Overview of Cystoscopy
In 1806, Phillip Bozzini, a German army doctor, created the first tool to look inside the human body. He called this tool the Lichtleiter. A candle and angled mirrors inside this tool allowed a doctor to look inside a person’s body. The tool was initially designed to look at the throat area, but it was soon used to examine the inside of the penis and the tube that carries urine from the bladder (urethra). This development paved the way for future advancements in medical tools that allowed doctors to examine the insides of the human body. Maximilian Carl-Friedrich Nitze and Joseph Leiter went on to develop the first fully functional diagnostic tool for viewing the bladder (cystoscope) in 1878. From then on, medical tools have continuously evolved and improved to become the devices that urologists use today.
Cystourethroscopy, a procedure where a doctor uses a device to view the urethra (the tube through which urine leaves the body) and the bladder, is a common procedure performed by urologists. This procedure also allows the doctor to view the muscle that controls the release of urine (urethral sphincter), the prostate in men, and the openings where urine flows from the kidneys to the bladder (ureteral orifices). There are several reasons why a doctor might perform a cystoscopy, and it can be done as a quick office procedure or in a surgery room under general anesthesia. There are both bendable and solid cystoscopes and a variety of tools that a doctor can use during a cystoscopy, depending on the situation. While cystoscopy is generally used for diagnosing health issues, in a limited number of cases, it can also be used for treatment purposes. Further, we will talk about the general anatomy of the urethra and bladder, when and why cystoscopy is performed, situations where cystoscopy should not be performed, the equipment used in this procedure, how the procedure is done, and potential complications of cystoscopy.
Anatomy and Physiology of Cystoscopy
When a doctor performs a cystourethroscopy, which is a procedure to look inside the urinary bladder and urethra using a tiny camera, they first see the urethra. The urethra is the tube that carries urine out of the body from the bladder.
In men, the urethra has several segments. Starting from the bladder, these are: the bladder neck (before the prostate), prostatic urethra (in the prostate), membranous urethra, and penile urethra (in the penis). The penile urethra itself has further subdivisions, including the bulbous urethra and the fossa navicularis. There is a structure called the verumontanum in the prostatic urethra. This contains openings for other parts of the male reproductive system, such as the ejaculatory ducts, which carry sperm during ejaculation.
On the other hand, the female urethra, which is shorter, about 4 cm long, does not have these segments. It just connects the bladder to an opening outside the body, the external meatus, where urine is expelled.
After the urethra, the doctor then sees the bladder neck, also called the internal sphincter. This is the entrance to the bladder, which is then revealed by the cystoscope. Once inside the bladder, when the scope is tilted downwards, it will show the trigone. This is a triangular area at the base of the bladder, bordered by the internal urethral opening and the openings for the right and left ureters – these are tubes which carry urine from the kidneys to the bladder. The ureteral orifices, or openings, are usually 2 to 3 cm apart. There is also a raised area named the interureteric ridge between the ureteral openings. This serves as a guide for the doctors to locate these openings.
Why do People Need Cystoscopy
A cystourethroscopy is a procedure done in a doctor’s office where a tiny camera is used to view the inside of the urinary tract. This is usually done to diagnose different urinary problems. Some people are advised to undergo this procedure because they have blood in their urine that can be seen with the naked eye (known as “gross hematuria”) or under a microscope (called “microscopic hematuria”). A referral to a urologist, a doctor specialized in the urinary tract, commonly happens when someone has such symptoms.
Another reason this procedure might be performed is if someone has a history of cancer in the urinary tract, such as in the urethra (the tube that allows urine to pass out of the body), bladder, or upper urinary tract. Regular cystourethroscopy can be used to monitor these patients to check if the cancer has returned or progressed.
Other symptoms that might require a cystourethroscopy examination include problems with urine flow, feelings of irritation when urinating, loss of bladder control, recurring urinary tract infections (UTIs), and chronic pelvic pain. Any indications of injury in the lower urinary tract or abnormal results from imaging studies of the bladder can also lead to a recommendation for cystourethroscopy. Additionally, the procedure might be performed to remove foreign objects like an unnecessary urinary stent or if there is concern for a hole or passage (known as a fistula) in the bladder or lower urinary tract.
Advanced versions of the cystourethroscopy procedure can be done in an operating room setting. These are usually done when the issue requires more significant treatment. During these procedures, additional instruments can be used for treatment, such as tools that allow surgeons to visualize the kidneys or remove bladder tumors. Other applications can include surgery on the prostate, injection of Botox into the bladder muscle, and many more procedures. However, these advanced procedures aren’t usually covered in typical discussions about cystourethroscopy.
Overall, cystourethroscopy can be used to diagnose and check for the following conditions or symptoms:
- Blood in the urine, whether visible to the naked eye or under a microscope
- History or suspicion of cancer in the urinary tract
- Problems with urination, like slow or disrupted urine flow, irritation during urination, urinary incontinence, chronic pelvic pain, or recurring UTIs
- Concern about injury or abnormalities in the urinary tract as seen in imaging studies, or presence of a fistula
- Presence of a foreign object that needs to be removed from the urinary tract
When a Person Should Avoid Cystoscopy
There are certain situations where performing a cystoscopy, a medical examination of the bladder, may not be safe. For example, if any signs of an active urinary infection are detected, the procedure should not be performed as it could lead to a very serious, and potentially life-threatening, full-body infection, known as sepsis, that starts in the urinary system. To avoid this, doctors usually test a person’s urine 5 to 7 days before a planned cystoscopy. If a urinary tract infection (UTI) is found, it should be treated properly before the procedure.
People who cannot tolerate pain or discomfort may also not be suitable for a cystoscopy, especially one done without general anesthesia in a doctor’s office. Because this procedure can be uncomfortable, these individuals may need to have the procedure done in an operating room under anesthesia, which puts you to sleep.
Lastly, if a person has a narrowed or blocked urinary passage, termed as a urethral stricture, a cystoscopy may not be possible because the scope may not be able to pass through the blockage or narrow area.
Equipment used for Cystoscopy
Cystoscopes, or medical instruments used to examine the inside of the bladder, come in two types: flexible and rigid. Their sizes vary and are often measured using a unit known as French (Fr), where 1 Fr is equal to approximately a third of a millimeter in circumference.
Rigid cystoscopes include a special optical system called the Hopkins rod-lens that provides clearer images than the fiberoptic bundles used in flexible cystoscopes. However, flexible digital cystoscopes are starting to bridge this gap. Rigid cystoscopes also allow for a higher flow of irrigation fluid, which improves visibility, and have larger working channels. This permits the use of a greater range of medical tools.
Flexible cystoscopes are favoured for quick examinations called cystourethroscopy because they are smaller, more comfortable for the patient, and work well with patients lying on their back. The flexible tip can bend, which makes it easier to inspect the bladder and navigate areas, such as a higher bladder neck or enlarged prostate stem. Rigid cystoscopes need multiple lenses with different angles to inspect all areas of the bladder.
Rigid Cystourethroscopy, a process of examining the urethra using a rigid cystoscope, uses sets that include a lens, bridge, sheath, and obturator. These sets come from various vendors like Karl Storz, Olympus, Gyrus/ACMI, and Wolf. The lens can tilt between 0 and 120 degrees, with the common ones being the 30-degree lens for surgical use and the 70 or 120-degree lens for inspecting different parts of the bladder. The bridge connects the lens to the sheath and can have none to two working channels, depending on its use. The sheaths come in sizes from 15/17 Fr to 25 Fr. Smaller ones are ideal for diagnostic purposes to reduce trauma, while larger ones are used for surgery.
Flexible cystoscopes are between 16 and 17 Fr and vary in their features like direction of view, field of view, working channel size, illumination, and optics. They generally offer a field of view of around 120 degrees. The maximum bending of the tip varies between 120 to 210 degrees. Passing medical tools through the working channel of the cystoscope requires halting the irrigation. Some special adaptors have been created to pass tools while maintaining irrigation, though the amount of irrigation is considerably reduced.
Digital scopes, now available in high definition, do not need focusing or white balancing. Studies have shown that high definition scopes offer significantly better resolution and depth of field, with slight improvements in colour representation, compared to fiberoptic models. However, fiberoptic scopes have better illumination.
Irrigation fluid, which aids visibility, is typically sterile water or saline solution. If monopolar electrocautery, a surgical procedure that uses electricity to cut body tissue, is used, nonionic irrigating fluids are used. When bipolar electrocautery is used, isotonic irrigating fluids like saline/lactated ringers can be used. If bladder samples need to be collected for examination, sterile water should be used.
Who is needed to perform Cystoscopy?
If a cystoscopy (a medical procedure used to examine the inside of the bladder) happens at a doctor’s office, it usually requires fewer medical helpers because this procedure doesn’t involve anesthesia (medicine that helps you sleep or numbs a part of the body). It’s handy to have a nurse present to assist in case the doctor needs an extra pair of hands. For instance, if the doctor is using the cystoscopy to take out a ureteral stent (a small tube inserted into the ureter to help urine pass from the kidney to the bladder), having a nurse on hand can make the job easier. The nurse can help by using an instrument called a flexible grasper while the doctor handles the cystoscope (a thin instrument with a light and a camera on the end).
However, it’s important to note that having a nurse isn’t always necessary. If the cystoscopy is being done in an operating room, more people are needed. This includes anesthesia staff (who administer anesthesia), circulating nurses (who help before, during, and after the surgery) and scrub techs (who assist by handing instruments to the surgeon and helping keep the operating area clean).
Preparing for Cystoscopy
Before undergoing a medical procedure like cystoscopy, it’s a requirement for doctors to acquire your informed consent. Often, urine tests are also conducted before the procedure. Interestingly, automatic administration of antibiotics, known as antimicrobial prophylaxis, isn’t always recommended for routine diagnostic cystoscopy. However, this depends on whether the patient has certain risk factors.
These risk factors can vary and may include being older, having abnormalities in the urinary tract, long-term usage of corticosteroids, colonization of endogenous or exogenous material, having another infection somewhere else in the body, weak immune system, poor nutrition, a long-standing infection, or a history of smoking. Patients with these risk factors are often given antibiotics as a precautionary measure.
For therapeutic procedures, it’s usually recommended that patients take either fluoroquinolone or trimethoprim-sulfamethoxazole for less than 24 hours as a preventive measure. However, there are alternative options available too, such as aminoglycoside with or without ampicillin, a first or second-generation cephalosporin, or amoxicillin/clavulanate.
Before the procedure, doctors prepare the skin by applying an antiseptic agent to prevent infection. Products containing alcohol or chlorhexidine gluconate can harm sensitive areas and are therefore not used for cleaning the genital area. Instead, water-based products containing iodophors like Betadine, which are safe for all skin, are usually used.
Following the application of the antiseptic, a lubricating gel is applied inside the urethra. This can be a plain gel or one with lidocaine. Some studies suggest that patients who receive lidocaine gel are less likely to experience moderate to severe pain during the procedure.
How is Cystoscopy performed
Before using a special procedure called cystourethroscopy, the doctor looks at the external parts of the reproductive system for any issues or abnormal-looking areas. In women, a cystourethroscopy can be done using a set of tools called a sheath obturator. As the doctor guides the tool into the bladder, they will have to angle it forward. A flexible tool can be placed in a similar way to a urinary catheter, with adjustments made as needed.
In men, the penis is gently straightened out to create a path for the scope. If the doctor uses a rigid scope, they hold the penis with the hand they don’t write with. If the doctor uses a flexible tool, the penis is held between the third and fourth fingers of the non-dominant hand. This frees up the thumb and first finger to guide the tool into the urethra. The penis should be held at a 45 to 90-degree angle relative to the belly as the scope is guided through the front part of the urethra. Once the tool is through the inner urethra, it is directed forward to enter the bladder. This is done by actively bending the flexible tool upwards or by lowering the end of the rigid tool towards the operating table.
The lower urinary tract is thoroughly inspected as the scope is moved forward, with maximum irrigation or fluid flow. The doctor checks the penile and bulbar urethra (the tube that carries urine from the bladder) for any signs of a narrowed passage. The patient is asked to relax when the scope is moving through the inner urethra. When the scope is in the prostate part of the urethra, specific anatomical features can be seen at the back. The size of the prostate lobe, the length of the prostate urethra, and the presence of a central lobe or bladder neck obstruction are noted.
Upon entering the bladder, the internal lining is carefully inspected. When using a rigid scope, a 30-degree scope is usually used initially to check as much of the bladder as possible. The floor and back of the bladder are inspected, with the identification of the urethral openings which lead to the kidneys, noting their location and number. The doctor will look for any indications of blood. The rest of the bladder is inspected for bladder stones, pouches of the bladder (diverticula), red patches or unusual-looking bladder lesions. The doctor can see the sides of the bladder by turning the scope and keeping the camera in a fixed position. The top and back walls of the bladder are seen using a 70 or 120-degree lens on a rigid scope or by bending the flexible scope backwards. Before taking out the scope, the bladder is drained.
Possible Complications of Cystoscopy
Complications from a cystoscopy, which is a procedure to look inside your bladder, are generally small and relatively easy to handle. Some problems that might occur after this procedure include a urinary tract infection, which is an infection in your urinary system; hematuria, or blood in your urine; dysuria, which means pain or discomfort while urinating; and injury to your bladder or urethra, the tube that carries urine from your bladder out of your body. A known possible complication is the forming of a urethral stricture due to the procedure. A urethral stricture is a narrowing of the urethra that can make it difficult to urinate.
What Else Should I Know About Cystoscopy?
A cystoscopy is a key tool used by doctors who specialize in urinary system health (urologists). It’s a pretty straightforward procedure that can usually be carried out in the doctor’s office. This tool helps in diagnosing a variety of urinary system problems and can also be used for treatment in some cases. It’s a common procedure that all urologists should be equipped to perform as part of their work.
