Cystourethroscopy is one of the most common procedures performed by a urologic surgeon. It allows for direct visualization of the urethra, urethral sphincter, prostate, bladder, and ureteral orifices. There are various indications to perform a cystoscopy, and it can be performed as a simple office procedure or as a procedure in the operating room with the patient under general anesthesia. This activity describes the indications, contraindications of cystoscopy, and highlights the role of the interprofessional team in managing patients with urological problems.
Cystoscopy and ureteroscopy are common procedures performed by a urologist to look inside the urinary tract. A urologist is a doctor who specializes in urinary tract problems.
Cystoscopy – A cystoscopy uses a cystoscope to look inside the urethra and bladder. A cystoscope is a long, thin optical instrument with an eyepiece at one end, a rigid or flexible tube in the middle, and a tiny lens and light at the other end of the tube. By looking through the cystoscope, the urologist can see detailed images of the lining of the urethra and bladder. The urethra and bladder are part of the urinary tract.
Ureteroscopy – Ureteroscopy uses a ureteroscope to look inside the ureters and kidneys. Like a cystoscope, a ureteroscope has an eyepiece at one end, a rigid or flexible tube in the middle, and a tiny lens and light at the other end of the tube. However, a ureteroscope is longer and thinner than a cystoscope so the urologist can see detailed images of the lining of the ureters and kidneys. The ureters and kidneys are also part of the urinary tract.
What is the urinary tract and how does it work?
The urinary tract is the body’s drainage system for removing urine, which is composed of wastes and extra fluid. In order for normal urination to occur, all body parts in the urinary tract need to work together in the correct order.
- Kidneys – The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the spine. Every day, the kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine. The kidneys work around the clock; a person does not control what they do.
- Ureters – Ureters are the thin tubes of muscle—one on each side of the bladder—that carry urine from each of the kidneys to the bladder.
- Bladder – The bladder, located in the pelvis between the pelvic bones, is a hollow, muscular, balloon-shaped organ that expands as it fills with urine. Although a person does not control kidney function, a person does control when the bladder empties. Bladder emptying is known as urination. The bladder stores urine until the person finds an appropriate time and place to urinate. A normal bladder acts like a reservoir and can hold 1.5 to 2 cups of urine. How often a person needs to urinate depends on how quickly the kidneys produce the urine that fills the bladder. The muscles of the bladder wall remain relaxed while the bladder fills with urine. As the bladder fills to capacity, signals sent to the brain tell a person to find a toilet soon. During urination, the bladder empties through the urethra, located at the bottom of the bladder. Three sets of muscles work together like a dam, keeping urine in the bladder.
The first set is the muscles of the urethra itself. The area where the urethra joins the bladder is the bladder neck. The bladder neck, composed of the second set of muscles known as the internal sphincter, helps urine stay in the bladder. The third set of muscles in the pelvic floor muscles also referred to as the external sphincter, which surrounds and supports the urethra.
To urinate, the brain signals the muscular bladder wall to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincters to relax. As the sphincters relax, urine exits the bladder through the urethra.
Why is a cystoscopy or ureteroscopy performed?
A urologist performs a cystoscopy or ureteroscopy to find the cause of, and sometimes treat, urinary tract problems.
Cystoscopy. A urologist performs a cystoscopy to find the cause of urinary tract problems such as
- frequent urinary tract infections (UTIs)
- hematuria—blood in the urine
- urinary frequency—urination eight or more times a day
- urinary urgency—the inability to delay urination
- urinary retention—the inability to empty the bladder completely
- urinary incontinence—the accidental loss of urine
- pain or burning before, during, or after urination
- trouble starting urination, completing urination, or both
- abnormal cells, such as cancer cells, found in a urine sample
During a cystoscopy, a urologist can see
- stones—solid pieces of material in the bladder that may have formed in the kidneys or in the bladder when substances that are normally in the urine become highly concentrated.
- abnormal tissue, polyps, tumors, or cancer in the urethra or bladder.
- stricture, a narrowing of the urethra. Stricture can be a sign of an enlarged prostate in men or of scar tissue in the urethra.
During a cystoscopy, a urologist can treat problems such as bleeding in the bladder and blockage in the urethra. A urologist may also use cystoscopy to
- remove a stone in the bladder or urethra.
- remove or treat abnormal tissue, polyps, and some types of tumors.
- take small pieces of urethral or bladder tissue for examination with a microscope—a procedure called a biopsy.
- inject material into the wall of the urethra to treat urinary leakage.
- inject medication into the bladder to treat urinary leakage.
- obtain urine samples from the ureters.
- perform retrograde pyelography—an x-ray procedure in which a urologist injects a special dye, called contrast medium, into a ureter to the kidney to create images of urinary flow. The test can show causes of obstruction, such as kidney stones and tumors.
- remove a stent that was placed in the ureter after a ureteroscopy with biopsy or stone removal. A stent is a small, soft tube.
Ureteroscopy. In addition to the causes of urinary tract problems he or she can find with a cystoscope, a urologist performs a ureteroscopy to find the cause of urine blockage in a ureter or to evaluate other abnormalities inside the ureters or kidneys.
During a ureteroscopy, a urologist can see
- a stone in a ureter or kidney
- abnormal tissue, polyps, tumors, or cancer in a ureter or in the lining of a kidney
During a ureteroscopy, a urologist can treat problems such as urine blockage in a ureter. The urologist can also
- remove a stone from a ureter or kidney
- remove or treat abnormal tissue, polyps, and some types of tumors
- perform a biopsy of a ureter or kidney
After a ureteroscopy, the urologist may need to place a stent in a ureter to drain urine from the kidney to the bladder while swelling in the ureter goes away. The stent, which is completely inside the body, may cause some discomfort in the kidney or bladder area. The discomfort is generally mild. The stent may be left in the ureter for a few days to a week or more. The urologist may need to perform a cystoscopy to remove the stent in the ureter.
How does a patient prepare for a cystoscopy or ureteroscopy?
In many cases, a patient does not need special preparations for a cystoscopy. A health care provider may ask the patient to drink plenty of liquids before the procedure, as well as urinate immediately before the procedure.
The patient may need to give a urine sample to test for a UTI. If the patient has a UTI, the urologist may treat the infection with antibiotics before performing a cystoscopy or ureteroscopy. A health care provider will provide instructions before the cystoscopy or ureteroscopy. These instructions may include
- when to stop certain medications, such as blood thinners
- when to stop eating and drinking
- when to empty the bladder before the procedure
- arranging for a ride home after the procedure
The urologist will ask about the patient’s medical history, current prescription and over-the-counter medications, and allergies to medications, including anesthetics. The urologist will talk about which anesthetic is best for the procedure and explain what the patient can expect after the procedure.
Indications of Cystourethroscopy
There are many indications for office-based cystourethroscopy. Most office cystoscopy is performed for diagnostic purposes. One of the most common reasons for a patient to be referred to a urologist is the presence of hematuria, gross or microscopic. Gross hematuria is defined as blood in the urine that can be seen with the naked eye. Microscopic hematuria is defined as 3 or greater red blood cells per high-powered field. Another common indication for regular cystoscopy is any history of malignancy including urethral, bladder, or upper tract UCC. This is often done on a surveillance basis with intervals depending on the type of cancer. Lower urinary tract symptoms (LUTS) are another indication of cystourethroscopy. These symptoms can include obstructive voiding symptoms, irritative voiding symptoms, urinary incontinence, chronic pelvic pain syndrome, or recurrent UTIs. Any trauma in which there is a concern for injury to the lower urinary tract necessitates cystourethroscopy, as well as any bladder abnormalities discovered during imaging studies. Removal of foreign bodies, for example, if a patient has an indwelling urinary stent that requires removal, hematospermia, azoospermia, or concern for a bladder or lower urinary tract fistula are also reasons for cystourethroscopy.
Rigid cystoscopy in the operating room is indicated for more therapeutic indications. In this setting, it is possible to have fluoroscopy and perform retrograde pyelography. There is also the ability to use multiple additional instruments including resectoscopes to perform procedures such as transurethral resection of bladder tumors, transurethral resection of the prostate, direct vision internal urethrotomy, injection of Botox into the detrusor muscle, and numerous other interventions. Further discussion of these different procedures is beyond the scope of this article.
Indications include:
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Hematuria, gross or microscopic
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Surveillance/evaluation of malignancy (bladder, urethra, upper tract UCC, abnormal cytology)
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Lower Urinary Tract Symptoms (LUTS): The irritative voiding symptoms, obstructive voiding symptoms, urinary incontinence, chronic pelvic pain syndrome, recurrent UTIs
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Trauma, abnormal imaging of bladder, concern for fistula, removal of foreign body, hematospermia, azoospermia
Contraindications of Cystourethroscopy
Contraindications to cystoscopy are relatively straightforward. If there is any evidence of acute urinary infection, the procedure would be contraindicated as it could put the patient at risk for developing sepsis from a urinary source. For this reason, it is recommended to obtain a urinalysis 5 to 7 days before any scheduled cystoscopy procedure. If a UTI is identified, the patient should be treated appropriately prior to the procedure. A contraindication for flexible cystoscopy in the office would be any intolerance to pain or discomfort with the procedure. This may necessitate a trip to the operating room (OR) for cystoscopy under anesthesia. A urethral stricture can sometimes make cystoscopy impossible, as the scope will not be able to pass.
Equipment
Cystoscopes come in both flexible and rigid options. They are manufactured in a variety of sizes expressed in French (Fr) gauge. A 1 French instrument has a circumference of one-third of a millimeter. Rigid cystoscopes use the Hopkins rod-lens optical system which has the advantage of providing improved optical clarity when compared with the fiberoptic bundles used in flexible cystoscopes. However, this is becoming less noticeable with the adoption of flexible digital cystoscopes. Visualization is also enhanced in the rigid model due to the greater irrigant flow rate. Rigid scopes also have larger working channels which allow for a wider variety of instruments that can be used with them. The advantage of the flexible scopes is that they are smaller in size and provide greater patient comfort, which is why they are used for routine flexible cystourethroscopy in the office setting. The flexible endoscope can also be passed easily with a patient in the supine position; whereas, in rigid cystoscopy, the patient must be in the frog-leg or lithotomy position. Another excellent advantage is the movement of the tip of the flexible cystoscope which allows for easier inspection of the bladder and negotiating around an elevated bladder neck or large median lobe of the prostate. With a rigid cystoscope, it is necessary to use multiple lenses with varying degrees of angle to achieve proper inspection of the entire bladder.
Rigid Cystourethroscopy
Rigid cystoscopes are produced in sets that consist of an optical lens, bridge, sheath, and obturator. These configurations are different depending on the vendor. Vendors that produce these sets include Karl Storz, Olympus, Gyrus/ACMI, and Wolf.
The optical lenses come with tip angles that range from 0 to 120 degrees. The most common lens degrees used during a typical rigid cystourethroscopy include the 30-degree lens and the 70-degree lens. The urethra is best visualized using the 0 to 12-degree lens. A 30-degree lens is most often used for therapeutic purposes. The 70 or 120-degree lens are often required to inspect the anterior and inferolateral walls, dome, and neck of the bladder.
The bridge connects the optical lens to the sheath. There are varying types of bridges. A diagnostic bridge has no working channels. Bridges used for therapeutic cases can have 1 to 2 working channels. An Albarran bridge is a specialized bridge that contains a lever that can deflect wires and catheters that pass through the working channel to facilitate ureteral orifice cannulation. This can sometimes be required in patients that have elevated bladder necks or large median lobes of the prostate. It can also be helpful when attempting to cannulate a transplanted ureter or ureters entering the bladder at odd locations.
The cystourethroscopy sheaths come in a variety of sizes. Sheaths can range in size from 15/17 Fr to 25 Fr. Smaller sheaths are ideal for diagnostic cystoscopy and cause less trauma. Larger sheaths are used for therapeutic procedures as they allow more irrigant flow and larger working channels for instruments. Each sheath has an obturator that blunts the distal end of the sheath for passage into the bladder without visual assistance. Blind endoscope passage is generally only recommended to be performed in a female.
Flexible Cystourethroscopy
Flexible cystoscopes range between 16 and 17 Fr. There are differences in all models with regard to their dip deflection, the direction of view, the field of view, working channel size, illumination and optics. Vendors that manufacture these scopes include Karl Storz, Olympus, and Wolf. Most models provide a field of view of approximately 120 degrees and do not have an offset lens. Tip deflection ranges between 120 to 210 degrees and can either be intuitive (same direction as lever deflection) or counterintuitive (opposite direction of lever deflection). The irrigation and instruments have to pass through the same working channel. This necessitates discontinuing the irrigation to pass a flexible grasper through the scope, for example. However, adaptors have been developed to allow the irrigation to be connected while passing instruments. The amount of irrigation is significantly decreased with the instrument passing through the channel. Photodynamic and narrow-band imaging capabilities are available in some models.
Both Karl Storz and Olympus produce fiberoptic and digital models. Digital scopes are now available in high definition (1920 x 1080 pixels) and standard definition (720 x 480 pixels). These scopes do not require focusing or white balancing. Studies have been performed to compare the resolution, contrast evaluation, depth of field, color representation and illumination of fiberoptic, standard, and high-definition flexible cystoscopes. One study demonstrated that the high definition scope had significantly higher resolution and depth of field, with slightly improved color representation and no difference in contrast evaluation. Illumination was significantly better in the fiberoptic models when compared to digital[rx]. A randomized study performed by Okhunov et al. in 2009 compared optics, performance, and durability of fiberoptic and standard-definition digital scopes. This showed a trend of surgeon optical ranking in favor of digital scopes. There was no difference in durability between models[rx].
Irrigant material depends on the situation, but sterile water or normal saline is most commonly used. Nonionic irrigants (water, glycine, sorbitol) are required when using monopolar electrocautery. Isotonic irrigating fluids (normal saline/lactated ringers) can be used when using bipolar electrocautery instruments. This offers the advantage of eliminating the risk of electrolyte disturbance from systemic uptakes, such as Transurethral Resection of the Prostate (TURP) syndrome. Sterile water should be used when bladder samples are collected for cytologic evaluation.
Personnel
The personnel required for cystoscopy depends on if it is being performed in the office or the operating room. A simple office cystoscopy requires minimal personnel as there is no anesthesia. It is beneficial to have a nurse as an assistant, especially if doing procedures that can be performed more smoothly with an extra set of hands. For example, if performing a cystoscopy to remove an indwelling ureteral stent, it can be beneficial for the surgeon to operate the cystoscope and have his/her assistant operate the flexible grasper. This is not necessary, however. When performing cystoscopy in the operating room, it is necessary to have anesthesia staff as well as circulating nurses and possibly scrub techs for assistance.
Preparation
Informed consent must be obtained before the procedure. A urinalysis and urine culture is commonly performed before cystoscopy. The AUA best practice policy statement on antimicrobial prophylaxis does not recommend antibiotic administration for routine diagnostic cystoscopy in the absence of patient-related risk factors[4]. The risk factors that require antimicrobial prophylaxis include:
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Advanced age
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Anatomic anomalies of the urinary tract
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Chronic corticosteroid use
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Colonized endogenous or exogenous material
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Distant coexistent infection
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Immunodeficiency
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Poor nutritional status
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Prolonged coexistent infection
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Smoking history
Prophylaxis lasting less than 24 hours with either a fluoroquinolone or trimethoprim-sulfamethoxazole is recommended for therapeutic procedures. Two-line alternatives include an aminoglycoside with or without ampicillin, a first or second-generation cephalosporin, or amoxicillin/clavulanate[rx].
Prior to the procedure, the skin should be prepared with an antiseptic agent. Both chlorhexidine gluconate and alcohol-based solutions can be damaging to mucous membranes and are therefore not recommended for use on the genitalia. Aqueous-based iodophor-containing products such as Betadine are safe on all skin surfaces and are most commonly used for preparation[rx].
After application of the antiseptic agent, a lubricating gel is injected into the urethra. A plain or lidocaine gel may be used. One meta-analysis of four randomized trials found that patients who received lidocaine gel were 1.7 times less likely to experience moderate to severe pain during the procedure[rx].
Technique
Before inserting the cystourethroscopy, the external genitalia is inspected for any lesions or anatomic abnormalities. In women, rigid cystourethroscopy insertion can be implemented using a sheath obturator. The scope will need to be directed anteriorly as it is advanced into the bladder. A flexible scope can be inserted similarly to a Foley catheter, with active deflection being used as needed.
In men, the penis is placed on the maximal stretch to straighten the urethra. When a rigid scope is passed, the penis is grasped with 5 fingers of the surgeon’s non-dominant hand. When a flexible scope is passed, the penis is pinched between the third and fourth digits of the non-dominant hand, allowing the thumb and index finger to be free to help guide the scope into the urethra. The penis should be angled 45 to 90 degrees relative to the abdominal wall as the scope passes through the anterior urethra. Once beyond the membranous urethra, the scope is directed anteriorly to enter the bladder. This is accomplished with active upward flexion when using the flexible scope and by dropping the distal end of the scope toward the operative table when using a rigid scope.
The lower urinary tract is systematically evaluated as the scope is advanced, with maximal irrigation running. The penile and bulbar urethra should be evaluated for any sign of stricture. The patient should be encouraged to relax when the scope is advanced through the membranous urethra. Once the scope is in the prostatic urethra, the verumontanum and utricle can be identified posteriorly. The size of the prostatic lobe, length of the prostatic urethra and presence of a median lobe or bladder neck obstruction should be noted.
Upon entering the bladder, the mucosa should be carefully inspected. When using a rigid cystoscope, generally a 30-degree scope is used initially to inspect as much of the bladder as can be visualized. The floor and trigone of the bladder are initially inspected, with the identification of the ureteral orifices, noting their location and number. Efflux from each ureter should be observed for the presence of blood. The remainder of the bladder should be inspected for bladder stones, trabeculation, bladder diverticula, erythematous patches or papillary/sessile bladder lesions. The surgeon can visualize the lateral walls by rotating the cystoscope and keeping the camera orientation fixed. The dome and posterolateral walls of the bladder are inspected using a 70 or 120-degree lens on a rigid scope, or by retroflection on a flexible scope. Prior to removing the scope, the bladder should be drained.
How is a cystoscopy or ureteroscopy performed?
A urologist performs a cystoscopy or ureteroscopy during an office visit or in an outpatient center or a hospital. For some patients, the urologist will apply an anesthetic gel around the urethral opening or inject a local anesthetic into the urethra. Some patients may require sedation or general anesthesia. The urologist often gives patients sedatives and general anesthesia for a
- ureteroscopy
- cystoscopy with biopsy
- cystoscopy to inject material into the wall of the urethra
- cystoscopy to inject medication into the bladder
For sedation and general anesthesia, a nurse or technician places an intravenous (IV) needle in a vein in the arm or hand to give the medication. Sedation helps the patient relax and be comfortable. General anesthesia puts the patient into a deep sleep during the procedure. The medical staff will monitor the patient’s vital signs and try to make him or her as comfortable as possible. During both procedures, a woman will lie on her back with the knees up and spread apart. During a cystoscopy, a man can lie on his back or be in a sitting position.
After the anesthetic has taken effect, the urologist gently inserts the tip of the cystoscope or ureteroscope into the urethra and slowly glides it through the urethra and into the bladder. A sterile liquid—water or saltwater, called saline—flows through the cystoscope or ureteroscope to slowly fill the bladder and stretch it so the urologist has a better view of the bladder wall. As the bladder fills with liquid, the patient may feel some discomfort and the urge to urinate. The urologist may remove some of the liquid from the bladder during the procedure. As soon as the procedure is over, the urologist may remove the liquid from the bladder or the patient may empty the bladder.
For a cystoscopy, the urologist examines the lining of the urethra as he or she passes the cystoscope into the bladder. The urologist then examines the lining of the bladder. The urologist can insert small instruments through the cystoscope to treat problems in the urethra and bladder or perform a biopsy.
For a ureteroscopy, the urologist passes the ureteroscope through the bladder and into a ureter. The urologist then examines the lining of the ureter. He or she may pass the ureteroscope all the way up into the kidney. The urologist can insert small instruments through the ureteroscope to treat problems in the ureter or kidney or perform a biopsy.
When a urologist performs a cystoscopy or a ureteroscopy to make a diagnosis, both procedures—including preparation—take 15 to 30 minutes. The time may be longer if the urologist removes a stone in the bladder or a ureter or if he or she performs a biopsy.
What can a patient expect after a cystoscopy or ureteroscopy?
After a cystoscopy or ureteroscopy, a patient may
- have a mild burning feeling when urinating
- see small amounts of blood in the urine
- have mild discomfort in the bladder area or kidney area when urinating
- need to urinate more frequently or urgently
These problems should not last more than 24 hours. The patient should tell a health care provider right away if bleeding or pain is severe or if problems last more than a day.
The health care provider may recommend that the patient
- drink 16 ounces of water each hour for 2 hours after the procedure
- take a warm bath to relieve the burning feeling
- hold a warm, damp washcloth over the urethral opening to relieve discomfort
- take an over-the-counter pain reliever
The health care provider may prescribe an antibiotic to take for 1 or 2 days to prevent an infection. A patient should report any signs of infection—including severe pain, chills, or fever—right away to the health care provider.
Most patients go home the same day as the procedure. Recovery depends on the type of anesthesia. A patient who receives only a local anesthetic can go home immediately. A patient who receives general anesthesia may have to wait 1 to 4 hours before going home. A health care provider usually asks the patient to urinate before leaving. In some cases, the patient may need to stay overnight in the hospital. A health care provider will provide discharge instructions for rest, driving, and physical activities after the procedure.
What are the risks of cystoscopy and ureteroscopy?
The risks of cystoscopy and ureteroscopy include
- UTIs
- abnormal bleeding
- abdominal pain
- a burning feeling or pain during urination
- injury to the urethra, bladder, or ureters
- urethral narrowing due to scar tissue formation
- the inability to urinate due to swelling of surrounding tissues
- complications from anesthesia
References
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