Cystourethroscopy for Gynecologists
Debjyoti Karmakar
Peter L. Dwyer
Introduction
The techniques for endoscopic evaluation of pelvic organs include laparoscopy, hysteroscopy, cystourethroscopy, and proctocolonoscopy and are essential in evaluating and treating pelvic disorders. Good skills and knowledge of cystourethroscopy and lower urinary tract conditions are critical to all surgeons operating in the pelvis. Although gynecologists were at the forefront of developing cystoscopy with Kelly and Hunner and urethroscopy with Jack Robertson, training in cystoscopy was neglected in gynecology in the 20th century despite being a safe and straightforward procedure. The proximity of the urinary tract to the genital tract and overlap of urogenital conditions and symptoms makes evaluation of both frequently necessary. Gynecologic surgery can result in urinary injuries which are frequently undiagnosed; 70% of ureteric injuries and 30% of bladder injuries are undetected at the time of hysterectomy without cystoscopic assessment.1
This chapter describes the technique of cystourethroscopy, the equipment used, indications for, and normal and abnormal lower urinary tract findings frequently found. The terms cystourethroscope and cystoscope are interchangeable; however, both the bladder and urethra need careful assessment often by different scopes or abnormalities and injuries will be missed. We are using the term cystourethroscope/cystourethroscopy throughout this chapter.
THE PROCEDURE AND THE EQUIPMENT
Cystourethroscopy can be done as an outpatient procedure without sedation or general anesthesia for most indications (see following text).
The components of setup include the following:
A light source
An endoscopic video system/tower
A suspending stand for a sterile water bag and related tubing
A cystourethroscope
The comprising parts are the following:
The sheath: The outermost rigid part protects the interchangeable fragile telescopes. It acts as the conduit for distending media (irrigation) and a channel for instruments. They can vary in size from pediatric (#8 to #12 French) to adult from #17 French to larger caliber for operating devices.
regular cystoscopic sheath has a fenestrated tip to allow completion of the bladder visualization with 30- and 70-degree scopes.
Urethroscope sheaths (Sachse sheath) are flush at the distal end with no fenestration to allow distention and visualization of the urethral walls important in detecting urethral diverticulum orifices and other pathology (Fig. 24.1).
The obturator is used to introduce the sheath providing a smooth tip for insertion.
The bridge serves as a connection between the scope and the sheath with side arms for instrument placement (Fig. 24.2A,B). It is a water-tight attachment. Some bridges have specialized functions such as providing a channel for biopsy forceps or the Albarran bridge with a defector to allow more accurate ureteric stent placement (Fig. 24.2C,D).
The telescopes carry the illuminating system, extending from the eyepiece to the tip, which provides 70-, 30-, and 0-degree views (Fig. 24.3). The illuminating system uses optical fiber. The 70-degree lens is best for operative cystoscopy and inspection of anterolateral bladder walls and is useful in seeing the ureteric orifices, especially after urethral suspensions or prolapse surgery. The 0-degree scope is used for a complete examination of the urethra.
Rigid or Flexible Scopes
Rigid scopes can be inserted painlessly in women using local anesthetic lubricant and have another channel to insert needles or biopsy forceps for outpatient procedures such as Botox injections. General anesthesia is required when cystoscopy is expected to be painful, for example,
cystodistention in interstitial cystitis (IC), procedures with biopsy or cautery, or when more careful evaluation bladder and vagina for urinary fistulas is needed.
cystodistention in interstitial cystitis (IC), procedures with biopsy or cautery, or when more careful evaluation bladder and vagina for urinary fistulas is needed.
 FIGURE 24.1 Urethroscope sheaths. Upper image is a 70 degree cystoscope with a fenestrated introducer. Lower image is a 0 degree urethroscope with a sheath (Sachse sheath) cut flush to distal end with no fenestration so as to allow urethral distension and visualization of urethral walls. |
 FIGURE 24.2 Cystoscopic bridges. A,B: Bridges with single channel (A) and dual channels (B). C,D: Cystoscopic sheath with Albarran lever (C) and Albarran bridge (D). |
 FIGURE 24.3 Cystoscope lenses: 0 degree (A), 30 degrees (B), 70 degrees (C). |
 FIGURE 24.4 Flexible cystoscope. |
Flexible scopes give excellent 360-degree views of both the bladder and the urethra and are convenient for clinicians and comfortable for patients (Fig. 24.4).
Rigid cystoscopy can be performed with 70-, 30-, or 0-degree scopes
A 70- or 30-degree lens can be used to carefully evaluate bladder abnormalities, the bladder mucosa for infection or neoplastic change, and the bladder wall for trabeculation and diverticulum. Bladder trabeculation (Fig. 24.5) is muscular hypertrophy of the bladder wall and can be secondary to detrusor overactivity, urethral obstruction, or the ageing process. The ureteric orifices are sited at the most lateral point of the interureteric bar (interureteric ridge) and upper trigone. Their patency can be confirmed by the efflux of urine, which can be enhanced with intravenous dyes such as indigo
carmine (Fig. 24.6) or oral agents such as vitamin B complex and phenazopyridine (Pyridium). Another alternative is to fill the bladder retrogradely with 50% dextrose which creates a difference of specific gravity from urine and any efflux is clearly visualized. We use all of these methods in our unit depending on the availability and surgeon preference.
FIGURE 24.5 Moderate bladder trabeculation with diverticulum.
FIGURE 24.6 Indigo carmine efflux confirming right ureteric patency.
The air bubble identifies the dome. Once the ureteric orifices are identified, the trigone is seen between the interureteric bar (interureteric ridge) and bladder neck. Pearly gray-white epithelial patches with irregular borders called squamous metaplasia (Fig. 24.7) are frequently present in the urethra and the trigone. It is the stratified squamous epithelium, a normal variant not needing a biopsy. The epithelium changes from keratinized squamous epithelium at the distal urethra to nonkeratinized squamous epithelium to pseudostratified with urethral glands to transitional mucosa in the bladder.
FIGURE 24.7 Squamous metaplasia of the trigone. Common finding and histologic analysis shows stratified squamous epithelium on a background of normal transitional cell mucosa.
Cystoscopy is performed in the sitting, lithotomy or supine position with general, regional, or local anesthesia with a size #17 French sheath or a #21 French sheath with an operating channel for the passage of ureteral guidewires, stents, biopsy forceps and scissors (Fig. 24.8), and electrosurgical instruments (Fig. 24.9).
Distention Media
Can be conductive or nonconductive fluids or gases (carbon dioxide)
Nonconductive fluids (e.g., glycine and water) should be used when electrocautery is required. Because the risk of fluid absorption is low in diagnostic procedures, we prefer glycine as visualization is better in the presence of active bleeding and hemolysis.
Monitoring fluid absorption to avoid volume overload and possible hyponatremia is necessary when an operative procedure is performed, such as resecting a bladder tumor.
 FIGURE 24.8 A-C: Cystoscopic instruments including biopsy forceps. |
 FIGURE 24.9 Cystoscopic diathermy instruments. |
PROCEDURE
The patient is positioned in the sitting or dorsal lithotomy position with 1% lignocaine (lidocaine), such as Instillagel (CliniMed Ltd, High Wycombe, United Kingdom), instilled in the urethra for anesthesia and lubrication.
The cystourethroscope is placed into the urethra under direct vision with the scope facing anteriorly to minimize urethral trauma. The urethra should be assessed with a 0-degree scope for any abnormalities, such as diverticulum or tumors, and function (Video 24.1).
Prophylactic oral antibiotics are not routinely recommended except for women at higher risk of urinary tract infection (UTI) with a history of recurrent infection or women with functional or anatomical urinary tract abnormalities. Oral phenazopyridine (Pyridium) preprocedure or postprocedure urinary alkalizer like Ural (Amcal Pharmacy) can alleviate postprocedure dysuria with or without UTI.
INDICATIONS FOR CYSTOURETHROSCOPY IN UROGYNECOLOGY
The broad categories of indications for gynecologists are the following:
Urinary tract injury
Irritative bladder symptoms, including interstitial cystitis (IC)/bladder pain syndrome
Exclude urinary tract cancer
Urinary fistula
Congenital abnormalities of the urinary tract and anatomical lesions
Evaluation of recurrent UTIs
Evaluation of voiding difficulty
Evaluation of macroscopic/microscopic hematuria
Injection of therapeutic agents—bulking agents, botulinum toxin
Cystoscopy-guided suprapubic catheter placement
Ureteral stent placement
Urinary Tract Injury
Early detection of injury to the ureter, bladder, or urethra intraoperatively will allow any injury to be repaired without significant sequelae such as urinary fistulas or renal failure secondary to ureteric obstruction. Intraoperative detection of injury can be performed by inspecting the urinary tract for injury or urine leakage during and after surgery but is more accurately assessed by endoscopic inspection of the bladder for injury and the ureters for patency immediately after surgery.
Gynecologic surgery accounts for over three-quarters of iatrogenic urinary tract injuries.1 Presently, only 1 in 10 ureteral injuries and 1 in 3 bladder injuries are detected at the time of surgery without intraoperative cystoscopy.2 The risk of injury varies with the procedure performed but is common in urogynecology procedures for stress incontinence and prolapse. Gilmour et al.1 found the ureteric injury rate per 1,000 operations for vaginal hysterectomy was 0.2, subtotal abdominal hysterectomy was 0.6, total abdominal hysterectomy was 1.3, and laparoscopic hysterectomy was 7.8. The most typical cause of ureteric damage during laparoscopic surgery is electrocoagulation, but injury from clamping, misplaced sutures, and trocar entry has been reported. In a prospective study with routine cystoscopy after hysterectomy, Vakili et al.3 reported a urinary tract injury rate between 4% and 5% in 471 women with a bladder and ureteral injury rate of 3.6% and 1.7%. Ibeanu et al.4 reported a 2.9% bladder and 1.8% ureteral injury rate in 839 women. The majority of ureteric injuries were only diagnosed on cystoscopy and missed at the time of surgery.1,5 Cystourethroscopy can identify the presence of trauma to the bladder either by direct vision or by the leakage of fluid to the abdomen/vagina during cystodistention. The cause of the trauma to the bladder (suture/cystotomy/trocar injury) and proximity to ureteric orifices, urethra, and trigone should be documented.
The incidence of bladder perforation at the insertion of a midurethral sling is 1% to 20%. Risk factors are previous Cesarean section and Burch colposuspension, body mass index less than 30 kg/m2, rectocele, inexperienced surgeon, and local anesthesia.6 Cystoscopy is a routine part of tension-free vaginal tape procedures. The common areas for perforation are the lateral corner and dome of the bladder and best seen using a 70-degree cystourethroscope at 11 and 1 o’clock. The risk of bladder injury is less with the transobturator midurethral sling, but urethral perforation is higher, and in our opinion, cystourethroscopy should be performed routinely (Fig. 24.10). Pelvic reconstructive surgery for pelvic organ prolapse (POP) and stress incontinence and major vaginal/abdominal/laparoscopic gynecologic (such as hysterectomy, adnexectomy) surgery carry an inherent risk of urinary tract injury.1,5,7 The risk of ligation has significantly increased in recent years with pelvic mesh usage, for example, sacrocolpopexy and vaginal repair
with mesh and midurethral slings.8 A frequently asked question by lawyers is whether early diagnosis can prevent the consequences of urinary tract injury (fistula, nonfunctioning kidney)? The answer is often yes.2
with mesh and midurethral slings.8 A frequently asked question by lawyers is whether early diagnosis can prevent the consequences of urinary tract injury (fistula, nonfunctioning kidney)? The answer is often yes.2
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