DIAGNOSTIC AND OPERATIVE CYSTOSCOPY AND CYSTOURETHROSCOPY
Diagnostic cystoscopy often is indicated following procedures that carry risks of bladder and ureteral injury. Additionally, operative cystoscopy is within the scope of many gynecologists for the passage of ureteral catheters or stents, bladder biopsy, and foreign-body removal.
Both rigid and flexible cystoscopes are available, although in gynecology, a rigid scope offers advantages. First, viewing is enhanced by its capability for higher irrigation flow rates. Rigid scopes also have larger working channels, which allow a wider variety of instruments to pass.
Of components, a cystoscope contains an outer sheath, bridge, endoscope (optical lens), and obturator. The sheath contains one port for fluid infusion and a second port for fluid egress. For office cystoscopy, a sheath measuring 17F affords greater patient comfort. However, for operative cases, a 21F or wider-diameter sheath is preferred to allow rapid fluid infusion and easier instrument and stent passage. The end of the sheath tapers, and in women with a narrow urethral meatus, an obturator can be placed inside the sheath to create a rounded tip for smooth introduction. In selected instances, gentle dilation of the external urethral opening using narrow cervical dilators is needed prior to sheath introduction.
The bridge attaches to the proximal portion of the sheath and connects the optical lens to the sheath. A diagnostic bridge has no working channels. For therapeutic cases, a bridge that has one to two working channels is preferred. In addition, the specialized Albarran bridge contains a lever, which can deflect wires and catheters that pass through its working channels. This aids the angling needed to cannulate ureteral orifices.
Several endoscope viewing angles are available and include 0-, 30-, and 70-degree optical views (Fig. 45-1.1). Zero-degree endoscopes are used for urethroscopy. For cystoscopy, a 70-degree endoscope is superior for 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 examination. For operative cystoscopic cases in which instruments are passed down the sheath, a 30-degree endoscope should be used. With 0- and 70-degree endoscopes, operative instruments generally lie outside the optical field of view.
Cystoscopic optical views.
Direct viewing through the endoscope’s eyepiece is feasible. However, a camera system usually is coupled to the endoscope during both office and operating room cases. Images are projected to a video screen.
Prior to office cystoscopy, urinary tract infection (UTI) is excluded to avoid upper tract infection. If diagnostic cystoscopy is performed properly, complications are rare. Of these, infection is the most common and ...