Historical Perspective
The first description of an endoscopic technique for evaluating the female urethra and bladder involved a cumbersome device developed by Bozzini in 1805. Visibility using this device was limited by the poor illumination provided by a candle reflected through a funnel in the urethra and the tendency of the operator to burn himself if the stand was tilted to provide a better view. Nineteenth-century refinements to this crude instrument included the addition of a surrounding cannula and, later, a lens system to provide magnification of the field of view. The greatest drawback of the early cystoscopes remained poor illumination, despite efforts to overcome the problem using reflective mirrors, an alcohol lamp, a platinum wire loop, and, finally, an incandescent light source. Even with these improvements in the cystoscope and in illumination, visualization remained poor without bladder distention. Consequently, by the end of the nineteenth century, cystoscopy was merely an adjunct to the established practice of urethral dilation and bimanual palpation of the bladder.
changed the role of cystoscopy by developing a technique that provided adequate bladder distention. The Kelly cystoscope, essentially a hollow tube without a lens, was not innovative, but Kelly’s technique was. The cystoscope was introduced using an obturator, with the patient in the knee-chest position. The negative intra-abdominal pressure created in this position allowed air to distend the bladder when the cystoscope was introduced. A head mirror was used to reflect an electric light into the bladder for illumination (see Fig. 1.15 ). The technique was simple but provided an excellent view. Its simplicity dramatically enhanced the accessibility of cystoscopy to all physicians. Moreover, Kelly’s fame as a genitourinary surgeon, and as the founder of the Johns Hopkins Hospital residency training program in gynecology, the first in the nation, established cystoscopy as a gynecologic technique.
The twentieth century provided many innovations in cystoscopy. introduced a fiberoptic telescope and, later, a rod lens system, which dramatically improved light transmission and resolution. Their rod lens design is the system used in today’s rigid cystoscopes. Replacement of the air chamber with a series of glass rods with optically finished ends, separated by intervening air spaces, provides a wider viewing field and permits a change in the viewing angle. The innovation of angled telescopes improved the extent of visualization and facilitated more invasive procedures. Increasingly complex instruments were developed that allowed operative procedures through a cystoscope. General surgeons began to embrace these techniques and, gradually, developed the subspecialty of urology around this new technology. The development of the subspecialty of urology coincided with changes in gynecology, including amalgamation with obstetrics to create a single training program that de-emphasized cystoscopy in gynecologic training. Gynecologists gradually became less skilled in the technique, while urologists continued to develop it.
, the “father of urogynecology,” reintroduced cystoscopy to the field of gynecology with the development of the Robertson urethroscope. He addressed the deficiencies of the cystoscope for viewing the urethra by applying the rod lens technology of the Hopkins cystoscope to a shorter straight-on telescope with a nonfenestrated sheath designed specifically for viewing the urethra. He also outlined a technique―dynamic urethroscopy―for evaluating incontinent women by using the Robertson urethroscope. Dynamic urethroscopy offered a simple office procedure that considerably improved the diagnostic evaluation of the lower urinary tract compared with the alternatives of the time.
The most recent development in cystoscopy is the flexible cystoscope. A flexible cystoscope takes advantage of the flexibility of the fiberoptic lens system to create a cystoscope that bends, thereby increasing the range of the field of view. Some authors report an improved view of the bladder neck using a flexible fiber cystoscope, whereas others advocate flexible cystoscopy to limit the necessary instrumentation and improve patient tolerance.
Indications
Cystourethroscopy is an invaluable procedure for today’s urogynecologist. It has both diagnostic and operative indications. Diagnostic indications include hematuria, lower urinary tract symptoms, urinary incontinence, urethral diverticula, and urogenital fistulas.
The differential diagnosis of hematuria is extensive but falls into conditions that are primarily renal or postrenal in origin. Endoscopy is useful in the diagnosis of postrenal conditions, including neoplasms of the bladder and urethra, urethral polyps, chronic cystitis, recurrent cystitis, interstitial cystitis, urolithiasis, and foreign bodies.
The differential diagnosis for lower urinary tract symptoms is extensive, including many nebulous conditions. Possible causes include acute cystitis, chronic cystitis, radiation cystitis, urethral pain syndrome, urethral diverticula, urethritis, and interstitial cystitis. Other conditions that may cause similar symptoms include detrusor overactivity, urolithiasis, suture or mesh in the bladder or urethra, partial urinary retention, and moderate to severe pelvic organ prolapse. Cystourethroscopy is indicated when the presenting symptoms strongly suggest a diagnosis of urethral diverticulum, interstitial cystitis, urolithiasis, foreign body, or tumor, as well as for patients who do not respond to initial therapy. Endoscopy should be avoided in the presence of an active urinary tract infection.
There is general agreement that cystoscopy is indicated for patients complaining of persistent incontinence or voiding symptoms following incontinence surgery, but there is less agreement about the role of cystoscopy in the baseline evaluation of patients with urinary incontinence. The refinement of urodynamic evaluation since the 1980s has demonstrated its superiority for diagnosing the common causes of urinary incontinence such as urodynamic stress incontinence and detrusor overactivity. While urodynamic testing excels at providing an objective assessment of lower urinary tract function, it provides little information about lower urinary tract anatomy. Cystourethroscopy contributes an anatomic assessment of the urethra and bladder that is not achieved with urodynamic tests alone. Anatomic abnormalities, such as urethral diverticula, urogenital fistulas, and intravesical foreign bodies causing detrusor overactivity, might be suspected based on history or urodynamic tests but require an anatomic assessment for confirmation. Cystourethroscopy also can reveal unsuspected neoplasia in the incontinent patient.
For many urogynecologists, cystourethroscopy also has a role in the diagnosis of intrinsic sphincteric deficiency, a condition that has no standardized diagnostic criteria. Some advocate a single urodynamic parameter to make the diagnosis. In the absence of validated standard criteria for diagnosing intrinsic sphincteric deficiency, we advocate combining clinical measures of severity, urodynamic evidence of poor urethral resistance, and an anatomic evaluation of urethral coaptation. Cystourethroscopy is perhaps the simplest way to achieve such an anatomic evaluation of the urethrovesical junction (UVJ).
Operative cystourethroscopy in the female lower urinary tract includes both minor procedures that can be performed through an operative cystoscope in an ambulatory setting and the use of a cystoscope to facilitate other operations. In the former category, cystourethroscopy is commonly used to perform urethral bulking injections and intravesical botulinum toxin type A injections. In the latter category, intraoperative cystoscopy is an important adjuvant to mid-urethral sling procedures and facilitates the surgical repair of urinary tract fistula and urethral diverticula. It is also invaluable to evaluate the ureters and bladder mucosa for inadvertent damage at the time of surgery and to ensure the safe placement of ureteral catheters and suprapubic catheters.
Instrumentation
Rigid Cystoscope
There are three components to the rigid cystoscope: the telescope, the bridge, and the sheath ( Fig. 12.1 ). Each component serves a distinct function and is available with various options to facilitate its role under different circumstances.
The telescope transmits light to the bladder cavity and an image to the viewer. Telescopes designed for cystoscopy are available with several viewing angles including 0 degrees (straight), 30 degrees (forward-oblique), 70 degrees (lateral), and 120 degrees (retro-view). The different angles facilitate the inspection of the entire bladder wall. Although the 0-degree lens is ideal for adequate urethroscopy, it is insufficient for cystoscopy. The 30-degree lens provides the best view of the bladder base and posterior wall, and the 70-degree lens permits inspection of the anterior and lateral walls. The retro-view of the 120-degree lens is not usually necessary for cystoscopy of the female bladder but can be useful for evaluating the urethral opening into the bladder. For many applications, a single telescope often is preferable. In diagnostic cystoscopy, the 30-degree telescope usually is sufficient, although a 70-degree telescope may be required in the presence of elevation of the UVJ. For operative cystoscopy, the 70-degree telescope often is preferable. The angled telescopes have a field marker, visible as a blackened notch at the outside of the visual field opposite the angle of deflection, that helps facilitate orientation.
The cystoscope sheath provides a vehicle for introducing the telescope and distending medium into the vesical cavity. Sheaths are available in various calibers, ranging from 17 to 28 French for use in adults and smaller calibers for use in pediatric patients. When placed within the sheath, the telescope, which measures 15 French, only partially fills the lumen, leaving an irrigation/working channel. The smaller sheath is better tolerated for diagnostic procedures, whereas the larger-caliber sheaths provide space to accommodate instruments in the irrigation/working channel. The proximal end of the sheath has two irrigating ports: one for introduction of the distending medium and another for removal of the medium. The distal end of the cystoscope sheath is fenestrated to permit use of instrumentation in the angled field of view. It is also beveled, opposite the fenestrae, to increase the comfort of introduction of the cystoscope into the urethra. Bevels increase with the diameter of the cystoscope, and larger sheaths may require an obturator for atraumatic placement.
The bridge serves as a connector between the telescope and sheath and forms a watertight seal with both. It may also have one or two ports for the introduction of instruments into the irrigation/working channel. The Albarran bridge is a variation that has a deflector mechanism at the end of an inner sheath ( Fig. 12.1 ). When placed in the cystoscope sheath, the deflector mechanism is located at the distal end of the inner sheath within the fenestra of the outer sheath. In this location, elevation of the deflector mechanism assists the manipulation of instruments and ureteral catheters within the field of view.
Rigid Urethroscope
The rigid urethroscope is a modification of the cystoscope designed exclusively for evaluation of the urethra ( Fig. 12.2 ). Because it is primarily a diagnostic instrument, it does not have a bridge. The telescope is shorter and has a 0-degree viewing angle, which provides a circumferential view of the urethral lumen because the mucosa in front of the urethroscope is distended by the distention medium. The 0-degree lens is essential for adequate urethroscopy.
The urethroscope sheath is designed to maximize distention of the urethral lumen. The proximal end of the sheath has a single irrigating port, and the telescope only partially fills the sheath, leaving space for the irrigant to flow around it. Sheaths are available in 15- and 24-French calibers. If tolerated, the larger sheath is useful because it provides the best view of the urethral lumen by providing more rapid fluid flow for maximal distention.
Flexible Cystoscope
Unlike the rigid cystoscope, the flexible cystoscope combines the optical systems and irrigation-working channel in a single unit. The coated tip is 15 to 18 French in diameter and 6 to 7 cm in length; the working unit makes up half the length. The optical system consists of a single image-bearing fiberoptic bundle and two light-bearing fiberoptic bundles. The fibers of these bundles are coated, parallel coherent optical fibers that transmit light even when bent. The coating of the fibers results in a somewhat granular image, and the delicate 5- to 10-μm diameter makes them susceptible to damage. Gentle handling is essential to good visualization and instrument longevity. The flexibility of the fibers permits incorporation of a distal tip-deflecting mechanism, controlled by a lever at the eyepiece that will deflect the tip 290 degrees in a single plane. The optical fibers are fitted to a lens system that magnifies and focuses the image. A focusing knob is located just distal to the eyepiece. The irrigation-working port enters the instrument at the eyepiece opposite the deflecting mechanism.
Many urologists prefer the flexible cystoscope because of improved patient comfort, especially in male patients. The absence of a prostate and the short length of the female urethra make rigid cystoscopy well tolerated by most women. This may offset any perceived advantage of flexible cystoscopy in female patients. Moreover, there are several disadvantages to the flexible cystoscope. The flow rate of the irrigation-working channel is approximately one-fourth that of a similar-size rigid cystoscope and is further curtailed by the passage of instruments down this channel. Some tip deflection is also lost with use of the instrument channel. In addition, because the view afforded by the flexible cystoscope is not as clear as that of a rigid cystoscope, greater operator skill is required to completely visualize the vesical cavity. There is no difference in the postprocedural morbidity compared with rigid cystourethroscopy.
Light Sources and Video Monitors
While any light source that provides adequate illumination via a fiberoptic cable is sufficient, a high-intensity (xenon) light source is recommended for the use of video monitoring or photography. The cable attaches to the telescope at the eyepiece. Light cables are usually fiberoptic, although fluid-filled cables are also available; they tend to be more expensive and more durable. Fiberoptic cables use flexible optic fibers that are comparable to those of the flexible cystoscope and are similarly prone to damage.
Although all cystoscopic procedures can be performed with direct visualization through the eyepiece, video monitoring eliminates awkward positioning required for direct visualization. It permits video documentation, which facilitates teaching, and often improves patient tolerance by providing distraction during the procedure. The video camera attaches directly to the eyepiece and should be maintained in an upright orientation. Changing the direction of view is accomplished by rotating the cystoscope without moving the camera.
Distending Media
The three types of distention media are nonconductive fluids, conductive fluids, and gases. Cystourethroscopy is feasible with carbon dioxide, but most practitioners prefer to use water or saline to distend the bladder and urethra. A liquid medium prevents the carbon dioxide from bubbling and washes away blood or debris that can limit visualization. Moreover, the bladder volumes achieved using a liquid medium more accurately approximate physiologic volumes.
The choice of liquid medium depends on the procedure for which it is to be used. For diagnostic cystourethroscopy, sterile water is an ideal medium that is readily available and inexpensive. If absorption of a large volume of fluid into the vascular space is anticipated, an osmotic solution such as normal saline should be used. Similarly, if electrocautery is to be used, a nonconducting solution, such as glycine, should be used.
If a liquid medium is used, the water is instilled via gravity through a standard intravenous infusion set. The bag should be at a height of 100 cm above the patient’s pubic symphysis to provide adequate flow.
Operative Instrumentation
A wide range of instrumentation is available for use through a cystoscope. Those most pertinent to urogynecology are grasping forceps with a rat tooth or alligator jaws, biopsy forceps, and scissors. These instruments can be obtained in semirigid or flexible varieties and come in various diameters. A flexible monopolar ball electrode is useful for electrocautery during operative cystoscopy. A specialized sheath with a mechanism to advance and retract a long needle is useful for urethral injections and intra-vesical bladder injections.
Instrument Care
Blood and debris should be removed from the equipment promptly to avoid accumulation in crevices and pitting of metal surfaces. The most common method of sterilization is immersion in a 2% activated glutaraldehyde solution (Cidex; Surgikos, Inc., Arlington, TX). Cystourethroscopic equipment should be soaked for 20 min and then transferred to a basin of sterile water until ready for use. Longer soaks shorten the life of the telescope by deteriorating the lens system and seals. If more permanent storage is desired, the scopes are cleaned with detergent and water, rinsed, and stored. Once a week, the inside and outside of the scopes are cleaned with alcohol, and super oil is used for lubrication. The irrigating ports and locking mechanisms also should be lubricated regularly.
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