This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
ABSTRACT: Cystourethroscopy can be performed for diagnostic and a few operative indications by obstetrician–gynecologists to help improve patient care. Perhaps the most important indications for cystourethroscopy are to rule out cystotomy and intravesical or intraurethral suture or mesh placement and to verify bilateral ureteral patency during or after certain gynecologic surgical procedures. The granting of privileges for cystourethroscopy and other urogynecologic procedures should be based on training, experience, and demonstrated competence. Postgraduate education, including residency training programs in obstetrics and gynecology and continuing medical education, should include education in the instrumentation, technique, and evaluation of findings of cystourethroscopy, and in the pathophysiology of diseases of the lower urinary tract.
Although many of the pioneers of cystourethroscopy, most notably Howard Kelly, were gynecologists, for decades the procedure has been performed mainly by urologists. However, cystourethroscopy can be performed for diagnostic and a few operative indications by obstetrician–gynecologists to help improve patient care. This document reviews the definition and indications for cystourethroscopy and discusses the evidence and recommendations for its use in the generalist obstetrician–gynecologist practice. situations and be prepared to respond in a professional, ethical manner to patient requests for information and procedures.
Cystoscopy is a surgical procedure in which a rigid or flexible fiberoptic endoscope is used to examine the lumen of the bladder. Urethroscopy, in which the urethral lumen is examined for urethral diseases or abnormalities, is a related procedure. For cystoscopy, the endoscope is introduced through the urethra, allowing the surgeon to visualize both the bladder and urethra, thus the term cystourethroscopy.
When performing cystourethroscopy for diagnostic indications, the surgeon should follow a technical routine in which the entire lumen of the urethra and bladder are examined systematically. The instrumentation, surgical technique, and typical findings (normal and abnormal) have been reviewed in most textbooks on urogynecology and female urology. Briefly, diagnostic cystourethroscopy is performed using sterile techniques, usually with local anesthesia, while the patient is awake and in the supine lithotomy position. It also can be performed during or after gynecologic surgery with the patient under general or regional anesthesia. The urine should be free of infection before the procedure. After sterile preparation of the urethral meatus and surrounding vulvar vestibule, 2% lidocaine jelly can be introduced into the urethra and then used as lubrication for the endoscope. Sterile water or saline is used to fill the bladder by gravity during the procedure. If electrocautery is to be performed, a nonconducting solution, such as glycine, should be used.
Depending on the indication for the cystourethroscopy, the surgeon generally starts with a 30-degree endoscope and, with the solution running, introduces it through the urethra under direct vision with or without video assistance. After partial distention of the bladder, the trigone is examined for mucosal abnormalities, lesions, or foreign bodies, as indicated. The interureteric ridge is noted above the trigone, and both ureteral orifices are visualized. If the goal is to examine for ureteral patency, 5 mL of indigo carmine can be given intravenously 10–15 minutes before the cystoscopy, followed by observation of blue-stained urine from the ureteral orifices. An in–out technique is used to circumferentially examine sections of the bladder surface, usually starting at the trigone at the 6-o'clock position, progressing clockwise around the right bladder surface to the dome at the 12-o'clock position, and then back to the trigone on the left side of the bladder (1). After the entire bladder examination is accomplished, the urethra is reexamined with removal of the endoscope. If the specific goal is to examine for lesions or for suture or mesh material in the lateral edges of the bladder, a 70-degree rigid or flexible endoscope can be reintroduced to reexamine the bladder. If the specific goal is to examine the urethra, a 0-degree or 25-degree endoscope can be used. The findings should be documented carefully, noting the systematic nature of the procedure.
Shortly before the procedure, a single dose of prophylactic antibiotics is recommended to prevent urinary tract infection or septicemia for patients at moderate or high risk of endocarditis, those who are neutropenic, and those with preoperative bacteriuria or an indwelling catheter (2, 3).
Indications and Complications
The indications for cystourethroscopy, like hysteroscopy, are both diagnostic and operative and are for symptoms and diseases related to the lower urinary tract. Diagnostic cystourethroscopy can be performed as part of an evaluation of abnormal symptoms, signs, or laboratory findings; intraoperatively during gynecologic or urogynecologic surgery to rule out bladder, urethral, or ureteral trauma; and as part of staging or surgery for gynecologic malignancy. A list of possible indications for diagnostic cystourethroscopy during gynecologic surgery is shown in the box. Operative cystoscopy usually involves the introduction of additional instruments, such as biopsy forceps or scissors, through an operating channel in the cystoscope to perform procedures or interventions. It also can be done as part of a reparative procedure to the bladder or urethra, such as vesicovaginal fistula or urethral diverticulum repair. Operative procedures generally are performed by urologists and selectively by urogynecologists and gynecologic oncologists. However, generalist obstetrician–gynecologists with special expertise and experience may perform minor operative procedures such as passage of ureteral stents and injection of urethral bulking agents.
Possible Indications for Diagnostic Cystourethroscopy During Gynecologic Surgery
- During or after surgery for pelvic organ prolapse or stress urinary incontinence to rule out cystotomy and intravesical or intraurethral suture or mesh placement
- Verification of bilateral ureteral flow during or after obstetric, gynecologic, urogynecologic, or gynecologic oncologic surgery
- Evaluation of suspected urine leak during or after laparotomy, laparoscopy, or vaginal surgery
- Verification of suprapubic catheter placement, if desired
Complications after cystourethroscopy are few. These generally involve minor pain related to the procedure and the small risk of postoperative urinary tract infection. These risks usually are negligible with use of local anesthesia and single-dose prophylactic antibiotics in patients at moderate or high risk for endocarditis. Other rare complications include perforation of the urethra or bladder or ureteral perforation if instruments or stents are placed into the ureter.
There is a small risk that the surgeon will not recognize abnormalities that are present, such as bladder lesions or mesh or sutures in the bladder. For example, in one study, urologists had less than perfect agreement between cystoscopic and histologic diagnoses when biopsies were performed for suspicious bladder lesions (4). Because routine intraoperative cystourethroscopy examines only the bladder and urethral mucosal surfaces and ureteral orifices, it does not guarantee recognition of all lower urinary tract injuries (5). Nonobstructive, partially obstructive, or late ureteral injuries may not be recognized or prevented (6–8). When cystourethroscopy is performed, there are minimal additional costs and time spent in the operating room.
Recommendations for the Generalist Obstetrician–Gynecologist
Few studies have been conducted that provide evidence-based recommendations for the use of cystourethroscopy in a general obstetric and gynecologic practice. Typically, recommendations for the use of cystourethroscopy in general obstetric and gynecologic practice imply that the physician has knowledge and competency in the instrumentation and surgical technique; can recognize normal and abnormal bladder and urethral findings; and has knowledge of pathology, diagnosis, and treatment of specific diseases of the female lower urinary tract. Specialists in female pelvic medicine and reconstructive surgery and gynecologic oncology have an expanded use of cystourethroscopy based on their additional training and resulting greater level of expertise and experience.
The granting of privileges for cystourethroscopy and other urogynecologic procedures should be based on training, experience, and demonstrated competence. Obstetrician–gynecologists who are appropriately trained in a technique, have sufficient experience performing it, and have demonstrated current clinical competence should be granted privileges accordingly.
In 1996, the Agency for Healthcare Research and Quality (then known as the Agency for Healthcare Policy and Research) provided recommendations for cystoscopy (regardless of specialty), but none of the recommendations were supported by scientific evidence from properly designed and implemented controlled trials and are no longer considered current (9). In that document, cystoscopy was recommended for the evaluation of patients who have sterile hematuria or pyuria; new-onset irritative voiding symptoms such as frequency, urgency, and urge incontinence in the absence of any reversible causes; bladder pain; recurrent cystitis; suspected presence of a foreign body; or when urodynamic testing failed to duplicate symptoms of urinary incontinence. Cystoscopy was not recommended in the basic evaluation of urinary incontinence. Likewise, routine cystoscopy in women with urinary incontinence to exclude neoplasia was not indicated because the risk of bladder lesions is less than 2% (9, 10).
Cystourethroscopy is indicated during or after some surgical procedures performed 1) to treat stress urinary incontinence and anterior vaginal prolapse, such as Burch colposuspension, paravaginal defect repair, pubovaginal sling procedure, and tension-free vaginal tape procedure; 2) to rule out intravesical placement of sutures or mesh; and 3) to verify ureteral patency. Tension-free vaginal tape and related mid-urethral sling procedures that pass through the retropubic space especially require routine cystourethroscopy to detect intraoperative bladder perforation, which occurs in 3–9% of cases (11, 12). As noted earlier, certain other surgical procedures usually performed by specialists, such as repair of vesicovaginal fistula or urethral diverticulum, routinely require cystourethroscopy to aid the surgical repair.
The issue of whether cystourethroscopy should be performed during and after gynecologic surgery to evaluate for bladder integrity and for ureteral patency remains unresolved. Intraoperative cystotomies usually are noted at the time of the injury, especially if retrograde bladder filling is used to aid recognition. However, sutures or mesh placed in the bladder or urethral lumen during surgical procedures usually are not recognized unless cystourethroscopy is performed.
Ureteral injuries are of particular concern to practicing obstetrician–gynecologists. Although the incidence of bladder and ureteral injury during common gynecologic procedures is low, wide ranges have been reported in the literature making estimation of risk difficult for individual surgical procedures. A recent systematic review of urinary tract injuries during gynecologic surgery with routine intraoperative cystourethroscopy for benign disease reported crude ureteral injury rates for laparoscopic hysterectomy with bilateral salpingo-oophorectomy of 17.3 per 1,000 procedures (95% confidence interval [CI], 0.3–66.3); for other gynecologic and urogynecologic surgical procedures, including other types of hysterectomy, the overall ureteral injury rate was 8.8 per 1,000 procedures (95% CI, 2.3–12.6) (13). The overall bladder injury rate per 1,000 laparoscopic hysterectomies with bilateral salpingo-oophorectomy was 29.2 (95% CI, 7.5–148.0); after other gynecologic and urogynecologic surgical procedures, the rate was 16.3 (95% CI, 4.3–26.6) (13).
Factors that should be considered when deciding when to perform diagnostic cystourethroscopy include complication rates associated with the procedure and the difficulty of the individual surgical case. Cystourethroscopy is indicated during or after tension-free vaginal tape procedure, Burch colposuspension, and high uterosacral ligament vaginal vault suspension. Surgical procedures such as McCall culdoplasty, colpocleisis, and perhaps certain advanced and difficult vaginal and laparoscopic procedures and hysterectomies may be indications for intraoperative diagnostic cystourethroscopy.
Cystourethroscopy is a low-risk operative procedure used to examine the lumen of the bladder and urethra. Perhaps the most important indications for cystourethroscopy are to rule out cystotomy and intravesical or intraurethral suture or mesh placement and to verify bilateral ureteral patency during or after certain gynecologic surgical procedures. The procedures that have a relatively high risk for these complications (at least 1–2%) may benefit from cystourethroscopy to help avoid additional surgery, permanent loss of renal function, fistulas, and other abnormalities. Because intraoperative cystourethroscopy examines only the bladder and urethral mucosal surfaces and ureteral orifices, it does not guarantee recognition of all lower urinary tract injuries. Nonobstructive, partially obstructive, or late ureteral or bladder injuries may not be recognized or prevented. Whether the routine use of intraoperative cystourethroscopy during hysterectomy and other gynecologic surgical procedures with a lower risk of urinary tract injury is advisable requires further study.
Postgraduate education, including residency training programs in obstetrics and gynecology and continuing medical education, should include education in the instrumentation, technique, and evaluation of findings of cystourethroscopy, and in the pathophysiology of diseases of the lower urinary tract.
- Cundiff GW, Bent AE. Endoscopic evaluation of the lower urinary tract. In: Walters MD, Karram MM, editors. Urogynecology and reconstructive pelvic surgery. 3rd ed. Philadelphia (PA): Mosby Elsevier; 2007. p. 114–23.
- Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA 1997;277:1794–801.
- Olson ES, Cookson BD. Do antimicrobials have a role in preventing septicemia following instrumentation of the urinary tract? J Hosp Infect 2000;45:85–97.
- Mitropoulos D, Kiroudi-Voulgari A, Nikolopoulos P, Manousakas T, Zervas A. Accuracy of cystoscopy in predicting histologic features of bladder lesions. J Endourol 2005;19:861–4.
- Dwyer PL, Carey MP, Rosamilia A. Suture injury to the urinary tract in urethral suspension procedures for stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1999;10:15–21.
- Councell RB, Thorp JM Jr, Sandridge DA, Hill ST. Assessments of laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc 1994;2:49–56.
- Dandolu V, Mathai E, Chatwani A, Harmanli O, Pontari M, Hernandez E. Accuracy of cystoscopy in the diagnosis of ureteral injury in benign gynecologic surgery. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:427–31.
- Gustilo-Ashby AM, Jelovsek JE, Barber MD, Yoo EH, Paraiso MF, Walters MD. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol 2006;194:1478–85.
- Agency for Health Care Policy and Research. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline, No. 2, 1996 update. AHCPR Publication No. 96-0682. Rockville (MD): AHCPR; 1996.
- Ouslander J, Leach G, Staskin D, Abelson S, Blaustein J, Morishita L, et al. Prospective evaluation of an assessment strategy for geriatric urinary incontinence. J Am Geriatr Soc 1989;37:715–24.
- Ward K, Hilton P. Prospective multicentre randomised trial of tension-free vaginal tape and colposuspension as primary treatment for stress incontinence. United Kingdom and Ireland Tension-Free Vaginal Tape Trial Group. BMJ 2002;325:67–70.
- Tamussino KF, Hanzal E, Kolle D, Ralph G, Riss PA. Tension-free vaginal tape operation: results of the Austrian registry. Austrian Urogynecology Working Group. Obstet Gynecol 2001;98:732–6.
- Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol 2006;107:1366–72.