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Simulation

Cystoscopy

Module

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Objectives

  • Name all of the components of, correctly assemble, and manipulate a cystoscope
  • Demonstrate how to use diagnostic cystoscopy to assess for urinary tract injury during gynecologic procedures
  • Describe ureteral patency and appropriate techniques to demonstrate it

Cystoscopes

  • Cystoscopes come in 5 varieties
    • Rigid: 0°, 12°, 30°, 70°, 120°
  • Three components:
    • Sheath
    • Bridge: can be simple or specialty
    • Telescope
  • Flexible: All 3 parts in one
  • Also need light source and cable. Camera is +/-
Cystoscope set.
Assembled rigid cystoscope.
Flexible scope. 
Flexible scope.

Sheaths and Bridges

  • Sheaths
    • There are various diameter sheaths with most sets ranging from 17 to 24 Fr
    • Larger sheathes accommodate operative instruments and are rarely necessary for diagnostic cystoscopy
  • Bridges
    • There are various bridges that allow for operative procedures
    • Simple bridges are all that is necessary for diagnostic cystoscopy

Cystoscope Parts

Sheath and obturator. 
Sheath and obturator.
Standard bridges. 
Standard bridges.
Telescope. 
Telescope (optics).

Steps for Performing a Diagnostic Cystoscopy

  1. Following assembly, turn off all fluid channels except for inflow attached to your distention media
  2. With fluid flowing from the tip insert the scope atraumatically visualizing the urethral lumen
  3. A sheath with an obturator may be placed first, but is not obligatory
  4. Once in the bladder identify the dome by following the air bubbles
  5. Then inspect the bladder in a clockwise fashion ending with visualization of the trigone and the right and left ureteric orifices
    • This requires manipulating the scope to take advantage of the angle of deflection of the lens

Manipulating the Scope to Use an Angled Lens

Diagram of angled lens scope.
Orient post, then rotate to target.
  • The angled lens allows you to view lateral structures without angling the scope
  • All you have to do is rotate the scope when post (P) is right view (V) is left, etc.

Cystoscopic Applications in Gynecology

  • Evaluate the bladder for injury during gynecologic surgery
  • Confirm ureteral patency
  • Identify bladder injury or foreign material from surgical procedures
    • Identify vesicovaginal fistulas
    • Identify intra-vesical pathology

Lower Urinary Tract Injury is Not Infrequent with Gynecologic Surgery

  • Ureteral injury rates for:
    • LAVH BSO are 1.7%
    • other types of hysterectomy and urogynecologic procedures are 1%
  • Bladder injury rates for:
    • LAVH BSO are 2.9%
    • Other types of hysterectomy and urogynecologic procedures are 1.6%

Source: Gilmour et al. Obstet Gynecol 2006;107:1366–72.

When to Perform Cystoscopy?

  • When the risk of lower urinary tract injury exceeds 1.5%, the routine use of diagnostic cystoscopy is justifiable
  • Procedures whose risk exceeds this rate include:
    • Laparoscopic and robotic hysterectomy
    • Anti-incontinence procedures
    • Majority of procedures for correcting pelvic organ prolapse
  • The safety profile for intra-operative diagnostic cystoscopy is excellent

Surgical Introduction of Foreign Bodies into the Bladder

Metallic object protruding into bladder.

The metallic tip of a tack used in sacrocolpopexy protruding into the bladder dome.

Loop suture in the bladder.

A Loop of Prolene suture in the bladder.

Object in the bladder wall.

Sling arm noted in the lateral bladder wall.

Cystoscope Can Identify Free Urine Flow in Suspected Ureteral Injury Cases

  • After intravenous indigo carmine, free flow of blue-stained urine from ureteral orifice confirms patency
  • Cystoscopy cannot diagnose ureteral injury just its absence
  • There are rare times when ureteral flow can occur in the presence of injury
    • Thermal injury to a ureter
    • Partial compromise of ureteral lumen

Blue-stained urine flowing into ureteral orifice.

Other Intra-vesical Pathology Occasionally Noted

  • Transitional cell cancer
    • 90% of bladder cancer
    • Frequently multifocal

Transitional cell cancer of the bladder.

Transitional cell cancer of the bladder.

  • Bladder stones can be smooth or irregular

Smooth bladder stone.

Irregular bladder stone.

Causes of Hematuria/Irritative Symptoms

  • Interstitial cystitis
    • Inflammation with petechial hemorrhages following fill and re-fill
Interstitial cystitis before hydrodistention.
Before hydrodistention.
Interstitial cystitis before hydrodistention.
After hydrodistention.
  • Chronic lower urinary tract infection
  • Erythema and induration

Vesicovaginal Fistula

  • Classically noted in the midline above the trigone
  • Simple hole with a mature fistulous epithelial tract

Hole with a mature fistulous epithelial tract.

Summary

  • You should now have:
    • Knowledge of the components of a cystoscope and an understanding about how to use an angled lens, which are imperative before attempting cystoscopy
    • The ability to recognize bladder injury and document ureteral patency during pelvic surgery, which will
      • Aid in prompt recognition
      • Allow for early correction of injuries common to gynecologic surgery
    • Knowledge of typical lesions, which is important for recognition of pathology and appropriate therapy

Author

  • Steven Swift, M.D. Professor, Department of obstetrics and Gynecology Medical University of South Carolina

Developed in association with Advancing Female Pelvic Medicine and Reconstructive Surgery.

Version 2.0, reaffirmed August 2016