Rigid cystoscopy is one of the most commonly performed procedures in urology. Routinely performed in operating room setting under general anaesthesia, it provides direct visualization of the urethra, bladder and access to the upper urinary tract. Common indications for the procedure are summarised in Table 1.1.

Compared to flexible cystoscopy, rigid cystoscopy is performed largely for therapeutic purposes. Frequently, bladder lesions or larger tumours are biopsied, fulgurated or resected through rigid cystoscopy. Access to the upper urinary tracts allows treatment of ureteric stones, tumours and placements of ureteric stents, as well as retrograde pyelography for assessment of the upper tracts.

Basic setup for rigid cystoscopy requires an endoscope, light source and irrigation fluid. Irrigation fluid includes normal saline, glycine or sterile water. In the absence of an endoscopic camera the surgeons views the image directly through the optical eyepiece at the proximal end of the instrument.

Cystoscopes are manufactured in a variety of sizes expressed in French (Fr) gauge. One French gauge denotes an instrument circumference of 1/3 mm. Rigid cystoscopes are manufactured in sets consisting of an optical lens, bridge, sheath, and visual obturator. (Fig. 1.1) The typical scope sizes used in adults are 20 and 22 Fr. The optical lenses come with tip angles ranging from 0° to 120°. The bridge connects the optical lens to the sheath, and usually has one or two working channels.

Zero-degree lens provides optimal view of the urethra and often used for procedures such as optical urethrotomy. A 30° lens is useful for both diagnostic and therapeutic purposes; and the 70–120° lens are used in patients with high bladder necks.

Informed consent must be obtained before any cystoscopic procedure is performed. A urinalysis and culture should be obtained to ensure sterile urine prior to procedure. Commonly digital rectal examination is performed under anaesthesia to assess the prostate in men prior to cystoscopy.

Before cystoscopy the skin is prepared with an antiseptic agent . Common agents contain iodophors or chlorhexidine gluconate in either an aqueous or alcohol-based solution. The prepared field is then protected with sterile drapes. A lubricating gel with topical anaesthetic agent is injected into the urethra.

Before insertion of cystoscope, external genitalia should be inspected for cutaneous lesions, anatomical anomalies and meatal stenosis. Mild meatal or sub-meatal stenosis can be treated with sequential dilators.

In women, rigid cystoscope insertion is safest using the sheath obturator. In men, the penis needs to be placed on maximal stretch to straighten the urethra. This is optimally achieved by grasping the penis with all five fingers of the surgeon’s non-dominant hand. (Fig. 1.2) The penis should be angled at 45–90° relative to the torso while the scope is passed through the urethra (Fig. 1.3) Once beyond the membranous urethra the cystoscope is directed anteriorly by lowering the distal end of the scope to enter the bladder. This is due to the fact that the proximal part of membranous urethra takes a right-angled curve forwards to become the prostatic urethra.

The passage of the scope through the urethra should be assisted by adequate irrigation and maintaining constant vision of the centre of the lumen. Do not advance the scope unless the scope is in the centre of the lumen. This will help to minimise trauma to urethra and prevent stricture formation.

Once the scope is in the bladder, the mucosa is carefully inspected. Rigid cystoscopy usually begins with a 30° lens for inspection of the floor and trigone of the bladder. The number, location, and configuration of the ureteral orifices are noted. The remainder of the bladder is inspected for stones, trabeculation, debris, diverticula, mucosal changes and tumours. Visualization of the lateral, anterior and dome of the bladder walls is accomplished by rotating the cystoscope while keeping the camera orientation fixed.