141 Judson D. Davies & Sam S. Chang Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA Cystourethroscopic examination of the bladder and urethra remains the gold standard for the diagnosis of lower urinary tract disorders. It offers direct visualization of the bladder urothelium and provides initial access to the ureteral orifices for assessment and treatment of the upper urinary tracts. It is a cornerstone in the evaluation of gross and microscopic hematuria, and is useful in the investigation of lower urinary tract symptoms. Instruments passed through the cystoscope or specially designed resectoscopes allow minimally invasive diagnosis and treatment of identified pathology. This chapter summarizes the role of cystoscopy (both rigid and flexible) as well as recent innovations in office cystoscopy. Cystourethroscopy is performed using either rigid or flexible endoscopes. Endoscopes are measured with the French scale and are available in sizes to accommodate both pediatric (8–12 Fr) and adult patients (16–25 Fr). The French scale is equal to the diameter of the cylinder in millimeters multiplied by 3, not the circumference as is sometimes thought. Increasing French units correspond to larger diameter endoscopes. Rigid cystoscopes are multicomponent instruments that consist of a sheath, an obturator, a bridge, and a telescope (Figure 141.1). The sheath provides a connection to the irrigation system. An obturator is placed through the sheath that aids entry into the bladder through the urethra. Most are hinged to allow a better angled approach past the male bulbar and prostatic urethra. Once inside the bladder, the obturator can be exchanged for a telescope with a bridge that allows for the passage of a variety of treatment implements (i.e. wires, stents, ureteral catheters, laser fibers). The light source connects directly to the telescope, which uses fiber‐optic illumination and a rod–lens imaging system to transmit the light and image to the eyepiece. Various lens angles enable the endoscopist to evaluate adequately the entire urethra and bladder. The 0° lens allows the best view of the urethra, providing a straight image. This degree lens is many times the most useful in patients with urethral stricture disease. A 30° lens is used to visualize the trigone, posterior wall of the bladder, as well as the lateral side walls. It is the most commonly used lens in rigid cystoscopy. A 70–90° lens is often used to assess the dome and anterior bladder neck. Figure 141.1 Basics of the rigid cystoscope (from top to bottom): metal sheath with inflow and outflow ports, bridge, and rod–lens system to which the light source it attached. Spring‐loaded resectoscopes are typically used for the resection of bladder lesions and prostatic hyperplasia. These implements are best used in conjunction with a 30° lens–rod system and require the use of a large‐bore sheath (24–26 Fr). Continuous‐flow irrigation, which utilizes an outer sheath with both inflow and outflow ports, prevents the bladder from compressing on itself during the procedure. This allows the area of interest (e.g. a bladder tumor) to remain fixed in space to facilitate resection. Continuous irrigation provides for more efficient resection and enhanced visualization, especially in the setting of transurethral resection of the prostate (TURP). Rigid cystoscopes provide a relatively large working port to accommodate a variety of accessory instruments. This is a major advantage; however, the large size of the rigid cystoscope decreases its applicability in males unless general or regional anesthesia is utilized. In addition, patients must be placed in the dorsal lithotomy position to facilitate an adequate examination. Rigid cystoscopy, therefore, is difficult to perform in the male patient outside of the modern operating room. Rigid cystoscopy is utilized to assess the bladder and upper urinary tracts for diagnostic evaluation of multiple clinical entities, such as hematuria, voiding complaints, and urothelial carcinoma. Retrograde imaging of the ureter and renal pelvis can be accomplished with the use of contrast injected through small catheters passed into the ureteral orifice under cystoscopic guidance. Ureteral stents are commonly inserted via the rigid cystoscope. Upper tract access for ureteroscopy may also be established with the use of wires and open‐ended catheters. After wire passage has been confirmed with the use of fluoroscopy, the rigid cystoscope may be exchanged for a ureteroscope. Other uses are possible but have been largely supplanted with flexible cystoscopy. After obtaining informed consent and verifying proper instrument sterilization and availability, the patient should be prepped and draped in a standard sterile fashion. In both male and female patients, lubricant jelly should be instilled into the urethra before the procedure. If the meatus or urethra is unable to comfortably accommodate the cystoscope, dilation should be performed. This can be accomplished with the use of urethral sounds in a serial fashion. The urethra should be dilated to a diameter of at least 2 Fr units greater than the instrument (e.g. dilate to 26 Fr if utilizing a 24 Fr cystoscope). In the male, the penis should be grasped and straightened as the endoscope is introduced to allow for inspection of the fossa navicularis and the anterior urethra. As the scope traverses the anterior urethra, the examiner’s hand should be depressed to bring the penis parallel with the floor. This allows for examination of the membranous urethra and prepares the examiner to view the prostatic urethra. The verumontanum is noted when the examiner reaches the prostatic urethra. The prostatic lobes are seen laterally at this point in the examination. When the bladder neck is in view, it is often necessary for the examiner to depress the endoscope by dropping their hand toward the floor so as to account for the gentle upward angulation encountered before entering the bladder [1]. Once the endoscope is inside the bladder, a systematic evaluation of the entire bladder surface is performed in a routine and reproducible fashion. The trigone is the first landmark encountered when visualizing the bladder with a 30° lens. The examiner should follow the trigone laterally to identify the ureteral orifices effluxing clear urine. Next, attention should turn toward examination of the bladder floor beyond the trigone and the posterior wall. The lateral walls are then carefully inspected by rotating the lens side to side. The dome and anterior bladder wall are best viewed with the 70° lens. The scope should be rotated 180° to facilitate this part of the procedure, paying close attention to keeping the camera head level (if one is being utilized). The air bubble serves as the landmark for the dome. It is often necessary to apply pressure just superior to the pubic bone when visualizing the anterior bladder neck. Flexible cystoscopy of the urinary tract is a fairly recent phenomenon. In 1973, Tsuchida and Sugawara reported utilizing a flexible “fibercystoscope” for examination of the bladder neck [2]. Since the development of the first purpose‐built flexible cystoscope in 1984, flexible fiber‐optic cystoscopy has become an accepted diagnostic and therapeutic modality, and today is the most commonly performed in‐office procedure by the practicing urologist. The development of working ports, smaller cystoscope diameter with preserved image quality, active deflection, and most recently digital cystoscopes, have greatly enhanced the ability of the user to apply flexible cystoscopy for a variety of diagnostic and therapeutic applications. When compared to rigid cystoscopy, flexible cystoscopy is more comfortable for patients and can be performed with only local anesthesia. The deflection capabilities of the flexible cystoscope allow for easier passage through the bladder neck, as well as superior visualization of the anterior bladder wall (Figure 141.2).
Office‐based Cystoscopy: Continued Advances
Introduction
Rigid cystoscopy
Procedures
Technique
Flexible cystoscopy
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