system

The advance of videoendoscopy has improved cystoscopy considerably, providing a more comfortable position for the examiner, reducing the chances of soiling and contamination for the operating team, enhancing teaching techniques, and enabling video recording. Videoendoscopy allows patients to watch the important cystoscopic findings and become more aware of their conditions.

Irrigating medium

The most commonly used irrigating media are sterile water and normal saline. Normal saline should not be used when electrocauterization is attempted; sterile water should not be used when bladder samples are collected for cytologic evaluation.

The irrigating medium should be warmed to body temperature before use. It flows under the effect of gravity; no additional external pressure is needed.

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Patient Preparation

The introduction of flexible endoscopes has led to a reduction in the use of sedation, topical anesthetics, and general anesthesia for cystourethroscopy. In the author’s practice, flexible cystoscopy as a diagnostic procedure is performed without the use of analgesia or sedation. A non-randomized study by Cano-Garcia et al found that there is no pain relief benefit in the use of lidocaine gel vs. lubricant gel in flexible cystoscopy.[8] This supports the findings of a meta-analysis of 9 prospective randomized controlled trials by Patel et al.[9]

Those who prefer a rigid cystoscope or are performing an office procedural cystoscopy that necessitates the use of a rigid cystoscope typically instill local lidocaine gel into the urethra 10-15 minutes before the procedure, with or without mild sedation.[10] Some studies support the use of lidocaine spray, which takes effect more quickly (within 1-5 minutes).[1] This option may reduce anxiety in patients waiting for the procedure, as well as save time in the setting of a busy clinic.

The most commonly used position for cystoscopy is the lithotomy position. However, most males undergoing flexible cystoscopy in the clinic can be examined in the supine position.

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Contributor Information and Disclosures
Author

Gamal Mostafa Ghoniem, MD, FACS Professor and Vice Chair of Urology, Chief, Division of Female Urology, Pelvic Reconstructive Surgery, and Voiding Dysfunction, Department of Urology, University of California, Irvine, School of Medicine

Gamal Mostafa Ghoniem, MD, FACS is a member of the following medical societies: American Urogynecologic Society, International Continence Society, International Urogynaecology Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, American College of Surgeons, American Urological Association

Disclosure: Received honoraria from Astellas for speaking and teaching; Received grant/research funds from Uroplasty for none; Partner received honoraria from Allergan for speaking and teaching.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Acknowledgements

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Acknowledgments

Medscape Reference thanks Michel Rivlin, MD, G Rodney Meeks, MD, Dennis G Lusaya, MD, and Edgar V Lerma, MD, for assistance with the video contribution to this article.

References
  1. Choe JH, Kwak KW, Hong JH, Lee HM. Efficacy of lidocaine spray as topical anesthesia for outpatient rigid cystoscopy in women: a prospective, randomized, double-blind trial. Urology. 2008 Apr. 71(4):561-6. [Medline].

  2. Karabacak OR, Cakmakci E, Ozturk U, Demirel F, Dilli A, Hekimoglu B, et al. Virtual cystoscopy: the evaluation of bladder lesions with computed tomographic virtual cystoscopy. Can Urol Assoc J. 2011 Feb. 5(1):34-7. [Medline]. [Full Text].

  3. Kuehhas FE, Weibl P, Tosev G, Schatzl G, Heinz-Peer G. Multidetector computed tomography virtual cystoscopy: an effective diagnostic tool in patients with hematuria. Urology. 2012 Feb. 79(2):270-6. [Medline].

  4. Dimon M, Williams C. Continuous Retroflexion Cystoscopy During Prostate Cryoablation. J Endourol. 2012 Jan 4. [Medline].

  5. Wolf JS Jr, Bennett CJ, Dmochowski RR, Hollenbeck BK, Pearle MS, Schaeffer AJ. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol. 2008 Apr. 179(4):1379-90. [Medline].

  6. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Oct 9. 116(15):1736-54. [Medline].

  7. Zhang ZS, Tang L, Wang XL, Xu CL, Sun YH. Seeing Is Believing: A Randomized Controlled Study from China of Real-Time Visualization of Flexible Cystoscopy to Improve Male Patient Comfort. J Endourol. 2011 Jul 11. [Medline].

  8. Cano-Garcia Mdel C, Casares-Perez R, Arrabal-Martin M, Merino-Salas S, Arrabal-Polo MA. Use of Lidocaine 2% Gel Does Not Reduce Pain during Flexible Cystoscopy and Is Not Cost-Effective. Urol J. 2015 Nov 14. 12 (5):2362-5. [Medline].

  9. Patel AR, Jones JS, Babineau D. Lidocaine 2% gel versus plain lubricating gel for pain reduction during flexible cystoscopy: a meta-analysis of prospective, randomized, controlled trials. J Urol. 2008 Mar. 179 (3):986-90. [Medline].

  10. Rodríguez-Rubio F, Sanz G, Garrido S, Sánchez C, Estudillo F. Patient tolerance during outpatient flexible cystoscopy--a prospective, randomized, double-blind study comparing plain lubrication and lidocaine gel. Scand J Urol Nephrol. 2004. 38(6):477-80. [Medline].

  11. Clark KR, Higgs MJ. Urinary infection following out-patient flexible cystoscopy. Br J Urol. 1990 Nov. 66(5):503-5. [Medline].

  12. Seklehner S, Remzi M, Fajkovic H, Saratlija-Novakovic Z, Skopek M, Resch I, et al. Prospective multi-institutional study analyzing pain perception of flexible and rigid cystoscopy in men. Urology. 2015 Apr. 85 (4):737-41. [Medline].

 
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Rigid cystoscope with connections to irrigation and light source.
Flexible cystoscope.
Bladder distention in patient with interstitial cystitis.
Large supratrigonal vesicovaginal fistula, showing tip of vaginal clamp.
Cystoscope assembly, part 1. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
Cystoscope assembly, part 2. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
Cystoscopy, part 1. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
Cystoscopy, part 2. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
Cystoscopy supplies. Image courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
Cystolithotripsy, part 1. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Cystolithotripsy, part 2. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Cystolithotripsy, part 3. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Gross anatomy of the bladder.
 
 
 
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