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During gynecologic surgery, the lower urinary tract may be injured. Therefore, diagnostic cystoscopic evaluation is typically warranted following procedures in which the bladder and ureters have been placed at risk. Additionally, operative cystoscopy allows the passage of ureteral stents, lesion biopsy, and foreign-body removal. Of these, ureteral stenting may be indicated to assess ureteral patency following gynecologic surgery or to delineate the ureter's course in cases with abnormal pelvic anatomy.

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Rigid and flexible cystoscopes are available, although in gynecology, a rigid scope is typically used. A cystoscope is composed of an outer sheath, a bridge, and an endoscope. The sheath contains one port for fluid infusion and a second port for fluid egress. For office cystoscopy, a sheath measuring 17 French affords greater comfort, whereas for operative cases, a 21 French or wider diameter cystoscope is preferred to allow rapid infusion of fluids. The sheath's end is sharp, and in cases in which the urethral meatus is narrow, an obturator can be placed inside the sheath to permit smooth introduction of the sheath and is then removed to insert the endoscope. The bridge attaches to the proximal portion of the sheath and allows coupling between the endoscope and sheath.

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Several viewing angles are available and include 0-, 30-, and 70-degree optical views (Fig. 43-1.1). 0-degree endoscopes are used for urethroscopy. For cystoscopy, a 70-degree endoscope is superior in providing the most comprehensive view of the lateral, anterior, and posterior walls; trigone; and ureteral orifices. To achieve a comparable view, a 30-degree endoscope requires additional manipulation. However, a 30-degree endoscope does offer advantages and allows surgeons greater flexibility as it can be used for either urethroscopy or cystoscopy during a given case. For operative cystoscopic cases in which instruments are passed down the sheath, a 30-degree endoscope must be used because with 0- and 70-degree endoscopes, operative instruments lie outside the field of view.

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Preoperative

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Patient Evaluation

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A significant incidence of bacteruria follows cystoscopy. Thus, prior to office cystoscopy, urinary tract infection should be excluded.

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Consent

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If performed properly, complications of diagnostic cystoscopy are rare. Of these, infection is the most common.

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Patient Preparation

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Although evidence-based data are lacking for its use, oral antibiotic prophylaxis is commonly given postoperatively to cover common urinary tract pathogens.

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Intraoperative

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Surgical Steps

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1 Anesthesia and Patient Positioning
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Cystoscopy may be performed in any lithotomy position with the legs positioned in stirrups. For office cystoscopy, 2-percent lidocaine jelly is instilled into the urethra 5 to 10 minutes prior to cystoscope insertion. For operative procedures, an additional 50 mL of 4-percent lidocaine solution is instilled ...

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