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R b t L H ll MS MD FPMRSR b t L H ll MS MD FPMRSRobert L. Holley, MSc, MD, FPMRSRobert L. Holley, MSc, MD, FPMRS

Professor of Obstetrics and GynecologyProfessor of Obstetrics and Gynecology

Division of Urogynecology and Pelvic Reconstructive SurgeryDivision of Urogynecology and Pelvic Reconstructive Surgery

Department of Obstetrics and GynecologyDepartment of Obstetrics and Gynecology

University of Alabama at Birmingham School of MedicineUniversity of Alabama at Birmingham School of Medicine

DisclosuresDisclosures

I have no conflicts of interest pertinent to this lecture.I have no conflicts of interest pertinent to this lecture.

ObjectivesObjectives

Appreciate the history associated with the Appreciate the history associated with the development of the development of the cystoscopecystoscope

Review indications for diagnostic Review indications for diagnostic cystourethroscopycystourethroscopy

Become familiar with instrumentation for Become familiar with instrumentation for diagnostic and operative cystoscopydiagnostic and operative cystoscopy

Become familiar with normal bladder/urethral Become familiar with normal bladder/urethral anatomy and identify abnormal anatomy and identify abnormal cystoscopiccystoscopicfindingsfindings

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Howard KellyHoward Kelly

Bladder distensionBladder distension

Scope introduced using an Scope introduced using an obturator, with obturator, with ptpt in kneein knee--chest chest positionposition

Negative intraNegative intra--abdominal abdominal pressure allowed air to distend pressure allowed air to distend bladderbladder

Head mirror to reflect lightHead mirror to reflect light

Greatly improved visualizationGreatly improved visualization

20th Century and Today20th Century and Today

Hopkins/Kopany 1954Hopkins/Kopany 1954

FiberFiber--optic scopeoptic scope

Rod lens system Rod lens system

Angled scopesAngled scopes

Complex instrumentationComplex instrumentation

Flexible cystoscopeFlexible cystoscope

General surgeons developed Urology subspecialtyGeneral surgeons developed Urology subspecialty

Ob/Gyn combined program decreased cystoscopy Ob/Gyn combined program decreased cystoscopy training by gynecologiststraining by gynecologists

Granting Of Privileges For Granting Of Privileges For CystourethroscopyCystourethroscopy

“Should be based on training, experience and “Should be based on training, experience and demonstrated competence”demonstrated competence”

“Implies that the physician has knowledge and “Implies that the physician has knowledge and competency in the instrumentation and surgical competency in the instrumentation and surgical co pete cy t e st u e tat o a d su g caco pete cy t e st u e tat o a d su g catechnique; can recognize normal and abnormal technique; can recognize normal and abnormal bladder and urethral findings: and has knowledge bladder and urethral findings: and has knowledge of pathology, diagnosis and treatment of specific of pathology, diagnosis and treatment of specific diseases of the lower urinary tract”diseases of the lower urinary tract”

ACOG Committee Opinion Number 372 July 2007, Reaffirmed 2010

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Indications for Diagnostic Cystoscopy Indications for Diagnostic Cystoscopy

Identify intraoperative urinary tract injury:Identify intraoperative urinary tract injury:

--Bladder perforation during TVTBladder perforation during TVT

--Ureteral patency after vault suspensionUreteral patency after vault suspension

Recurrent UTIs Recurrent UTIs

Irritative voiding symptoms in the absence of UTI, Irritative voiding symptoms in the absence of UTI, esp following prior mesh procedure:esp following prior mesh procedure:

--Bladder stonesBladder stones

--Foreign body in bladder and/or urethraForeign body in bladder and/or urethra

Diagnosis and/or treatment of interstitial cystitisDiagnosis and/or treatment of interstitial cystitis

Indications for Diagnostic Cystoscopy.... Indications for Diagnostic Cystoscopy....

VesicovaginalVesicovaginal fistulafistula

Bladder/urethral diverticulumBladder/urethral diverticulum

HematuriaHematuria

Evaluate for spread of gynecologic malignancyEvaluate for spread of gynecologic malignancy Evaluate for spread of gynecologic malignancyEvaluate for spread of gynecologic malignancy

Operative Operative cystocysto in in GynGyn::

BiopsyBiopsy

Foreign body removal (stone, mesh)Foreign body removal (stone, mesh)

IntradetrusorIntradetrusor Botox injectionsBotox injections

Urethral bulking agentsUrethral bulking agents

When to do cystoscopy?When to do cystoscopy?

When the risk of lower urinary tract injury exceeds When the risk of lower urinary tract injury exceeds 1.5%, the routine use of diagnostic cystoscopy is 1.5%, the routine use of diagnostic cystoscopy is warrantedwarranted

Procedures whose risk exceeds this rate include:Procedures whose risk exceeds this rate include:

Laparoscopic and robotic h sterectomLaparoscopic and robotic h sterectom Laparoscopic and robotic hysterectomyLaparoscopic and robotic hysterectomy

AntiAnti--incontinence procedures incontinence procedures

Majority of procedures for correcting pelvic organ Majority of procedures for correcting pelvic organ prolapseprolapse

The safety profile for intraThe safety profile for intra--operative diagnostic operative diagnostic cystoscopy is excellentcystoscopy is excellent

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Intraoperative cystoscopy....Intraoperative cystoscopy....Who needs it? Who needs it?

ACOG recommendation: all ACOG recommendation: all pt’spt’s undergoing undergoing prolapse and/or incontinence proceduresprolapse and/or incontinence procedures

Hysterectomy: depends on routeHysterectomy: depends on route

Rate of injury diagnosed with routine cystoscopy:Rate of injury diagnosed with routine cystoscopy:

Route Bladder Ureter

Abdominal 2.2-2.5% 1.7-2.2%

Vaginal 4-6% 1.4-2.6%

LSC 2-3% 0-1.5%

Gilmour, ObGyn ‘06Ibeanu, ObGyn ‘09Vakili, AJOG ‘05

Intraoperative cystoscopy....Intraoperative cystoscopy....Who needs it? Who needs it?

Other surgical/patient factors that increase risk of Other surgical/patient factors that increase risk of urinary tract injuryurinary tract injury

Prior C/S or laparotomyPrior C/S or laparotomy

EndometriosisEndometriosis EndometriosisEndometriosis

ObesityObesity

Large pelvic massLarge pelvic mass

History of pelvic radiationHistory of pelvic radiation

Instrumentation: Rigid CystoscopyInstrumentation: Rigid Cystoscopy

TelescopeTelescope

0, 12, 30 or 700, 12, 30 or 70°°

BridgeBridge

Connector for scope and sheathConnector for scope and sheath

Operative portsOperative ports

Sheath (17Sheath (17--28 French)28 French)

Vehicle for introducing scope, distending media and Vehicle for introducing scope, distending media and instruments into bladderinstruments into bladder

ObturatorObturator

Allows for atraumatic placement of larger caliber sheathsAllows for atraumatic placement of larger caliber sheaths

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Rigid Rigid CystoscopeCystoscope

Components of a rigid cystoscope

A: Telescopes. 70-degree lateral angled-view telescope (above) and a 30-degree forward-oblique telescope (below).

B: Bridges. Single-port bridge (below) and dual-port deflecting bridge (above).

C: Sheath, 22-French operating.

D: Assembled cystoscope with a diagnostic 17-French sheath.

Rigid CystoscopyRigid Cystoscopy

TelescopesTelescopes

Degree of scope Advantages Disadvantages

70- Good visualization of entire bladder wall (esp for

- Urethroscopy difficult- Diagnostic only

TVT trocar placement)- Diagnostic only

30Visualize all quadrantsOperative cysto

- None (pt discomfort if awake)

0, 12- Urethroscopy- Operative cysto (biopsy, stents, bulking)

- Poor visualization of dome, anterolateral walls

Flexible CystoscopyFlexible Cystoscopy

Useful for office diagnostic cystoscopyUseful for office diagnostic cystoscopy

All 3 parts (scope, bridge, sheath) in oneAll 3 parts (scope, bridge, sheath) in one

1515--FrenchFrench

Learning curveLearning curveea g cu eea g cu e

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Cystourethroscopy SetupCystourethroscopy Setup

Lithotomy position (high or low)Lithotomy position (high or low)

Must have:Must have:

CystoscopeCystoscope

Light sourceLight source

Can fill bladder through catheter and look through Can fill bladder through catheter and look through eyepiece on scopeeyepiece on scope

Helpful, but not necessary:Helpful, but not necessary:

Bag of cysto fluid/tubing (80cm above bladder)Bag of cysto fluid/tubing (80cm above bladder)

CameraCamera

Cystourethroscopy SetupCystourethroscopy Setup

Distension mediumDistension medium

Normal salineNormal saline

Sterile water Sterile water –– safe for electrocauterysafe for electrocautery

Antibiotic prophylaxisAntibiotic prophylaxis

Not indicated for diagnostic cysto unless urine Not indicated for diagnostic cysto unless urine dip/culture are positive (ACOG, AUA)dip/culture are positive (ACOG, AUA)

No endocarditis prophylaxis (AHA)No endocarditis prophylaxis (AHA)

Indicated for operative cysto (biopsy, etc)Indicated for operative cysto (biopsy, etc)

Single dose of Cipro 500mg or Bactrim DSSingle dose of Cipro 500mg or Bactrim DS

Operative CystoscopyOperative Cystoscopy

Numerous instruments availableNumerous instruments available

Most pertinent to Gynecologic proceduresMost pertinent to Gynecologic procedures

Grasping forcepsGrasping forceps

Biopsy forcepsBiopsy forceps

ScissorsScissors

Needle/syringe for Botox/bulking agentsNeedle/syringe for Botox/bulking agents

BugbeeBugbee monopolarmonopolar ball electrodeball electrode

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Diagnostic Cystoscopy TechniqueDiagnostic Cystoscopy Technique

3030°°/ 70/ 70°° scope w/ 17scope w/ 17--French sheathFrench sheath

2% lidocaine jelly2% lidocaine jelly

Identify air bubble for orientationIdentify air bubble for orientation

InIn--andand--out technique for 12 sweeps, out technique for 12 sweeps, a da d ou ec que o s eeps,ou ec que o s eeps,corresponding to numbers on a clockcorresponding to numbers on a clock

If If ptpt has cystocele, vaginal finger can aid in has cystocele, vaginal finger can aid in visualization of visualization of trigonetrigone/UOs/UOs

Key point: be systematic and thorough, same way Key point: be systematic and thorough, same way every time, documentationevery time, documentation

Normal Bladder MucosaNormal Bladder Mucosa

Smooth surfaceSmooth surface

Pale Pale pink/glistening whitepink/glistening white

Fine vasculatureFine vasculature Fine vasculatureFine vasculature

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TrigoneTrigone

Formed by ureteral orifices Formed by ureteral orifices and UVJand UVJ

Thicker, more granular Thicker, more granular texture than dometexture than dometexture than dometexture than dome

InteruretericInterureteric ridgeridge

UO’s usually circular/UO’s usually circular/slitlikeslitlikeopeningsopenings

Trigonal MetaplasiaTrigonal Metaplasia

Squamous metaplasia on Squamous metaplasia on histologyhistology

Thickened white membrane Thickened white membrane with villous contourwith villous contour

Common finding atCommon finding at trigonetrigone Common finding at Common finding at trigonetrigone(>50% reproductive age (>50% reproductive age women)women)

Response to irritative or Response to irritative or infectious process (chronic infectious process (chronic UTI, catheter, UTI, catheter, etcetc))

AKA AKA trigonitistrigonitis

Urethrovesical JunctionUrethrovesical Junction

Usually round or inverted Usually round or inverted horseshoe in shapehorseshoe in shape

Should be closed at rest until Should be closed at rest until cystocysto fluid opens the lumenfluid opens the lumencystocysto u d ope s t e u eu d ope s t e u e

Should close with hold/stress Should close with hold/stress maneuversmaneuvers

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Normal UrethraNormal Urethra

Pink, lush epithelium in Pink, lush epithelium in folds (estrogenfolds (estrogen--dependent)dependent)

Urethral crest may be seen Urethral crest may be seen as a posterior longitudinal as a posterior longitudinal ridgeridgeridgeridge

Walls of UVJ and urethra Walls of UVJ and urethra may not may not coaptcoapt in in pt’spt’s with with intrinsic sphincter intrinsic sphincter deficiencydeficiency

Ureteral PatencyUreteral Patency

Free flow of urine from ureteral orifice confirms Free flow of urine from ureteral orifice confirms patencypatency

Cystoscopy cannot diagnose ureteral injury just its Cystoscopy cannot diagnose ureteral injury just its absenceabsence

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Acute CystitisAcute Cystitis

Reddened and edematous mucosa obscures Reddened and edematous mucosa obscures vasculaturevasculature

May have hemorrhagesMay have hemorrhages

Known bacterial cystitis contraindication to Known bacterial cystitis contraindication to cystoscopycystoscopy

NonNon--infectious causes:infectious causes:

RadiationRadiation

HemorrhagicHemorrhagic

Catheter reactionCatheter reaction

Interstitial cystitisInterstitial cystitis

TrabeculationTrabeculation

Hypertrophied detrusor musculatureHypertrophied detrusor musculature

Associated with detrusor Associated with detrusor overactivityoveractivity and obstructionand obstruction

Enlargement of intervening Enlargement of intervening sacculessaccules can lead to can lead to diverticuladiverticula

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Chronic inflammation leads to Chronic inflammation leads to fibrosis in bladder wallfibrosis in bladder wall

Present with pain, urgency, Present with pain, urgency, frequencyfrequency

HydrodistensionHydrodistension to max to max capacity under general capacity under general anesthesiaanesthesia

Punctate hemorrhages (A) and Punctate hemorrhages (A) and glomerulationsglomerulations (B) are (B) are pathognomonicpathognomonic

Interstitial CystitisInterstitial Cystitis

Hunner’sHunner’s ulcerulcer

Uncommon finding seen in severe, longUncommon finding seen in severe, long--standing ICstanding IC

Surface epithelium destroyed by inflammationSurface epithelium destroyed by inflammation

Appear as velvety red patches or linear cracksAppear as velvety red patches or linear cracks

May crack and bleed with May crack and bleed with hydrodistensionhydrodistension

Cystitis CysticaCystitis Cystica

Benign 1Benign 1-- to 2to 2--mm clear mucosal cysts at the bladder mm clear mucosal cysts at the bladder basebase

Formed by single layers of Formed by single layers of subepithelialsubepithelial transitional transitional cellscells

Associated with chronic irritation and commonly Associated with chronic irritation and commonly surrounded by inflammationsurrounded by inflammation

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Bladder PolypBladder Polyp

Benign growth covered by epitheliumBenign growth covered by epithelium

Variable in appearanceVariable in appearance

Usually asymptomaticUsually asymptomatic

5 5 –– 10% may progress to cancer, so should be 10% may progress to cancer, so should be biopsiedbiopsied

Bladder CancerBladder Cancer

Transitional cell carcinomaTransitional cell carcinoma

Most common followed by adenoMost common followed by adeno-- and squamous celland squamous cell

Typical raised lesion with villous or papillary Typical raised lesion with villous or papillary appearance and surrounding inflammationappearance and surrounding inflammation

May be associated with CIS, which can mimic the May be associated with CIS, which can mimic the appearance of infectious cystitisappearance of infectious cystitis

VesicovaginalVesicovaginal FistulaFistula

Vast majority are postVast majority are post--hysterectomyhysterectomy

Usual location is bladder base, superior to Usual location is bladder base, superior to interuretericinterureteric ridge in area of vaginal cuffridge in area of vaginal cuff

Fistula may be large with obvious opening into vagina Fistula may be large with obvious opening into vagina or small with scarring being the only mucosal or small with scarring being the only mucosal abnormalityabnormality

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Acute UrethritisAcute Urethritis

Reddened, edematous mucosa along the length of the Reddened, edematous mucosa along the length of the urethraurethra

Urethral PolypsUrethral Polyps

Inflammatory polyps and Inflammatory polyps and fronds found at or near the fronds found at or near the UVJUVJ

Response to chronic Response to chronic inflammationinflammation

Usually translucent with Usually translucent with villous appearancevillous appearance

Can become large enough to Can become large enough to fill the proximal urethral fill the proximal urethral lumenlumen

UrethrovaginalUrethrovaginal FistulaFistula

Opening seen along lateral or posterior surface of Opening seen along lateral or posterior surface of urethraurethra

Urethral diverticulum has similar appearance, but Urethral diverticulum has similar appearance, but may express an exudate with palpationmay express an exudate with palpation

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Mesh ErosionMesh Erosion

A: vaginal mesh erosion A: vaginal mesh erosion viewed with a viewed with a cystoscopecystoscope

B: mesh within the B: mesh within the urethral lumen during urethral lumen during urethroscopyurethroscopyurethroscopyurethroscopy

High index of suspicion in High index of suspicion in anyone with LUTS and anyone with LUTS and h/o sling or other mesh h/o sling or other mesh procedureprocedure

Surgical introduction of forgeign bodies into the bladder

This is the metallic This is the metallic tip of a tack used in tip of a tack used in sacrocolpopexy sacrocolpopexy protruding into theprotruding into theprotruding into the protruding into the bladder dome.bladder dome.

A Loop of Prolene A Loop of Prolene suture in the bladder.suture in the bladder.

Sling arm noted in Sling arm noted in the lateral bladder the lateral bladder wallwall

Complications Associated with CystoscopyComplications Associated with Cystoscopy

InfectionInfection

Asymptomatic Asymptomatic BacteriuriaBacteriuria 55--8%8%

Symptomatic UTI 2Symptomatic UTI 2--5%5%

Send urine cx on anyone with symptoms preSend urine cx on anyone with symptoms pre oror Send urine cx on anyone with symptoms preSend urine cx on anyone with symptoms pre-- or or postpost--opop

CystoscopicCystoscopic findings consistent with acute cystitis findings consistent with acute cystitis should be treatedshould be treated

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Cystoscopy ComplicationsCystoscopy Complications

Traumatic injury to bladder/urethraTraumatic injury to bladder/urethra

Incidence unknownIncidence unknown

Scope trauma to bladder wallScope trauma to bladder wall

Usually at bladder base above Usually at bladder base above trigonetrigone

Observe for bleeding;Observe for bleeding; electrocauteryelectrocautery if neededif needed Observe for bleeding; Observe for bleeding; electrocauteryelectrocautery if neededif needed

Bladder perforationBladder perforation

Control bleedingControl bleeding

Foley catheter drainageFoley catheter drainage

LSC/laparotomy only if concern for abdominal bleeding LSC/laparotomy only if concern for abdominal bleeding or extremely large defector extremely large defect

CaseCase

At the end of a TVH, uterosacral suspension and At the end of a TVH, uterosacral suspension and cystocele repair for stage 2 prolapse, you perform cystocele repair for stage 2 prolapse, you perform cystoscopy and ~2 minutes after indigo carmine is cystoscopy and ~2 minutes after indigo carmine is given, there is flow only from the right side. given, there is flow only from the right side. Management options…..Management options…..g pg p

Give it time… +/Give it time… +/-- IV Lasix 10IV Lasix 10--20mg20mg

Still no flow…Still no flow…

Confirm surgical history (nephrectomy, Confirm surgical history (nephrectomy, etcetc))

Cut uterosacral stitch on that side and look againCut uterosacral stitch on that side and look again

Attempt to pass stent/Urology consultAttempt to pass stent/Urology consult

IntraopIntraop or postor post--op renal ultrasound/retrogradeop renal ultrasound/retrograde

SummarySummary

Knowledge of the components of a Knowledge of the components of a cystoscopecystoscopeand how to use an angled lens are imperative and how to use an angled lens are imperative before attempting cystoscopy.before attempting cystoscopy.

Ability recognize bladder injury and document Ability recognize bladder injury and document ureteral patency during pelvic surgery will aid in ureteral patency during pelvic surgery will aid in prompt recognition and allow for early correction prompt recognition and allow for early correction of injuries common to gynecologic surgery.of injuries common to gynecologic surgery.

Knowledge of typical lesions is important for Knowledge of typical lesions is important for recognition of pathology and appropriate therapy.recognition of pathology and appropriate therapy.