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 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.
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, [8] 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.
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.
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.
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. [9] This supports the findings of a meta-analysis of 9 prospective randomized controlled trials by Patel et al. [10]
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. [11] 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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Rigid cystoscope with connections to irrigation and light source.
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Flexible cystoscope.
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Bladder distention in patient with interstitial cystitis.
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Large supratrigonal vesicovaginal fistula, showing tip of vaginal clamp.
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Cystoscope assembly, part 1. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
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Cystoscope assembly, part 2. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
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Cystoscopy, part 1. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
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Cystoscopy, part 2. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
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Cystoscopy supplies. Image courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
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Cystolithotripsy, part 1. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Cystolithotripsy, part 2. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Cystolithotripsy, part 3. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
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Gross anatomy of the bladder.
