Video Clips on DVD
Instrumentation for Cystourethroscopy
Urethroscopic View of a Urethrovaginal Fistula
Normal and Abnormal Findings Seen on Cystourethroscopy
Cystoscopic View of a Vesicovaginal Fistula
Cystoscopic View of a Vesicovaginal Fistula with Stone Formation
Cystoscopic View of an Obstructed Ureter
Technique for Placement of Ureteral Stents
Techniques to Perform Operative Cystourethroscopy
Cystoscopy for the Gynecologist
Technique for Botox Injection
Techniques for Suprapubic Teloscopy
From a historical perspective, the ability to look inside the living human body was sought by many physicians. In 1807, the first instrument used for visualizing the body from the inside was invented by Philipp Bozzini (1773-1809), a young German army surgeon. Bozzini used his innovation for viewing bullets in his patients. This instrument, called the Lichtleiter, represents the ancestor of modern endoscopes. Since then, the cystourethroscope has been improved with the introduction of cold light and the evolution of the optical system, videoendoscopy, flexible instruments, and virtual endoscopy. Today’s systems have evolved from the rod lens systems introduced by Hopkins and Kopany in 1954. These provide wider viewing and the ability to view at a variety of angles. This has improved the extent of visualization and allowed the ability to perform more complex and invasive procedures, including operative cystourethroscopy. Modern developments include the introduction of flexible scopes, which take advantage of flexible fiberoptic lens systems that allow expanded viewing ranges and may improve patient comfort.
Gynecologists need to be able to perform cystourethroscopic examinations both in the office and in the operative room settings. Cystourethroscopy can be used both for diagnosis and treatment purposes. As a diagnostic tool, cystourethroscopy provides visualization of the lower urinary tract including the urethra (diverticulum, fistula, foreign body), bladder neck area (polyps, fistula, bulking agents), and urinary bladder (foreign body, diverticula, trabeculation, fistula, mucosal abnormality). Evaluation of the upper urinary tract (ureters and kidneys) could also be achieved by using the cystourethroscope for ureteral injection of contrast materials under fluoroscopy, a procedure called retrograde pyelogram. This can be used to evaluate ureteral patency, stone disease, and other anatomic variants. When fluoroscopy is used, shielding of operative personnel with lead aprons is required and cumulative time for total fluoroscopic use should be noted. For therapeutic purposes, cystourethroscopy is used for diagnosing and treating many lower urinary tract pathologies. A summary of diagnostic and therapeutic indications for cystourethroscopy is given in Table 3-1 . Cystourethroscopy is contraindicated in patients with febrile urinary tract infections and/or severe coagulopathy.
There are Ib, III, and IV levels of evidence that antibiotic prophylaxis before simple cystourethroscopy should be used only in the presence of risk factors for urinary tract infection. These risk factors include advanced age, anatomic anomalies of the urinary tract, poor nutritional status, smoking, chronic corticosteroid use, immunodeficiency, fixed catheters, coexistent infection, and prolonged hospitalization. For those who have any of the risk factors, the recommended antibiotic prophylaxis includes a single dose of either fluoroquinolones or trimethoprim/sulfamethoxazole. Aminoglycoside (with or without ampicillin), first- or second-generation cephalosporin, and amoxicillin/clavulanate are suitable alternatives for this regimen. Patients with negative urine culture and those who do not have any of these risk factors do not need antibiotic prophylaxis before cystourethroscopy. Although this is the case for simple cystourethroscopy, all patients who will have cystourethroscopy with manipulations should have antibiotic prophylaxis. According to the American Heart Association, antimicrobials are no longer recommended solely to prevent infectious endocarditis in association with genitourinary procedures.
In the era of flexible endoscopes, the use of sedation, topical anesthetics, and general anesthesia for cystourethroscopy has diminished. When rigid scopes are used for cystoscopic procedures, topical anesthetics with or without sedation are usually used. Lidocaine gel is instilled into the urethra 10 to 15 minutes before cystourethroscopy. Recent studies support the use of lidocaine spray, because it takes less time to take effect (1 to 5 minutes). This might decrease associated patient anxiety while waiting for the procedure and also helps save time in the setting of a busy clinic. In our practice, we use flexible cystoscopy as a diagnostic procedure without the use of analgesia or sedation. For office procedural cystoscopies that necessitate the use of a rigid cystoscope, we use mild sedation with local lidocaine gel instillation in the urethra 10 to 15 minutes before the procedure.
The three parts of the rigid cystoscope are the telescope, the bridge, and the sheath ( Fig. 3-1 ). The telescope transmits the light into the urinary bladder and produces an image to the examiner. The telescopes have different viewing angles, each with different viewing capabilities and indications. The viewing angle could be 0 (straight), 12, 25, 30 (forward-oblique), 70 (lateral), or 120 (retroview) degrees. Each viewing angle has a certain use and indication. The 0- and 12-degree angle telescopes provide a straight view and are most suitable for urethral examination. The 12-degree angle in particular is best used for bulking agent injection. The 30- and 70-degree telescopes are used for bladder examination. The 30-degree telescope is commonly used to visualize the trigone and when placing ureteral stents. The 70-degree angle is important for viewing the anterolateral bladder wall. The 70-degree telescope is also best for bladder evaluation and, of particular importance, to exclude the possibility of bladder injury following some gynecologic procedures, such as incontinence and prolapse repairs. The 120-degree telescope is rarely used and provides a “retrograde” view to visualize the bladder neck area during cystourethroscopy.
The cystoscope sheath carries the telescope and provides a channel for the flow of irrigating medium. The sheath also provides access for the passage of the working elements (e.g., graspers and catheters) when procedural cystoscopy is performed. The cystoscope sheath diameter ranges from 17 to 28 French. The size of the sheath is found dorsally between the outflow and inflow channels ( Fig. 3-2 ). The size of the sheath limits the size of the working instruments. The diameter used most commonly for adults ranges from 15 to 24 French. In general, when the cystoscope is used solely for diagnosis, the smallest diameter should be used; if additional working channels are needed, then a larger size could be used.
The bridge connects the telescope to the sheath and has one or two ports for passage of working instruments. The ports are guarded with plastic nipples, which allow passage of working instruments in a watertight manner.
The advantages of the rigid cystoscope include better viewing quality, easy orientation during inspection, easier manipulation, larger working channels for auxiliary equipment, and larger irrigation channels, which improve vision and help with more efficient evacuation of bladder clots or debris.
The flexible cystoscope ( Fig. 3-3 ) is available in sizes from 15 to 18 French. The flexible cystoscope has the advantage of a distal tip deflection mechanism with an angle of 210 degrees upward and 120 degrees downward ( Fig. 3-4 ). This helps visualize the entire bladder. Of particular importance is retrograde visualization of the bladder neck area, which cannot be done using a rigid cystoscope. The flexible cystoscope is also less painful for the patient, provides full bladder inspection with one optical instrument, and is invaluable for cases in which lithotomy position cannot be achieved (e.g., frozen pelvis, limb deformities, or joint diseases). Figure 3-5 shows the correct way to hold the flexible cystoscope with one hand while the other hand inserts the scope into the patient’s urethra. The major disadvantage of the flexible cystoscope, however, is the limited irrigation flow port that impairs the visualization process. This is even more impaired with the use of working instruments through the same port. Furthermore, the use of working instruments limits the deflection mechanism.
The advance of videoendoscopy ( Fig. 3-6 ) has improved the cystoscopy procedure with more comfortable position for the examiner, less chance of soiling and contamination to the operating team, improved teaching techniques, and the possibility of video recording. The camera is attached to the lens and the image viewed on a monitor. When this facility is used in a clinical setting, patients can watch the important cystoscopic findings and become more aware of their conditions. In addition, important findings can be documented with still pictures or video footage.